The only reason we get away with giving such large doses of epinephrine to these patients is that they are already dead.

- Rogue Medic

Intubation as a Right – No Practice required

Also posted over at Paramedicine 101. Go check out the rest of what is there.

I was responding to a comment at 9-ECHO-1, by 9-ECHO-1, when I realized I was beginning to combine my responses to How things get done… and Do we make a difference?

As if I don’t already regularly get this little message from Blogger.

Your HTML cannot be accepted: Must be at most 4,096 characters

Your hints are wasted on me, Blogger!

9-ECHO-1 was writing about running a code and keeping it organized and low stress. Something about sitting back with his feet on an ottoman, a drink in his hand, receiving a massage, and . . . Well, he did say that he was sitting back with his feet up on an ottoman. And there is nothing wrong with that. An ottoman could easily be added to crash carts. :-)

9-ECHO-1’s description of the role of the person in charge at a code is important. We may not want to put our feet up in front of family, but I don’t believe 9-ECHO-1 would do that at a code where family is present. What is important is for the person in charge to communicate clearly to everyone that, This is not a high stress environment.

Stress is the enemy of organization. We have a lot to organize during codes. We have much more to organize, than we have good research to support including in a code, but that will change.

Either there will be some research that supports the Better Resuscitation Through Better Chemistry approach, or AHA/ILCOR will admit that pouring a bunch of cardiotoxic chemicals into a patient, then shaking – not stirring – the patient, is more appropriate for bartenders than for paramedics, nurses, PAs, NPs, doctors . . . .

Although many of us in EMS might appreciate the bump in pay to what a bartender makes.

I have been to some codes that have led me to believe that there is a role for benzodiazepines in the management of cardiac arrest. Not for the patient, but for the EMS personnel exhibiting signs of Tourette syndrome, who show up to treat the cardiac arrest patient. If not benzodiazepines, then this may be an indication for medical marijuana. There might be some problem with the rate and depth of compressions, but that might be less of a problem than the current model of Dr. Fine, Dr. Howard, and Dr. Fine run a code.

Isn’t this supposed to be about intubation?

OK. Back on track, or as close as I an going to get.

9-ECHO-1 wrote –

Place the King airway. In our system EMT-Bs on the ambulance can do this. Attach the ETCO2 and verify the waveform. Me personally, I will admit, I prefer the ET tube. I know, I know, there is all sorts of evidence out there about paramedics and tubes. And they all point to two things- practice and experience. More on that later.

In the comments, I responded –

I agree with you about the intubation. I think that the biggest part of the problem is that the systems studied do not provide excellent oversight of the quality of intubation and BLS. Otherwise, are we supposed to believe that these problems suddenly appeared during the study? More likely that they were there, just unrecognized.

The word unrecognized does not belong in a sentence describing excellent oversight.

9-ECHO-1’s response included –

I have read all of the studies about intubation and its ‘failings’. What I have noticed is that we NEVER PRACTICE. I used to practice all of the time- get me some spare time and a manikin and I would go at it, even practicing with someone doing chest compressions. But we never do that any more. No damn wonder we can’t hit the right hole, and then don’t recognize when it comes out or we missed completely.

I completely agree about practice. I used to spend so much time with the mannequin, that if my classmates weren’t starting rumors about me, they were missing a good opportunity.

I believe that simulations are a great way to avoid doing real harm to real patients. A lot of practice helps to keep the stress level down and the tunnel vision away.

My first live intubation was an asystolic little old lady. We were running lights and sirens to the hospital, because we didn’t know any better. I was riding with a supervisor for orientation vs. see if the new guy can avoid screwing up. We made a rendez-vous with the ambulance, so that they could give the new guy a chance to demonstrate skills on a real live patient.

We still put too much emphasis on the wrong skills.

While the mannequin is not as realistic as we would like, the practice with the laryngoscope and the tube is invaluable, when it comes to manipulating the airway of a real patient. Very handy experience when bouncing down the road about to perform my first tube.

I think that some of my But we did that when we covered airway classmates may be over-represented in the intubation studies with poor success rates/high wrong hole rates.

If medical directors would take more of an interest in the airway management practices of those they authorize to use lethal airways, I might not feel the need to describe endotracheal tubes as lethal airways.

Yearly (even quarterly) observation of mannequin management is not at all oversight of airway management. This is just documentation of an excuse, so that when a medic does mangle airway management, the medical director has an alibi.

It used to be that some schools/employers required medic students/new medics to manage an OR patient’s airway with a BVM before ever being allowed to touch an endotracheal tube. I do not believe in good old days. That is just selective memory. However, we have abandoned some useful practices.

Now it seems that being authorized to intubate means never having to touch a BVM again – even in some all medic systems.

That isn’t airway management.

Also, less than 8 – intubate, is not a rule, just a handy way of teaching one small idea in the much larger concept of airway management. Critical judgment is much more important than cute little rhymes.

If we think that we should be permitted to intubate, we need to put in the effort to become competent at airway management. Then we need to put in the effort to maintain competence at airway management. And we need to put in the effort to demonstrate excellence at airway management. Intubation is a very small part of airway management.

This is not about any right of the paramedic to intubate. This is about not abusing our patients.

I didn’t even get to comments on Do we make a difference? That will be another post.

The Airway Continuum is essential reading for anyone interested in intubation and airway management.

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Journal Club 3: Episode 53


ResearchBlogging.org
Also posted over at Paramedicine 101 and at Research Blogging. Go check out the rest of the excellent material at both sites.

Of the two podcasts I had the opportunity to be on this week, this one is more to my liking, due to my desire to increase the use of research-based treatments. Having the lead author of one of the studies on the show was another positive. Greg Friese hosts Journal Club 3: Episode 53.

There is a much more thorough discussion of these papers on the podcast.

The papers covered are:

Resuscitation on television: realistic or ridiculous? A quantitative observational analysis of the portrayal of cardiopulmonary resuscitation in television medical drama.
Harris D, Willoughby H.
Resuscitation. 2009 Nov;80(11):1275-9. Epub 2009 Aug 20.
PMID: 19699021 [PubMed – indexed for MEDLINE].
Presented by Rob Theriault.

This study raises a lot of interesting questions about the way that people learn about making end of life decisions, what they anticipate the outcome of resuscitation will be, and even how medical professionals may respond to skills presented in TV medical dramas.[1]

Dismissing TV dramas as trivial ignores the effect that they may have on members of the audience, up to and including doctors.

The Canadian prehospital evidence-based protocols project: knowledge translation in emergency medical services care.
Jensen JL, Petrie DA, Travers AH; PEP Project Team.
Acad Emerg Med. 2009 Jul;16(7):668-73.
PMID: 19691810 [PubMed – indexed for MEDLINE].
Presented by Joe Clark.

This is a study that deserves several posts to cover, so I will not even start here. As with the other studies, this paper is discussed on the podcast.

My impression is that this resource is wonderful. If you know of a relevant paper that they do not cover on the site, send them a link to it. As with all of science, this will always be a work in progress, but that is certainly not a bad thing.

Canadian Prehospital Evidence Based Protocols.

Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial.
Mason S, Knowles E, Colwell B, Dixon S, Wardrope J, Gorringe R, Snooks H, Perrin J, Nicholl J.
BMJ. 2007 Nov 3;335(7626):919. Epub 2007 Oct 4.
PMID: 17916813 [PubMed – indexed for MEDLINE].
Presented by Bill Toon.

In the US, we have studies that show an inability of the medics (at least the medics in US studies) to be able to safely direct patients to alternative destinations, such as an appointment with a general practitioner. Is the basic EMS education difference, between the US and the UK, the reason?

This study does show that specially trained experienced paramedics can identify stable patients and safely direct these patients to more appropriate resources than the Emergency Department (Accident & Emergency in the UK).

This is an education program that appears to focus on critical judgment, rather than protocol adherence. If done the right way, this should be good for patients, and therefore good for EMS and hospitals.

The full text PDFs of the three papers discussed on the podcast are available for free (until the next EMS EduCast Journal Club) at the Journal Club page of the EMS Educast.

Special guests on the show are Joseph F. Clark, PhD of JosephFClark.com and Jan Jensen of the Canadian Prehospital Evidence Based Protocols.

Footnotes:

^ 1 Positioning prior to endotracheal intubation on a television medical drama: perhaps life mimics art.
Brindley PG, Needham C.
Resuscitation. 2009 May;80(5):604. Epub 2009 Mar 18. No abstract available.
PMID: 19297069 [PubMed – indexed for MEDLINE]

Inadequate positioning of the head and neck was especially prevalent prior to intubation attempts, and improving this was seen as a simple but important first step.

As part of ongoing nationwide efforts to ensure basic resuscitation skills5 we explored all potential causes for the inadequate positioning, and this included trainees’ prior experiences. Many trainees reported limited supervision or hands-on training. Remarkably, however, when asked how they had therefore learned, after “trial and error”, a surprising number answered that television medical dramas had been an important influence.

Of the remaining 22, none (0/22) achieved more than one, let alone all three, components of optimal airway positioning. In terms of individual components, the lower cervical-spine was flexed in 0/22, the atlanto-occipital joint extended in 1/22, and the ears level with the sternum in only 3/22 cases.

While few would suggest that medical dramas can be held responsible for physician performance, it has been previously suggested that they can significantly influence beliefs.6, 7

This does show that ignoring the effect of medical dramas has the potential to be harmful to patients.

Harris, D., & Willoughby, H. (2009). Resuscitation on television: Realistic or ridiculous? A quantitative observational analysis of the portrayal of cardiopulmonary resuscitation in television medical drama☆ Resuscitation, 80 (11), 1275-1279 DOI: 10.1016/j.resuscitation.2009.07.008

Jensen, J., Petrie, D., Travers, A., & , . (2009). The Canadian Prehospital Evidence-based Protocols Project: Knowledge Translation in Emergency Medical Services Care Academic Emergency Medicine, 16 (7), 668-673 DOI: 10.1111/j.1553-2712.2009.00440.x

Mason, S., Knowles, E., Colwell, B., Dixon, S., Wardrope, J., Gorringe, R., Snooks, H., Perrin, J., & Nicholl, J. (2007). Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial BMJ, 335 (7626), 919-919 DOI: 10.1136/bmj.39343.649097.55

Brindley, P., & Needham, C. (2009). Positioning prior to endotracheal intubation on a television medical drama: Perhaps life mimics art Resuscitation, 80 (5), 604-604 DOI: 10.1016/j.resuscitation.2009.02.007

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Fight for your Right: EMS Garage Episode 79

I had the opportunity to be on a couple of good podcasts this week.

Fight for your Right: EMS Garage Episode 79

Podcast master Chris Montera had invited Steve Wirth of Page, Wolfberg & Wirth, probably the best known EMS law firm, to explain. The topic was the ways that the case best described by Ambulance Driver was handled, could have been handled, and should have been handled.

A lot of good information covered here, especially for those who feel the need to use social media at work. I had wanted to bring up the way the administration in Pittsburgh is handling discipline, but there was so much else covered in this episode.

An interesting aspect of this segment is that Justin Schorr of Happy Medic and Chronicles of EMS was at work for the show. He is in the unusual situation of having a lot of support from his employer. Many employers may not have addressed any of these social media issues.

Also on the show were several people much more involved in social media than I am:

Kyle David Bates of KyleDavidBates.com and more importantly, of Mrs. Kyle David Bates.

Greg Friese of Everyday EMS Tips, EMSBootCamp.com, EMSEduCast.com, EPS411.com, and PIOSocialMediaTraining.com.

David Konig of DavidKonig.com and PIOSocialMediaTraining.com.

Natalie Quebodeaux of Ms Paramedic and the Gen Med Show.

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Your Services Are No Longer Required

I always suspected that they only kept us around for their amusement.

This one appears to have had a bit too much catnip and did not realize that we should always assume that we are on camera. Their secret is out!

Don’t give me that helpless look. Get it yourself, Cat. I know you can.

Next we teach them intubation.

The laryngoscope handle may be a bit tricky, but they may not do any worse than some of the experienced paramedics and doctors I’ve seen attempt intubation.

h/t Cute OverloadYour Services Are No Longer Required.

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R-E-S-P-E-C-T

Also posted as part of the Handover over at Life Under The Lights. Go check out the rest of what is there.

Over at A Day In The Life Of An Ambulance Driver, there is a post titled R-E-S-P-E-C-T. There is a lot to say about this, but I will try to keep it short.

Ambulance Driver highlights the problem with the EMS entitlement attitude. We have cards that reads EMT (A, or B, or D, or I, or P, or whatever). We feel this entitles us to some kind of respect.

Is respect an entitlement?

Is respect something that is earned?

Is respect something we should worry about?

Next they’ll be taking our blessed intubation away!

Without the ability to administer our Laying on of the PVC, how will any of our patients survive?

Why is it that so many of us crawl out from under our rocks when we feel that our image has been impugned?

Why is it that so many of us seem to put more effort into demanding respect than we do into earning respect?

Why is it that so many of us cannot intubate safely, but can’t stand the thought of having that skill taken away from us?

Where are we when there is an opportunity to practice intubation?

Why aren’t we demanding that we be allowed to practice intubation, even if it is on our own time?

Why aren’t we trying to protect our patients from the deterioration of our skills?

Why do we feel that adding RSI (Rapid Sequence Induction/Intubation) to the ways that we can mismanage an airway will make us more professional?

We have pathetically low standards, but we wish to punish medics who were canceled; medics who were out working non-stop in a disaster; medics who were expected to also do the job of the snow plows; medics who did transport many more patients than usual; all without any help and short staffed.

Why?

Because we are to believe the claims of these armchair critics, that they would have disobeyed dispatch, walked to the patient, and waited in the residence for over a day for some backup to arrive, or would have safely carried Mr. Mitchell out through a quarter of a mile in snow and ice without any help, because that is the respectable thing to do. In the mean time, the other crews are making up for this canceled crew being out of service.

And because some inappropriate language was used on a recorded phone line, because that is not the respectable thing to do.

As if Curtis Mitchell died from inappropriate comments. The autopsy results have not yet been released, but I think it is safe to say that will not be the official cause of death. If there were never any inappropriate comments, would Curtis Mitchell be alive?

Well, Ambulance Driver gets the same kind of grief, just toned down, because nobody seems to be claiming that his use of Ambulance Driver in the title of his blog has killed anyone – yet.

I have known Kelly since before he began writing A Day In The Life Of An Ambulance Driver. We may not always agree, but the only criticism I have of him is that there are not enough people like him in EMS.

There are too many whiners in EMS, not enough leaders.

There are too many people satisfied with our ridiculously low standards in EMS.

There are too many of us demanding respect for having a card that suggests that we met the ridiculously low standards in EMS.

There are too many people worried more about protecting our image, rather than worried about caring for our patients.

There are not enough people demanding higher standards in EMS.

Why are we worried more about phone calls than about our patients?

Why are we worried more about skills than about our patients?

Why are we worried more about tiles of nobility[1] than about our patients?

I am a paramedic.

I am an EMT.

I am an ambulance driver.

I occasionally make inappropriate comments.

I do not ask for respect from anyone.

At some point, I will write something that will anger every one of you.

Maybe I already have.

I’m OK with that.

Footnotes:

^ 1 Title of Nobility Clause
Article I, Section 9, Clause 8
US Constitution
Full Text

No Title of Nobility shall be granted by the United States: And no Person holding any Office of Profit or Trust under them, shall, without the Consent of the Congress, accept of any present, Emolument, Office, or Title, of any kind whatever, from any King, Prince, or foreign State.

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Video From Pittsburgh City Council

Here is a link to a blog with the video of the medics statements to Pittsburgh City Council.

LastChunit

This is must see video.

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Pittsburgh – Punishment, not Planning

So much attention has been placed on the recording of phone calls between the 911 center and paramedics, that nobody seems to have any interest in preventing problems during future disaster conditions.

Did any comment by any paramedic during any phone conversation make any difference in the outcome?

No.

Curtis Mitchell would still be dead, even if they did not have cellular phones.

I was working in that storm. I was wet, cold, and frustrated. I was fortunate that I did not have the same problems reaching any patients. I did not make any inappropriate comments on a recorded phone line.

Nobody can confirm that, because none of my patients had any bad outcome that might lead management to try to blame the outcome on my phone conversation.

The release of the phone recording benefits people who are trying to scapegoat the medics.

The release of the phone recording does nothing to prevent this from happening again.

Have I made inappropriate comments at times, due to working under very difficult circumstances?

No!

Of course not!

Never!

I’m perfect!

How dare those evil medics make other medics look bad!

Now that I have your attention, there is a nice bridge that I would like to sell you. Today there is a special price. If you act now, I will throw in some gorgeous swamp land at no extra cost. . . .

The truth is a bit different.

I have made inappropriate comments.

Few of us have not.

Many of us may claim that we would never say anything like what said was on the recording, but how many of us can prove it. How many of us really have made other inappropriate comments.

People make mistakes.

Discipline is about learning from mistakes.

Discipline is about preventing future mistakes.

If you think discipline is about punishment, you do not understand discipline.

Imagine if someone were to release selected portions of your phone conversations from work.

Even better.

Imagine if we were able to listen to selected portions of the phone conversations between Mayor Luke Ravenstahl and Public Safety Director Michael Huss from that weekend.

Maybe that would not be comfortable to listen to, either.

When talking on a recorded line, we should always talk with the expectation that the recording will be played back in a courtroom, with the most devious lawyer possible spinning the story to make us look worse than Charles Manson on an especially evil day.

We need to avoid giving in to that emotional appeal to punish somebody because something does not sound good.

Why was EMS frustrated?

No plows.

Fewer crews.

Several times the number of patients.

The worst snow storm in over a century.

Oh, what about 1993?

1993? When there were many more people to drive plows?

1993? When there were many more 4 wheel drive plows?

1993? When the snow was heavy, but not turning to ice?

1993? When plows were actually sent to assist EMS?

1993?[1]

I can’t imagine why anyone would be frustrated under these circumstances.

The medical director investigated and did not blame the medics.

The state investigated and did not blame the medics.

Sharon Edge (Curtis Mitchell’s widow) does not blame the medics.

Maybe they know something that all of the people blaming the medics do not know.

Snow plows are for wimps!

We don’t need no stinkin’ snow plows!

Too Old To Work, Too Young To Retire also has a bit to say about this decision to fire someone for a phone conversation. Human Sacrifice.

Maybe you think that TOTWTYTR and I are a bunch of touchy feely, it’s all about feeling good about what you did – not about the result kind of people. We aren’t any good at coddling incompetents. We are usually the ones criticizing the incompetence.

Late addition – 3/24/10 17:56 David Konig writes about this in The Assassination Of Pittsburgh EMS By The Coward Michael Huss. He makes some excellent points, such as –

So if these standards are higher, why are they secret? I would think that is something the Mayor would be proud of… unless he thinks that he can just conjure up higher standards after the event and make them retroactive.

I have also written about this here –

City may discipline EMS workers – Public Safety Director Michael Huss – 02/18/10

Where Was Public Safety Director Michael Huss during the Death of Curtis Mitchell? – 02/20/10

Public Safety Director Michael Huss and Others Continue to Blame the Medics for the Snow – 02/22/10

The Need for Evidence Before Assessing Guilt – 02/24/10

Anonymous Comments on the Death of Curtis Mitchell – 03/02/10

Podcasting, Critical Judgment, and the Death of Curtis Mitchell Part I – 03/22/10

Podcasting, Critical Judgment, and the Death of Curtis Mitchell Part II – 03/22/10

Podcasting, Critical Judgment, and the Death of Curtis Mitchell Part III – 03/22/10

What kind of punishment do you get for NOT disobeying dispatch? – 03/23/10

The Scapegoats Will Be Punished – 03/23/10

Pittsburgh – Punishment, not Planning – 03/24/10

Josie Dimon was the Scapegoat of Public Safety Director Michael Huss in the Death of Curtis Mitchell – 02/16/11

Michael Huss – Pittsburgh EMS Only Needs Someone Good With a Shovel – 02/16/11

Links updated 02/16/11.

Footnotes:

[1] Cascade of Failures Paralyzed Pittsburgh During Snowstorm
The Pittsburgh Tribune-Review
by Carl Prine
Posted: Sunday, February 21, 2010
Updated: February 22nd, 2010 04:57 PM EDT
Article

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The Scapegoats Will Be Punished

Apparently, my last post was just about the time the news was published.

Acting Crew Chief Josie Dimon, a union employee was fired after she was heard on transmissions between paramedics making disparaging, profanity laced comments such as “this ain’t no [expletive] taxi service.”[1]

Is that inappropriate? Absolutely.

Should someone be fired for speaking that way with dispatch? There are going to be many different approaches to that question.

How has the city handled any previous cases of use of obscenity on the radio?

How has the city handled any previous cases of bad attitude expressed on the radio?

If there have been any cases of similar behavior, was the person(s) fired?

Is the use of a public forum (using a press conference to announce the firing) special to this case?

Did the bad attitude and use of obscenity contribute to the death of Curtis Mitchell in any way?

If she is such a bad employee that she needs to be fired, why did I hear that she was working on the street and had to be called back to base just before the press conference?

Why was the discipline kept a secret, even from those being disciplined?

What is the top secret higher standard that Mayor Luke Ravenstahl and Public Safety Director Michael Huss are enforcing?

It certainly is not a higher standard of disaster preparedness, because they did not fire themselves.

Or maybe they did, but it is also top secret.

Were EMS crews told that they would not receive any assistance?

Were EMS crews told that they would have to dig themselves through the snow to their patients?

Since the snow was coming down fast and being blown back where people shoveled, that would mean digging their way to the patient and then back to the ambulance with the patient.

How long do we want to have a patient outside, while having medics do the job that should be done by equipment?

If a patient is dropped, is that the fault of the crew carrying a patient on snow and ice covered roads?

Who came up with this plan?

Not the medics.

What about 4 wheel drive vehicles? Supervisors could respond with 4 wheel drive vehicles to safely transport patients, rather than dragging/pushing/dropping the patient through the snow and ice.

That would be a good plan.

That was not the plan in Pittsburgh.

After the storm, the decision was made to send the fire department on calls to help shovel snow and carry patients.

Apparently, Mayor Luke Ravenstahl and Public Safety Director Michael Huss think that Pittsburgh has a bunch of fire fighters sitting around with nothing to do.

Let’s send fire fighters to do the work that should be done by snow plows and/or 4 wheel drive vehicles.

If there is a fire, maybe Mayor Luke Ravenstahl and Public Safety Director Michael Huss will decide that the fire department should just walk to the fire and throw snow on the fire.

Why waste money on the appropriate equipment?

Nobody will mind waiting for fire fighters to walk to the fire. Would they?

We don’t need no stinkin’ snow plows!

An excellent plan!

What else is part of their plan?

Crew Chief Kim Long, also a union employee, and two non-union supervisors, District Chief Norman Aubil and District Chief Ron Curry were suspended for three days.[1]

There is no mention of anything they did that justifies these suspensions.

2 independent investigations cleared the medics. Even the wife of Curtis Mitchell does not blame the medics.

Scapegoats.

What about Mayor Luke Ravenstahl and Public Safety Director Michael Huss?

They may not have created all of this mess, but they couldn’t seem to be able to figure out how to call the National guard until days after the death of Curtis Mitchell.

We all had ample time to prepare.

- Cecil County Director of Emergency Services Richard Brooks.[2]

I agree. We did have time to prepare.

Why wasn’t Pittsburgh prepared?

Just get out and walk is not an acceptable disaster plan.

Don’t worry. If anything bad happens, we’ll just blame the people who did not work hard enough to make up for our lack of planning.

I have also written about this here –

City may discipline EMS workers – Public Safety Director Michael Huss – 02/18/10

Where Was Public Safety Director Michael Huss during the Death of Curtis Mitchell? – 02/20/10

Public Safety Director Michael Huss and Others Continue to Blame the Medics for the Snow – 02/22/10

The Need for Evidence Before Assessing Guilt – 02/24/10

Anonymous Comments on the Death of Curtis Mitchell – 03/02/10

Podcasting, Critical Judgment, and the Death of Curtis Mitchell Part I – 03/22/10

Podcasting, Critical Judgment, and the Death of Curtis Mitchell Part II – 03/22/10

Podcasting, Critical Judgment, and the Death of Curtis Mitchell Part III – 03/22/10

What kind of punishment do you get for NOT disobeying dispatch? – 03/23/10

The Scapegoats Will Be Punished – 03/23/10

Pittsburgh – Punishment, not Planning – 03/24/10

Josie Dimon was the Scapegoat of Public Safety Director Michael Huss in the Death of Curtis Mitchell – 02/16/11

Michael Huss – Pittsburgh EMS Only Needs Someone Good With a Shovel – 02/16/11

Links updated 02/16/11.

Footnotes:

[1] 4 Receive Disciplinary Action In Hazelwood Death
Mar 23, 2010 2:56 pm US/Eastern
KDKA.com Pittsburgh
Article

[2] From Mitigation Journal

EMS Under the Bus in Pittsburgh – 02/28/10

And in the Mitigation Journal podcast –

MJ156: Winter Storms: Interview with Mr. Richard Brooks, Director Cecil County MD, Emergency Services – 02/23/10

From the MedicCast

Snow Storm 2010 Response and Episode 208 of the MedicCast – 02/28/10

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