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Changing the Paradigm of the Emergency Medical Services


Can the Emergency Medical Services Evolve to Meet the Needs of Today?

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The emergency medical services (EMS) provide a means of rapid treatment and transportation to definitive care for those people who suffer immediate life-threatening injuries or illnesses (Department of Transportation, National Highway Traffic Safety Administration, n.d.; Mayer, 1980). There are a number of models across the country and the world that are seeking to redefine EMS in a way that is more meaningful in both of its missions, public safety and public health (Washko, 2012). However, financial constraints and overzealous regulations serve only to pigeon-hole EMS into the decade of its birth and refinement, the 1970s, by restricting incentive and growth and limiting the efficacy of directed research and its application towards the much needed restructuring of EMS.

In this brief literature review, I will examine the roots and context of EMS, its mission and current application, as well as possibilities for research, growth, and development. It is important to recognize that EMS is a grand resource for both public safety and public health, especially in light of the growing body of legislation that officials are using to redefine the current health care system within the United States. As we continue to develop EMS, other nations will look to us as they have in the past to adopt and adapt our system for use throughout the world.

A Brief History of Contemporary EMS

There were many forms of organized out-of-hospital medical aid provided throughout history from the biblical good Samaritan to the triage and extrication from the battlefields of the Roman conquests and the Napoleonic wars through the U.S. Civil War and every major war and conflict in U.S. history; however, it was not until the advent of combined mouth-to-mouth resuscitation and closed chest massage (what we know today as cardiopulmonary resuscitation, or CPR), enhanced 9-1-1 for use by the public in summoning emergency services, and the release of a 1966 white paper prepared by the Committee on Trauma and Committee on Shock of the National Academy of Sciences, National Research Council, that we have the EMS system that we are familiar with today (Department of Transportation, National Highway Traffic Safety Administration, 1996). It was about this time that the Department of Transportation (DOT) was given purview over EMS at the national level with the passage of the National Highway Safety Act of 1966.

During the 1970s, EMS had transitioned from mostly untrained funeral home drivers to providers trained by emergency physicians to treat many of the life-threatening scenarios that prevent people from seeking medical attention at hospitals, such as traumatic injuries, cardiac arrest, and many breathing problems. Since this time, there have been a number of concerted efforts and official recommendations by the DOT to augment and improve the delivery model of EMS throughout the country (Department of Transportation, National Highway Traffic Safety Administration, n.d., 1996, 2008). As early as 1996, the DOT published the vision of the future of EMS:

Emergency medical services (EMS) of the future will be community-based health management that is fully integrated with the overall health care system. It will have the ability to identify and modify illness and injury risks, provide acute illness and injury care and follow-up, and contribute to treatment of chronic conditions and community health monitoring. This new entity will be developed from redistribution of existing health care resources and will be integrated with other health care providers and public health and public safety agencies. It will improve community health and result in more appropriate use of acute health care resources. EMS will remain the public’s emergency medical safety net. (Department of Transportation, National Highway Traffic Safety Administration, 1996, p. iii)

Even as today’s emergency rooms, operating suites, and trauma centers throughout the world are overflowing capacity with an increasingly deficient workforce, EMS is expected to answer the call for help as the front-line of a fractured and inefficient health care system (Kellermann, 2006; Mason, Wardrope, & Perrin, 2003; O’Meara et al., 2006; Washko, 2012).

Hampered Efforts

EMS is known throughout the United States as rapid responders in times of medical and traumatic emergencies; however, ever-increasingly, EMS is being used as the front-line alternative to primary care for the non-emergent uninsured and under-insured patient population (Heightman & McCallion, 2011; Washko, 2012). There is a limited number of ambulances, EMTs, and paramedics available at any given moment, which is subject to financial constraints, and non-emergent use of these resources prevents their availability for when a true emergency arises. Secondary to the mission of providing care to the public, EMS is also needed to provide services for fire department and police department operations, such as firefighter rehabilitation at fire scenes and tactical medicine in concert with bomb squads, S.W.A.T. teams, and hazardous materials teams.

EMS resources are costly, and overburdened systems are negatively affected when these resources are misused, especially by those who are unwilling or unable to pay for the services.

Financial Impact

According to the DOT (2008) EMS workforce report, employers reported difficulties in retaining EMTs and paramedics partly due to the inability to raise wages or provide better fringe benefits. The report goes on to show that EMTs and paramedics suffer a wage disparity when compared to other similar public safety ($12.54/hr vs. firefighters: $26.82/hr; police officers: $22.25/hr) and health care workers (licensed vocational nurses and licensed practical nurses: $16.94/hr; respiratory therapists: $21.70/hr; registered nurses: $26.28/hr). In the five years leading up to 2005, the average wage for EMTs and paramedics grew only by $0.29/hr. It is important to note that these numbers do not take cross-trained firefighters and police officers into consideration.

Furthering the concern of wages, as the DOT (2008) report shows, is the lack of growth potential within EMS as most systems lack the ability to provide a meaningful career ladder to the EMTs and paramedics in their employ. These circumstances together create the scenario that EMS is an underpaid dead-end job causing high attrition as most EMTs and paramedics either suffer from burnout, culminated psychological stress from the job, or use the profession as a stepping stone into other health care fields, such as nursing, respiratory therapy, or physician-level medicine.

The DOT (2008) report provides evidence that transport-based reimbursement policies are likely to blame for the unusually low profit margin in EMS (Heightman & McCallion, 2011). The Medicare and Medicaid programs, as well as many private insurers, require documentation that the transport of a patient be medically necessary before they will pay; however, the Medicare and Medicaid reimbursement rates are very low and do not cover the cost of EMS operations. To complicate the matter, EMS providers are mandated by law to provide care to the public regardless of their insurance status or ability to pay (Heightman & McCallion, 2011). EMS is subsidized by either taxes or insurance reimbursement or some combination of the two.

Broad Mission

In addition to providing for the mundane care and transportation of the ill and injured and performing ancillary duties for the police and fire departments as noted above, EMS is tasked with disaster preparedness – preparing for the major incident that is highly unlikely to occur but would be devastating to lives and infrastructure if it does. That is if the EMT or paramedic is employed for an emergency service. Many of the EMTs and paramedics, today, are employed by private ambulance services who transport non-emergent patients to and from skilled nursing facilities and doctors’ offices. The multitude of these EMTs and paramedics are not considered when planning for emergency response schemes.

I consider EMS to be the caulking used to fill many of the fractures and gaps in today’s health care system. If it occurs outside of the hospital, then EMS will take responsibility, yet, they seldom get paid for their actions.

Proposed Solutions

There has been much talk over the past few years regarding the efficacy and efficiency of EMS, and all agree that the current definitive model is inefficient with, at best, questionable efficacy. Washko (2012) describes in detail the number of EMS schemes and their shortfalls. In his article, Washko is correct in stating that transport-based reimbursement policies fail to reward the greater EMS community for their willingness to take on further responsibility within the two scopes of operation: public health and public safety.

Wingrove and Laine (2008) explore the opportunity for training and equipping the most experienced paramedics for a public health centered role delivering community-based care. These community-based paramedics are described as augmenting the traditional emergency responder role with opportunities to direct patients to more appropriate care, such as doctor’s offices and urgent care centers instead of hospital emergency departments when appropriate to their condition. This model was researched recently in Australia with good results, and is now a recommended career path both there and in the United Kingdom (Mason, Wardrope, and Perrin, 2006; O’Meara et al., 2012). In the U.S., EMS professionals feel a responsibility to participate in disease and injury prevention efforts, and research on models that utilize specially-trained paramedics to perform home safety inspections, hazard mitigation, and reduce the risks of injuries to children have proven effective (Hawkins, Brice, & Overby, 2007; Lerner, Fernandez, & Shah, 2009). Hennepin Technical College, in Minnesota, now offers certification in Community Paramedic training when the recommended curriculum is provided by an accredited college, according to Wingrove and Laine.

Other, more immediate (but, arguably, less meaningful) solutions, as Washko (2012) describes, are incorporating operational tactics that better utilize ambulances by attempting to predict call volumes and locations based on historical data, the high-performance model. This, however, creates high-call volume, less resource driven scenarios with ambulances idling on street corners awaiting the next call. As mentioned earlier, attrition is a significant concern in EMS and these tactics are demanding on providers physically and psychologically leading to high incidences of burnout and injury (Department of Transportation, National Highway Traffic Safety Administration, n.d., 2008).


The standard operational benchmarks of EMS – response times and mortality and morbidity of cardiac arrest – are antiquated measures and typically distract policymakers when they are considering financial incentives for EMS (Heightman & McCallion, 2011; Washko, 2012). EMS needs to evolve with the changing health care system, and I feel that it is poised, specifically, to help address disparities in health and health care. Using the community-based paramedic model of health care delivery, we can address many public health concerns, provide for public safety, and still maintain the traditional role of emergency responder. The community-based paramedic model will provide an acceptable alternative to the options that lie ahead.

The economics of health care is a reality that must be considered by every EMS operation when approaching growth and change. As long as EMS can fill the gaps in the current health care system, it will be worth the money required to subsidize a robust, well-trained, and well-equipped contingent of emergency medical professionals. In the meantime, though, EMS agencies will have to seek more efficient models that maximize reimbursement while minimizing costs.


Committee on Trauma & Committee on Shock, Division of Medical Sciences, National Academy of Sciences, National Research Council. (1966). Accidental Death and Disability: The Neglected Disease of Modern Society. Washington, D.C.: Author.

Department of Transportation, National Highway Traffic Safety Administration. (n.d.). A leadership guide to quality improvement for emergency medical services (EMS) systems (Contract DTNH 22-95-C-05107). Retrieved from http://www.nhtsa.gov/people/injury/ems/Leaderguide/index.html

Department of Transportation, National Highway Traffic Safety Administration. (1996). Emergency medical services: agenda for the future (DOT HS 808441 – NTS-42). Retrieved from http://www.nremt.org/nremt/downloads/EMS%20Agenda%20for%20the%20Future.pdf

Department of Transportation, National Highway Traffic Safety Administration. (2008). EMS workforce for the 21st century: a national assessment. Retrieved from http://secure.naemse.org/services/EMSWorkforceReport.pdf

Hawkins, E. R., Brice, J. H., & Overby, B. A. (2007). Welcome to the World: Findings from an emergency medical services pediatric injury prevention program. Pediatric Emergency Care, 23(11), 790-795. doi:10.1097/PEC.0b013e318159ffd9

Heightman, A. J. & McCallion, T. (2011). Management lessons from Pinnacle: Key messages given to EMS leaders at the 2011 conference. Journal of EMS, 36(10), 50-54.

Kellermann, A. L. (2006). Crisis in the emergency department. New England Journal of Medicine, 355(13), 1300-1303. doi:10.1056/NEJMp068194

Lerner, E. B., Fernandez, A. R., & Shah, M. N. (2009). Do emergency medical services professionals think they should participate in disease prevention? Prehospital Emergency Care, 13(1), 64-70. doi:10.1080/10903120802471915

Mason, S., Wardrope, J., & Perrin, J. (2003). Developing a community paramedic practitioner intermediate care support scheme for older people with minor conditions. Emergency Medicine Journal, 20(2), 196-198. doi:10.1136/emj.20.2.196

Mayer, J. D. (1980). Response time and its significance in in medical emergencies. Geographical Review, 70(1), 79-87. Retrieved from http://www.ircp.info/Portals/22/Downloads/Performance/Response%20Time%20and%20Its%20Significance%20in%20Medical%20Emergencies.pdf

National Traffic and Motor Vehicle Safety Act of 1966, Pub. L. No. 89-563, 80 Stat. 718 (1966).

O’Meara, P., Walker, J., Stirling, C., Pedler, D., Tourle, V., Davis, K., … Wray, D. (2006, March). The rural and regional paramedic: moving beyond emergency response (Report to The Council of Ambulance Authorities, Inc.). Retrieved from http://www.ircp.info/Portals/22/Downloads/Expanded%20Role/The%20Rural%20and%20Regional%20Paramedic%20Moving%20Beyond%20Emergency%20Response.pdf

Washko, J. D. (2012). Rethinking delivery models: EMS industry may shift deployment methods. Journal of EMS, 37(7), 32-36.

Wingrove, G. & Laine, D. (2008). Community paramedic: A new expanded EMS model. Domain3, 32-37. Retrieved from http://www.ircp.info/Portals/22/Downloads/Expanded%20Role/NAEMSE%20Community%20Paramedic%20Article.pdf

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

Human Resources & Challenges in Health Care

The function of human resources is not without its challenges and difficulties. No matter the industry or organization, acquiring and managing a pool of employees can be overwhelming (Thompson, 2012). Human resources managers in health care organizations seem to face more challenges than most. From nursing and physician shortages to attracting innovative and contemporary researchers, health care organizations seem to search within thinning pools of prospective employees, yet still demand the best and brightest (Keenan, 2003; Lewis, 2010; Thompson, 2012).

One of the most challenging issues to health care over the last few decades has been a significant nationwide nursing shortage (Keenan, 2003; Lewis, 2010). Thompson (2012) outlines both a declining skilled workforce and an increasing population contributing to the problem. Both Keenan (2003) and Lewis (2010) cite the aging babyboomer population adding to the increased need for nurses through 2020 and beyond. Novel human resources strategies can result in an augmented workforce designed to meet the continually growing impact these forces have on health care organizations, specifically those with emergency departments.

One novel strategy includes consideration of other highly-skilled clinicians that do not traditionally work in hospitals. As Oglesby (2007) considers the possibility, paramedics are, by far, one of the best examples. By introducing paramedics into the emergency department, a hospital can redistribute the nurses to clinical areas more suited towards their training, decrease the patient-to-nurse ratios (thereby increasing patient safety and maximizing outcomes), and tap into a new pool of prospective employees that are well-suited to rise to the stressful demands of the emergency department (Keenan, 2003; Swain, Hoyle, & Long, 2010). Additionally, organizations employing paramedics can augment both their emergency department operations and home health care operations by sending paramedics to certain patients to mitigate their complaints and minimize the number of inappropriate patient transports to the emergency department (Swain, Hoyle, & Long, 2010). This alone would decrease emergency department overcrowding and maximize revenue and efficiency in the delivery of care. Additionally, turn-over rates should be significantly lower with a more productive work environment where stress is managed, outcomes are met, and patients are care for more effectively.

In conclusion, intelligent and novel planning of the workforce can, itself, lead to increases in recruitment and retention; however, efforts still need to focus on each individually in order to attract, maintain, and develop a first-class workforce (Thompson, 2012).


Keenan, P. (2003). The nursing workforce shortage: causes, consequences, proposed solutions (Issue brief #619). The Commonwealth Fund. Retrieved from http://mobile.commonwealthfund.org/

Lewis, L. (2010). Oregon takes the lead in addressing the nursing shortage: A collaborative effort to recruit and educate nurses. American Journal of Nursing, 110(3), 51-54. doi:10.1097/01.NAJ.0000368955.26377.e1

Oglesby, R. (2007). Recruitment and retention benefits of EMT—Paramedic utilization during ED nursing shortages. Journal of Emergency Nursing, 33(1), 21-25. doi:10.1016/j.jen.2006.10.009

Swain, A. H., Hoyle, S. R., & Long, A. W. (2010). The changing face of prehospital care in New Zealand: the role of extended care paramedics. Journal of the New Zealand Medical Association, 123(1309), 11-14. Retrieved from http://journal.nzma.org.nz/

Thompson, J. M. (2012). The strategic management of human resources. In S. B. Buckbinder & N. H. Shanks, Introduction to Healthcare Management (Custom ed.; pp. 81-118). Sudbury, MA: Jones & Bartlett.

Prior Proper Planning …

… Prevents Poor Performance

I am in the midst of planning an ad hoc merger of a number of local emergency medical service agencies into a single regional provider to reduce overall costs while maximizing revenue, improve training and the delivery of care, and to streamline the operational processes that support our providers in the field. Unfortunately, I have found that there are many obstacles that need to be dealt with at every step before moving on to the next. My research has certainly opened my eyes to developing a useful approach to these problems.

Planning “[provides] the appropriate focus and direction for … organizations” (Zuckerman, 2006, p. 3). Without planning, organizations risk stagnation and obsolescence. For any organization to succeed (and continue to do so), the strategy needs to focus both on the contemporary traditional needs as well as those anticipated in the future, but this focus needs to be comprehensive. Bartling (1997) writes of 25 different pitfalls any health care organization might face when considering strategic planning. These 25 pitfalls are just some of the issues I hope to avoid.

One of the largest difficulties in planning for emergency medical systems, however, is the sense of ‘fiefdom’, or an assertion of organizational ownership — in a truly feudal sense. A fiefdom is a literal power trip. In this area, there are 10 towns with an average of two ambulances each, and each department’s administration will fight tooth and nail to keep the organization from outgrowing them. What is interesting about the area is that many of the members of one department work for at least two of the other departments, also. This is because the pay is so meager they have to work as many hours as possible, and there is no chance of working more than 32 hours at any one service in any given week. The pay is low as is the quality of care. This needs to change, but how do I create an amalgumated organization from the bits and pieces that I have to work with? Add to that my lack of formal authority in this process. My vision is to reduce the number of ambulances by staffing eight ambulances at all times and tactically positioning them around the region. This alone would create 48 well-paid jobs, using the same 40 people who currently job share across organizational lines.

In reviewing the available resources, I have learned that there is no particular process or flow-chart pathway to effective planning (Bartling, 1997; Begun & Kaissi, 2005; Zuckerman, 2006). Critical forward thinking is needed, instead. Some of the particular issues that Bartling (1997) discusses and I foresee might be particular to my planning process are: inadequate planning, short-sightedness, underestimating the complexity of the process, post-merger angst, analysis paralysis, and lack of evaluative criteria, to name a few. Politics plays a large role in many of these issues I mention.

Inadequate planning, short-sightedness, and a lack of evaluative criteria are closely related. I see in the present that the system does not work as well as it should (short-sightedness), and I want to develop a plan that can be implemented immediately (probably suffering inadequate planning). This would leave me with a fragmented system devoid of vision and, therefore, crippled from improving (lacking that evaluative criteria). These are pitfalls that I need to avoid. These issues would give rise to the others dooming my effort to failure and, possibly, leaving the system in even worse shape than it began.

Perhaps, my only chance of fulfilling this process is to first perform a limited situational assessment by identifying the mission, vision, and values of all of the stakeholders and show how a streamlined process can better fulfill their visions (Casciani, 2012). By gaining stakeholder support, I might better leverage my idea against those who fear change.


Bartling, A. (1997). 25 pitfalls of strategic planning. Healthcare Executive, 12(5), 20–23.

Begun, J. & Kaissi, A. (2005). An exploratory study of healthcare strategic planning in two metropolitan areas. Journal of Healthcare Management, 50(4), 264–274.

Casciani, S. J. (2012). Strategic planning. In S. B. Buckbinder & N. H. Shanks (Eds.), Introduction to healthcare management (Custom ed.; pp. 3-23). Sudbury, MA: Jones & Bartlett.

Zuckerman, A. (2006). Advancing the state of the art in healthcare strategic planning. Frontiers of Health Services Management, 23(2), 3–15.

Codes of Ethics

Of the three ethical codes presented by Lewis and Tamparo (2007), I align myself most with the Principles of Medical Ethics: American Medical Association (AMA). The AMA promotes honesty, integrity, compassion, respect, and most importantly, responsibility. In all manners of occupation, it is virtuous to remain honest; this is paramount in medicine. Physicians, nurses, paramedics, and other health professionals may make mistakes during their career, and it is important that these mistakes be corrected as soon as possible and understood to promote practices that may minimize the same mistake from happening. Honesty leads to integrity. Integrity is a hallmark of professionalism and, in conjunction with honesty, promotes trust. Having compassion and respect for patients regardless of political, societal, economic, or other divisions allows a provider to actually care for his or her patients rather than just deal with them. As a paramedic, I try to be as trustworthy and caring as possible to each and every patient I see. Ultimately, I understand my responsibility to my community, to fellow clinicians and technicians, to patients, and to myself. I hold ultimate responsibility for my actions and inactions, and I take care to not let these adversely effect the perception others hold of me as a professional. The AMA expects this of all physicians, and as an extension of the physicians I work for, I must strive to meet the same demands.

The Hippocratic Oath is dated in its language and demands. Though the oath can be approached as symbolism, the metaphor can be lost on some. I appreciate the Hippocratic Oath for what it is (a foundation for the ethical practice of medicine), but contemporary words, meanings, and application serve me better.

I find the Code of Ethics of the American Association of Medical Assistants lacking in context, applicability, and substance when adopted for paramedicine, my chosen occupation; therefore, I do not align as well with this code as I do with the previously mentioned codes of ethics.

Codes of ethics provide baseline philosophies that serve to direct the actions of groups. By ascribing to such, the professional belonging to such a group allows the code to guide moral judgments when the answer is unclear. In medicine, this is especially true. Medical professionals deal with life and death decisions which stretch the boundaries of personal moral beliefs. By ascribing to a notion of a slightly higher directive than one’s self, the professional can remove his- or herself from the situation with more clarity and less bias.

My personal ethics are bound by a sense of personal liberty and the responsibility of that liberty. Without responsibility, there are no consequences. Without consequence, there is no learning. I like to learn so that I may be the best paramedic that I can to the next patient in my care. For me, it is always about the next patient; they deserve the best that I can offer.


Lewis, M. A. & Tamparo, C. D. (2007). Codes of ethics. In Medical law, ethics, and bioethics for the health professional (6th ed.; pp. 241-243). Philadelphia, P.A.: F. A. Davis.

Cognitive Development

“Children are naturally curious” (Kail & Cavanaugh, 2010, p. 98), and that is a good thing. The authors are describing a premise of Piagets theory of childhood cognition development. Piaget’s theory is based stages of adaptive learning and identifies stages associated with key development: infancy, school age, preteen, and adolescence. According to Piaget, in infancy, cognition is very basic and focused on sensorimotor schemes that the child forms based on experiences. As the child ages, Piaget claimed, these schemes become more complex. During school age, children start to form schemes based less on function and more on appearance. Preteens, on the other hand, start to understand emotion, individualism, and relative constructs. Adolescents build upon these relative constructs adding abstract thought processes which continues to build their problem solving skills well into adulthood. Vygotsky’s theory of cultural impact on cognitive development stresses that the individual and the environment are interactive, and this interaction has an impact on learning. Scaffolding, or building on information already known, effectively identifies where instruction is needed. Coupling Piaget’s understanding of cognition development with Vygotsky’s understanding of learning environments, a focused efficiency in teaching could be attained.

As we age, though, physiologic neural processing slows and the brain atrophies (Thibault, Gant, & Landfield, 2007). These changes cause information processing to slow bidirectionally, that is as input and output, and accelerates a functional decline in brain activity as we age. This is not a reversal of development but a systematic failure of physiologic processes. The effects of aging on brain tissue directly effect cognition as neural networks of synapses breakdown. Though this process is inevitable, researchers suggest certain diets and moderate exercise that can mediate the damaging effects of aging on cognition (Bugg & Head, 2009; Gómez-Pinilla, 2008).


Bugg, J. M. & Head, D. (2009). Exercise moderates age-related atrophy of the medial temporal lobe. Neurobiology of Aging. Advance online publication. doi:10.1016/j.neurobiolaging.2009.03.008

Gómez-Pinilla, F. (2008). Brain foods: The effects of nutrients on brain function. Nature Reviews Neuroscience, 9, 568-578. doi:10.1038/nrn2421

Kail, R. V. & Cavanaugh, J. C. (2010) Aging: A lifespan view (Laureate custom ed.). Mason, OH: Cengage Learning.

Thibault, O., Gant, J. C., & Landfield, P. W. (2007). Expansion of the calcium hypothesis of brain aging and Alzheimer’s disease: Minding the store. Aging Cell, 6(3), 307-317. doi:10.1111/j.1474-9726.2007.00295.x

The Impact of Stages of Life on Health

During our lifetimes, we are met with all kinds of obstacles to overcome, whether in business, society, or in moral dilemmas. None as true as in our health and wellness. During each major stage of life, there are many health challenges and risks that must be met and overcome. The importance of identifying challenges in each developmental stage of life is crucial to the promotion and adoption of healthy changes in behavior (Green, 1984). I will explore how lifestyle and behavioral choices, as well as social determinants of health, can impact these health risks and challenges as they relate to the various life-stages. Kolbe (as cited in Green, 1984) indicates a number of “health-related types of behaviors” (p.218), some of which I will address for each life-stage and transition between life-stages. As we transcend each stage of our lives, new and evolving concerns obstruct our path to wellness. We tend to approach our health from the present, the here and now, but it starts before our birth and, with genetics, possibly before conception.

Once we are conceived, we are locked into the care of our parents to be. Whether a mother and father, a single working parent, a single drug-addicted parent, caring grandparents, foster care, the State, or a host of other possibilities, each is suggestive of the environment to which we will be born and/or raised. This environment will surely shape our health from within the womb and health professionals are tasked with providing directed education to the parents-to-be to give the child the best chance of a healthy development.

The importance of maternal health to the fetus has become a focus in public health over the last century, but emerging research is showing how best to approach this topic. “Two principal threats to infant health are low birth weight and congenital disorders including birth defects” (Green, 1984). Though technological advances are proving helpful in high-risk pregnancies (Blincoe, 2007), prevention and education is still key. A recent literature review (Slama et al., 2008) has identified some links between environmental toxins and neonatal health, calling for more specialized research in this area. Exposure by pregnant women to toxins, such as that from pharmaceuticals, cigarette smoke, and contaminated fish, pose significant threats to the fetus (Gwiazda, Campbell, & Smith, 2005; Landrigan, Kimmel, Correa, & Eskenazi, 2004). Family violence towards the mother-to-be also serves a significant threat to children in utero. A study by Amaro, Fried, Cabral and Zuckerman (1990) reveals that women who have a poor support structure, a history of depression, and current alcohol and illicit drug abuse are more prone to be victims of violence, which threatens the pregnancy.

Infancy is the most crucial of the developmental stages for cognitive, social, and emotional development (Centers for Disease Control, 2009). The environment in which the infant development takes place is a key determinant to the level of neonatal and infant health. Lead, as well as other environmental toxins and notwithstanding comprehensive abatement programs, still threatens the development of infants and young children (Gwiazda et al., 2005; Landrigan et al., 2004). As infants develop into toddlers and young children, the threat focus shifts from indirect toxin exposure to direct accidental poisoning and physical trauma.

As children start to walk and gain enough strength and ingenuity to open doors and containers, there is an increased risk of accidental poisoning by household goods (Hockey, Reith, & Miles, 2000). Though accidental poisoning has been mitigated to a degree by the “Mr. Yuck” campaign (Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, 1971/2009) and the introduction of childproof containers, many poisonings still occur, some being purposeful by loved ones (Davis et al., 1998) but most are accidental. Poisoning included, trauma remains the leading cause of childhood death (Green, 1984, p. 225; Harkins, 2009).

The transition into puberty comes with a change in physiology, both in the body and in the brain. Adolescents must contend with a new found, and usually intense, libido. With this, the adolescent faces the threat of early pregnancy and a host of sexually transmitted diseases. Though public health education efforts seem to be effective on some levels, teenage pregnancy and STD’s remain a constant concern.

Green (1984) also finds that teenagers also find themselves expanding and exploring their environments with their increased autonomy. Increased risk-taking attitudes typically lead to a high likelihood of trauma, which, as is true for younger children, remains the leading cause of death for adolescents, though the associated poisoning is attributed more to recreational and experimental illicit drug use and abuse.

Transitioning into adulthood, the health focus begins to shift towards disease processes and away from trauma, except for, perhaps, motor vehicle and occupational incidents. Green (1984) supposes that this is from a “curtailed freedom [and] increased responsibility for lifestyle” along with “reduced parenting roles, changing bodily functions, [and] reduced activity” (Table 3). It is within these years that other responsibilities can seem to outweigh those of health, probably attributable to a high sense of health as active teenagers and a perceived need to be successful within their personal economy. This loss of health focus can certainly lead to disease processes, such as atherosclerosis, hypertension, and obesity, which can, in turn, lead to an early stroke or heart attack. It makes sense to consider that behavioral health changes within the early adult years can impact the later adult and senior adult years.

As we age towards our retirement, our picture of health tends to become more obvious. Many of us will suffer from hypertension, coronary artery disease, diabetes, and elevated cholesterol levels. Some of us will have already suffered a heart attack or stroke, and some others might soon. At this point in life, it is imperative to have frequent check ups with a physician who will probably attempt to control most of the underlying risk factor diseases mentioned above with pharmaceuticals. Though we can try to adopt healthier behaviors, by the time we reach our senior years, most of the physiologic damage is irreparable. There is some promise, however, as “the elderly are found in evaluative research studies to be as much if not more responsive to behavioral change supports than younger patients or subjects” (as cited in Green, 1984, p. 228).

One of these changes is osteoporosis, or a weakening of the calcium bone matrix. As we grow through childhood, our bones are formative and calcium is readily bonded within the bone structure providing the skeletal framework for the rest of our lives. The elderly suffer the most from any calcium deficiency, as the threat of simple fall can lead to a catastrophic injury requiring surgery for correction or a permanent fracture if the person does not have strong enough bones. This will most certainly result in the loss of the person’s ability to maintain his or her activities of daily living which can result in having to rely on residential nursing care. A lifetime of cigarette smoking, heart disease, or generally poor health can lead to the same degree of disability requiring the same type of care.

Skilled nursing facilities, though important for the continual care or rehabilitation of the elderly and infirm, have risks for the in-patient just as any other treatment might. Skilled nursing facilities are a vector of a number of nosocomial infections, usually medically resistant, which can and often does lead to a serious condition known as sepsis, a life-threatening infectious condition that overcomes the bodies ability to self-regulate. Sepsis is largely fatal. Confinement in a nursing facility is also associated with an increased incidence of depression and loss of constitution (Green, 1984).

As we have discussed some of the more prominent challenges that we face at each stage of our lives, we need to understand some of the determinants that affect our health. So long as we are aware of these, we can change our lifestyle and behaviors to minimize the impact of some of the negative determinants. In my opinion, the most important determinant of health is the availability of clean water, then perhaps, the availability of whole food and decent shelter. I feel that these are most important because they are the most difficult to correct as an individual. Following these, I feel that the availability of comprehensive health care is important.

This paper is based on research conducted primarily in developed Western society; therefore, it does not address the problem of extreme poverty and other determinants of health attributed to it. One example of this is provided by Kiapa-Iwa and Hart (2004) who show an increase risk of health with a prevalence of high-risk pregnancy and STD’s in the impoverished region of Uganda. Whether we are discussing Britain’s Liverpool, the Mid-west United States, or Uganda, we must admit that a focus on education and prevention, such as safe-sex programs, safe storage of medications and firearms, defensive driving, and others, seem to be the most effective means of mitigating some of the more controllable health determinants for parents and children, as well as adolescents. Older adults and seniors need to have a comprehensive program directed by their physician, including a healthy diet, exercise, and controlling medical problems such as hypertension and diabetes to increase their health status.


Amaro, H., Fried, L. E., Cabral, H., & Zuckerman, B. (1990). Violence during pregnancy and substance use [Abstract]. American Journal of Public Health, 80(5), 575-579. doi:10.2105/AJPH.80.5.575

Blincoe, A. J. (2007, October). Doppler sonography: Improving outcome in high risk pregnancy. British Journal of Midwifery, 15(10), 650-653. Retrieved from http://www.britishjournalofmidwifery.com/

Centers for Disease Control. (2009, May 7). Child development. Retrieved from http://www.cdc.gov/ncbddd/child/default.htm

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Davis, P., McClure, R. J., Rolfe, K., Chessman, N., Pearson, S., Sibert, J. R., Meadow, R. (1998). Procedures, placement, and risks of further abuse after Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation. Archives of Disease in Childhood, 78, 217-221. doi:10.1136/adc.78.3.217

Green, L. W. (1984). Modifying and developing health behavior. Annual Review of Public Health, 5, 215-236. doi:10.1146/annurev.pu.05.050184.001243

Gwiazda, R., Campbell, C., & Smith, D. (2005, January). A noninvasive isotopic approach to estimate the bone lead contribution to blood in children: Implications for assessing the efficacy of lead abatement. Environmental Health Perspectives, 113(1), 104-110. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1253718/pdf/ehp0113-000104.pdf

Hockey, R., Reith, D., Miles, E. (2000, July). Injury bulletin: Childhood poisoning and ingestion [Injury Bulletin No. 60]. Queensland Injury Surveillance Unit. Retrieved from http://www.qisu.org.au/modcore/PreviousBulliten/backend/upload_file/issue060.pdf

Harkins, D., (2009). Pediatric trauma in the spotlight. Journal of Trauma Nursing, 16(3), 123-125. Retrieved from http://content.ebscohost.com/pdf23_24/pdf/2009/39B/01Jul09/ 44454466.pdf

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Landrigan, P. J., Kimmel, C. A., Correa, A., & Eskenazi, B. (2004, February). Children’s health and the environment: public health issues and challenges for risk assessment. Environmental Health Perspectives, 112(2), 257-265. doi:10.1289/ehp.6115

Slama, R., Darrow, L., Parker, J., Woodruff, T. J., Strickland, M., Nieuwenhuijsen, M., …Ritz, B. (2008). Meeting report: Atmospheric pollution and human reproduction. Environmental Health Perspectives, 1161(61), 791-798. doi:10.1289/ehp.11074

Innovation of Technology

Any expansion of the core infrastructure has historically driven technological growth spurts. From the advent of fire, electricity, and assembly-line manufacturing, there has been huge growth in technology following these cataclysms, but what is truly impressive is the exponential growth when these technologies are combined.

The telephone is a great example of this growth. Telephone systems evolved from the telegraph when Alexander Graham Bell combined his expertise of acoustics and oration to his knowledge of electricity. Bell, at the time, was attempting to perfect a multi-band telegraph, or a musical telegraph (Casson, n.d.). I feel that Bell’s contribution to the telephone and others succeeding in the field resulted in his lifelong dream of the musical telegraph being realized as he meant for it to be, unfortunately well after his death. The computer modem is such a device using multiple tones in quick succession to communicate with other computers with modems. The same concepts have been applied to promulgate broadband technology which most of the world now relies upon.

Whenever an innovation of technology occurs, it allows more people more opportunity to expand on it. With this in mind, I feel the biggest benefit of Internet2 and IPv6 would be the spark of innovation that is sure to come soon after acceptance.


Casson, H. N. (n.d.). The History of the Telephone. Electronic Text Center, University of Virginia Library. Retrieved on 22 June 2009 from http://etext.virginia.edu/etcbin/toccer-new2?id=CasTele.sgm&images=images/modeng&data=/texts/english/modeng/parsed&tag=public∂=1&division=div1