Monthly Archives: July 2011

Academia, Health Care, Public Health

Comparing Hospital Care in My Area

Living in northeastern Connecticut, I find myself equidistant from two area hospitals. As a health care provider and consumer, I feel that it is important to choose the professionals who will provide my care based on fact. Websites created by the Joint Commission (2011) and the U.S. Department of Health and Human Services (HHS; 2011) prove to be a helpful repository of information regarding the safety and quality of care delivered by hospitals and practitioners across the country.

Using these two websites, I will compare the three closest hospitals to my zip code: 1) Day Kimball Hospital (10.3 mi), 2) Harrington Memorial Hospital (10.0 mi), and 3) Windham Community Memorial Hospital (21.7 mi). The mean distance from my home to these hospitals is 15.85 mi. with all three being acceptable by me in distance and time in the case of an emergency. Day Kimball Hospital (DKH; 2011) is a 104-bed acute care facility located in Putnam, Connecticut. Harrington Memorial Hospital (HMH; 2009) is a 114-bed acute care facility located in Southbridge, Massachusetts. Windham Community Memorial Hospital (WCMH; n.d.) is a 130-bed acute care facility located in Windham, Connecticut.

General process of care measures account for best practices in medicine and health care. The Surgical Care Improvement Project has set goals preventing untoward cardiac effects during certain surgical procedures along with infection control measures. According to Health Compare (HHS, 2011), cumulative scores for each hospital based on general process of care measures in the Surgical Care Improvement Project are as follows: DKH=0.954, HMH=0.901, WCMH=0.935. Another general process measure aimed at providing the standard of care of heart attack victims is the Heart Attack or Chest Pain Process of Care. The cumulative scores for these reported measures are: DKH=0.967, HMH=0.973, WCMH=0.956. Another cardiac related measure is the heart failure process of care measure. The cumulative results are: DKH=0.950, HMH=0.873, WCMH=0.893. Pneumonia process of care measures are important to gauge the appropriateness of treatments provided to stave off further development of respiratory failure and sepsis, two highly conditions with increase mortality. The cumulative scores for the pneumonia process of care measures are: DKH=0.932, HMH=0.860, WCMH=0.955. The last general process of care measure reflects the adherence to best practices in treating and managing children’s asthma; however, none of the three hospitals provided data for any of the process measures of this category.

Along with process of care measures, outcome of care measures are also important as they reflect the ability of each hospital to manage the risks of mortality and morbidity in caring for their patients. Outcome measures are based on both death and readmission of heart attack, heart failure, and pneumonia patients. For all three hospitals, DKH, HMH, and WCMH, the cumulative results for outcome of care measures were not statistically different from than the national rates in all categories. Health Compare (HHS, 2011) reports these measures as such.

One final measure that I find important in choosing a hospital is the patient satisfaction scores. Cumulative scores of the Survey of Patients’ Hospital Experience allow us to compare the three hospitals: DKH=0.695, HMH=0.701, WCMH=0.677.

In ranking each of the three hospitals, I used an average of the cumulative scores for each hospital’s measure discussed above. The final score, according to the averages of the Hospital Compare (HHS, 2011) scores, is: DKH=0.900, HMH=0.862, WCMH=0.883; therefore, my first choice of hospitals, according to the data presented in Hospital Compare is DKH with WCMH being second and HMH third. According to this data, though, each of the three hospitals appears to be equitable with the others striving in some measures and faltering in others. This is also evidenced by Quality Check (The Joint Commission, 2011), which shows a graphic representation of the same overall data, National Quality Improvement Goals and the Surgical Care Improvement Project, used by HHS (2011). Quality Check (The Joint Commission, 2011) compares quality data with the target ranges of other hospitals.

According to Quality Check (The Joint Commission, 2011), DKH met all the target goals while exceeding the goals set for infection prevention. HMH failed to meet the pneumonia care goal, but met all other goals. HMH did not exceed any of the goals. WCMH failed to meet the heart failure care goal, but met all other goals. WCMH did not exceed any of the goals.

In considering the data from Hospital Compare (HHS, 2011) and Quality Check (The Joint Commission, 2011), it is clear that this data can be used by consumers to make more informed decisions regarding their health care. Though the methods in this paper might be questionable and simple, consumers may disregard some measures while favoring others, depending on their perception of what measures are important in judging the provision of the care that they might receive. Additionally, the data used for the comparisons, many times, accounted for a small patient population; however, each hospital serves comparable communities with comparable levels of service. This may be a consideration when performing scientific statistical analyses, but that would be beyond the scope of this paper.

The provision of health care must be ethical, just, and equitable. Allowing consumers access to data regarding the performance of hospitals in their area can provide additional insight to patients when choosing their health care provider.

References

Day Kimball Hospital. (2011). Sevices and locations: Day Kimball Hospital. Retrieved from http://www.daykimball.org/services-and-locations/day-kimball-hospital/

Harrington Memorial Hospital. (2009). About us: Harrington at a glance. Retrieved from http://www.harringtonhospital.org/about_us/harrington_at_a_glance

The Joint Commission. (2011). Quality check. Retrieved from http://www.qualitycheck.org/ consumer/searchQCR.aspx

U.S. Department of Health and Human Services. (2011). Hospital compare. Retrieved from http://www.hospitalcompare.hhs.gov/

Windham Community Memorial Hospital. (n.d.). CEO’s message. Retrieved from http://www.windhamhospital.org/wh.nsf/View/CEOsMessage

Criminal Justice, Emergency Management, Health Care, Politics, Public Health, Society

Bioweapons of Mass Destruction: Actual Use or Hoax

Weapons of mass destruction (WMDs) provide an alternative impact when compared to conventional weapons (e.g. artillery, firearms, blades and knives, batons, et al.). WMDs can be chemical, biological, radiological, nuclear, or explosive (CBRNE) in nature attacking the human body in manners not typical of conventional weapons (Cameron, Pate, McCauley, & DeFazio, 2000). WMDs can, therefore, have devastating effects on the preparedness of the health care system (Macintyre et al., 2000; Subbarao, Bond, Johnson, Hsu, & Wasser, 2006).

Considering an attack such as a mass contamination of the money supply, there are two possibilities: actual contamination and hoax contamination. In actual contamination, the epidemiology of illness will correspond with the travel of contaminated bills, reaching long distances in short periods of time (as evidenced by the website http://www.wheresgeorge.com). As the contaminated money travels from one consumer to the next (possibly also infecting adjacent bills, wallets, counter-tops, and register drawers), it will do so undetected until the incubation period lapses and the first wave of infected people begin presenting to health care facilities for treatment (presumably, with a difficult diagnosis – an uncommon pathogen). These people should be geographically dispersed so that identification of the terrorist act is yet to be made. Not until epidemiologists track the vector to the money supply will the threat be discovered. Once this occurs, the populace will be suspicious of money, causing an entirely different catastrophe, but the fear will be real.

On the other hand, if the attack is a hoax, there will be no incubation period or actual illness, yet psychogenic effects will be almost immediate, causing many people to seek medical care at once overburdening the health care system (MacIntyre et al., 2000). Arguably, this type of attack will be short-lived; however, the effects can be disastrous.

Regardless of the type of attack, whether actual or hoax, there will be a large, resource-intensive response from national, state, and local levels of government and the private sector (Walsh et al., 2012). This would place a strain on response resources and other infrastructure, such as health care as previously mentioned. In both instances, though, lives could be lost, also. With the real attack, many people could die from the disease, but if resources are taken away from other sick patients, they are at risk of dying also. This holds true for hoax attacks. As many healthy people flood emergency rooms with mysteriously fleeting symptoms, truly sick patients are not being managed efficiently and are put at serious risk.

Though the example attack might not be feasible for one reason or another, it is interesting to think of the many ways in which we as a nation are vulnerable. This leads to the question of how much we value our freedom vs. how many freedoms are we willing to give up in order to feel safe. I have decided that I value my freedom, the freedom that most foreign terrorists despise, so much that I am not willing to part with it to any extent. So long as we live free and without fear, the terrorists cannot win.

References

Cameron, G., Pate, J., McCauley, D., & DeFazio, L. (2000). 1999 WMD terrorism chronology: Incidents involving sub-national actors and chemical, biological, radiological, and nuclear materials. The Nonproliferation Review, 157-174. Retrieved from https://www.piersystem.com/clients/PIERdemo/ACF1D7.pdf

MacIntyre, A. G., Christopher, G. W., Eitzen, E., Gum, R., Weir, S., DeAtley, C., … Barbera, J. A. (2000). Weapons of mass destruction events with contaminated casualties: Effective planning for health care facilities. Journal of the American Medical Association, 283(2), 242-249. doi:10.1001/jama.283.2.242

Subbarao, I., Bond, W. F., Johnson, C., Hsu, E. B., & Wasser, T. E. (2006). Using innovative simulation modalities for civilian-based, chemical, biological, radiological, nuclear, and explosive training in the acute management of terrorist victims: a pilot study. Prehospital and Disaster Medicine, 21(4), 272-275. Retrieved from http://www.hopkins-cepar.org/downloads/publications/using_sim_modalities.pdf

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.

Academia, Clinical, Emergency Management, Emergency Medical Services, Health Care, Public Health, Society

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.

References

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 http://www.josieking.org/page.cfm?pageID=10

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 http://teacherweb.com/NY/StBarnabas/Quality/JohnsHopkinsErrors.pdf

Zimmerman, R. (2004, May 18). Doctors’ New Tool To Fight Lawsuits: Saying ‘I’m Sorry’. Wall Street Journal, pp. A1. Retrieved from http://www.theoma.org/files/wsj%20-%20medical%20error%20-%2005-18-2004.pdf

Criminal Justice, Emergency Management, Politics, Society, Technology

Planning a Terrorist Attack

Planning a clandestine attack using a weapon of mass destruction (WMD) is not simple. First, in order to promote an attack, the target needs to be viewed to have violated some ideology, policy, or other deeply held belief (“Terrorism, definition and history of,” 2002). Usually, a symbol of the offense will be chosen as either a specific target, such as the case of the World Trade Center, or as a vehicle or vector for the attack, as in the case of the U.S. Postal Service anthrax attacks (“Biological terrorism,” 2002; Marshall, 2002; “Weapons of mass destruction,” 2002). The dollar is an international symbol of capitalism and the might of the United States. In the current climate, especially with the declining U.S. economy, I would expect the money supply, itself, to be a viable vector for disseminating some sort of substance capable of causing terror. A dollar bill has a circulating life of 42 months and changes hands, on average, twice a day, and by impregnating paper money with a chosen substance, a single dollar bill could potentially harm more than 2,500 people during its circulation (U.S. Department of the Treasury, Bureau of Engraving, n.d.).

Almost as important as the vehicle is the impregnating substance. Chemical and radiological substances would be too easy to eventually detect, and the amount dispersed on each dollar bill might not be enough to cause harm. A live biological agent suspended in an aqueous nutrient solution could easily coat a dollar bill without detection and easily transfer to hands, surfaces, and other bills. According to Winfield and Groisman (2003), Salmonella enterica might prove to be a hardy pathogen capable of existing in such a solution for months. S. enterica is responsible for typhoid fever in humans. Escherichia coli, though a highly pathenogenic mycobacterium, does not have the same persistance outside of a living host. Both S. enterica and E. coli have detrimental health effects, especially for those with deficient immune systems.

Delivery and dispersion of the weapon would be the next consideration. This would have to be accomplished using a number of distribution points, geographically distant, that transfer small denomination bills easily both in and out, such as gasoline stations, convenience stores, fast food restaurants, and liquor stores. Using a website designed to track dollar bills (http://www.wheresgeorge.com), a single bill has been tracked in about two and a half years, as follows: Florida, Georgia, Florida, Indiana, Arizona, Oregon, New York, Tennessee, and South Carolina. Another has been documented as travelling from Ohio to Michigan via Kentucky, Tennessee, Florida, Texas, Louisiana, Texas, and Utah in a mere 212 days. This is evidence that general dispersion techniques will work well if initially geographically distributed.

Additionally, as the Salmonella bills are being dispersed, I would encourage a technological attack on various credit card networks. If the hacking results in increased network downtime, the American citizenry would be encouraged to use paper money more often, potentiating the transfer of the Salmonella bills. As a final coup de grace, when the American populace finally begin to realize that the money supply, itself, is tainted, I would encourage conventional attacks on banking institutions to include random bombings, shootings, and threats of the same. This would further drive the message against the U.S. money supply and could crash the economy.

This plan was developed in about twenty minutes. The terrorists of the day have had decades to consider such plans, and I for one am glad that they tend to be grandiose. When the terrorists realize the simplicity required of causing terror in the U.S., we need to be very wary.

References

Biological terrorism. (2002). Encyclopedia of terrorism. Retrieved from http://sage-ereference.com.ezp.waldenulibrary.org/view/terrorism/n76.xml

Marshall, P. (2002, February 22). Policing the borders. CQ Researcher, 12, 145-168. Retrieved from http://library.cqpress.com.ezp.waldenulibrary.org/cqresearcher/

Terrorism, definition and history of. (2002). Encyclopedia of terrorism. Retrieved from http://sage-ereference.com.ezp.waldenulibrary.org/view/terrorism/n415.xml

U.S. Department of the Treasury, Bureau of Engraving. (n.d.). FAQ library. Retrieved from http://www.moneyfactory.gov/faqlibrary.html

Weapons of mass destruction. (2002). Encyclopedia of terrorism. Retrieved from http://sage-ereference.com.ezp.waldenulibrary.org/view/terrorism/n453.xml

Winfield, M. D. & Groisman, E. A. (2003). Role of Nonhost Environments in the Lifestyles of Salmonella and Escherichia coli. Applied Environmental Microbiology, 69(7), 3687-3694. doi:10.1128/AEM.69.7.3687-3694.2003

Emergency Management, Emergency Medical Services

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.

References

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.

Emergency Management, Emergency Medical Services, Politics

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.

References

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 Management, Politics, Society

Hurricane Katrina: Lessons Learned

The primary and causative failure of government, according to the U.S. House report (2006), was that officials did not develop an adequate or accurate situational picture in a timely fashion. This lead to minimal preparation, ineffective evacuation plans, and an slow logistical supply chains for moving needed assets into the area to aid with the response. The second mistake, according to the report, was officials distancing themselves from the failures politically. This sole act (by many in the leadership) served only to protract the response and recovery and confuse the populace. Understandably, however, the politicians certainly wanted to be removed from the situation, as they could have lessened the burden years earlier with use of specific appropriations. Funds designed to mitigate the exposure of the Gulf coast to hurricanes were not spent as intended, if at all.

Looking back on the situation, had each government activated their EOC and staffed it with reputable public safety officials to run the response, the situational picture would have been clearer, especially with the various EOCs communicating together (Walsh et al., 2012). The plan might have coalesced into the use of an area command with resources deployed in task force and strike team convention as needed. Certainly, though, the public message would have been singular, to the point, and helpful to the public (Walsh et al., 2012). This would have lead to an expedited response and coordinated evacuations prior to landfall of Hurricane Katrina, which was said to be “predicted with unprecedented timeliness and accuracy” (U.S. House of Representatives, 2006, ix).

References

U.S. House of Representatives. (2006). A failure of initiative: Final report of the select bipartisan committee to investigate the preparation for and response to Hurricane Katrina. Washington, DC: U.S. Government Printing Office.

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.

Criminal Justice, Emergency Management, Emergency Medical Services, Politics, Public Health

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.

References

U.S. Department of Homeland Security. (2008, January). National response framework. Retrieved from http://www.fema.gov/pdf/emergency/nrf/nrf-core.pdf

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.