Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Irresponsibility and Intubation – The EMS Standard Of Care


There is a petition to save EMS intubation, but it claims to be a petition to save patients. The petition is not to save patients.

Image source
Details here and here.

The petition states that its intent is to protect patients, but it does not provide any evidence. It only makes the same claims that every other quack makes to promote his snake oil.

We are worse than homeopaths, because homeopaths do not actively harm patients by depriving patients of oxygen, as we do when we intubate.

We are the quack, witch doctor, homeopath, horseshit peddlers Dara O’Briain is describing.


Today we are possibly facing the removal of the most effective airway intervention at our disposal as paramedics, endotracheal intubation.[1]


Most effective?

There is some evidence that intubation can be – in limited situations, by highly trained, competent people – beneficial. There is also plenty of evidence that intubation is harmful. It is easy to kill someone by taking away the patient’s airway.

Most effective?


This petition does not mention evidence, so it has no credibility when it comes to claims of whether intubation is effective. This petition expects us to believe in a faerie tale of magical improvement with intubation. This petition wants us to clap for Tinkerbell, because If we believe hard enough, it just might come true. Grow up.

Please sign this petition so that these patients have a chance to live[1]


Prove that requiring higher standards for intubation would take away a patient’s chance to live.

Prove that intubation improves outcomes.

This is a petition to keep standards low for paramedics.

This petition does not mention competence, or even what is involved in competence, because this petition is opposition to competence.

This is the Protect Incompetent Paramedics from Responsibility Petition.

Responsibility is for professionals. In EMS, we reject responsibility.

We are more concerned with whether our shoes are shiny, than whether we are harming, or helping, our patients. The reason EMS exists is to improve outcomes for patients.

We don’t deliver competent care, but only the appearance of competence. We are medical theater, putting on a fancy show. The TSA (Transportation Security Administration) is the same – all appearance and no substance.

Most effective? Maybe intubation is the most effective theater.

The outcomes of our patients are affected, but we refuse to learn if we are helping, harming, or doing equal amounts of harm and help.

We actually oppose learning. We are willfully ignorant – and proud of our defiant stand for ignorance.

How much hypoxia do we cause in our attempts to place the so called gold standard? The actual gold standard is helping the patient to protect his own airway, but who cares what’s best for the patient? Not those who sign the petition.

How much vomiting, and aspiration, do we cause?

How much airway swelling do we cause?

How many airway infections do we cause?

How much harm do we cause?

We don’t know. We don’t care. We oppose attempts to find out.

We are EMS and we believe that our actions should be protected from examination, because we are beautiful and unique snowflakes who demand our participation trophies without doing real work required to be competent.

Go ahead, snowflakes, demonstrate your incompetence by signing the petition, because this protect intubation petition is really a protect incompetence petition.

If we want to continue to intubate, and we want to improve outcomes for our patients, we need to demonstrate that intubation by EMS provides significant benefit and which patients are most likely to benefit. We can’t do that because we don’t care enough about our patients.

Brian Behn has a different reason for not signing the petition for low standards – Why I am Not Signing The Petition About Intubation.

Dave Konig also comments on the petition for low standards – Is ET Intubation Joining Backboards In Protocol?


[1] Allow paramedics to continue to save lives with endotracheal intubation!
Anthony Gantenbein United States
Petition site


Is EMS a Trade or a Profession?


In the current issue of JEMS, there is an article by Dr. Bryan Bledsoe that does an excellent job of identifying many of the problems with low standards in EMS – at least if the quality of care is important.

Also, if you will note, the welding curriculum was revised in 2011.

The paramedic curriculum was last revised in 2009. Which trades would you say have had the most changes in the last eight to 10 years? Certainly changes in EMS have occurred much more frequently and are much more significant than those that have occurred in welding.[1]

trade vs profession 1

In some places, EMS has been more aggressive in changing treatment guidelines/protocols to improve the care delivered to patients. In other places, change has been resisted.

Backboards are rarely used in the places that have admitted that we do not have any valid evidence that backboards improve outcomes, while we do have good evidence that backboards cause harm. Even more important is the evidence that manipulating the patient’s spine in order to stabilize the spine is wishful thinking that encourages us to do exactly what we claim to be trying to prevent.

High dose NTG (NiTroGlycerin – GTN GlycerylTriNitrate in Commonwealth countries) is becoming much more widely used for acute CHF/ADHF (Acute Decompensated Heart Failure), because high dose NTG dramatically improves survival and decreases the perceived need for aggressive airway manipulation.

Likewise, furosemide is being eliminated from the CHF/ADHF guidelines/protocols, because furosemide does not do what it is supposed to do and furosemide causes harm that it is not supposed to cause.

Ketamine is becoming the drug for many indications. Ketamine may be the best sedative, best analgesic, best agitated delirium treatment available to EMS.

How do we know that we have been harming patients?

Enough people stopped listening to the old timers, the QA/QI/CYA people who don’t understand quality, the brand new if it were dangerous, it wouldn’t be in the protocol people, and other opponents of quality care.

People are paying more attention to the evience, rather than making excuses for the absence of evidence.

What is important is whether or not the graduating paramedic is competent and ready to assume the important role of prehospital care.[1]


Many states use the NREMT (National Registry of EMTs) test to determine if a paramedic is ready to become a new hire paramedic with no experience, some day to be able to work without a supervisor present. Some states continue to require this babe in the woods test of outdated material as their goal for even experienced paramedics.

The NREMT is holding EMS back.

It is time for the national standard curriculum to go away. We must meet and decide what the core competencies of a paramedic will be. We must validate these core competencies through scientific study. Then, we should leave it up to the educators to determine how best to educate their students in these core competencies.[1]


The paramedic curriculum, revered by the NREMT, harms patients.

Why are we protecting a curriculum that harms patients?


[1] Is EMS a Trade or a Profession?
Thu, Jul 28, 2016
ByBryan Bledsoe, DO, FACEP, FAAEM, EMT-P
JEMS Editorial Board member
Journal of EMS (JEMS)


Remote CPR Skills Testing Online – A Crazy Idea?


On the MedicCast, Jamie Davis interviews Roy Shaw of SUMO about a method of remote CPR certification for health care providers.

The Single Use Manikin Option, or SUMO™, is an AHA-compliant way of getting certified in CPR completely online.[1]



It looks too simple, but how complicated should we make it?

One of the problems with EMS is that we do not maintain skills that we do not use frequently. We know that we lose our skills very quickly, but we only retrain every couple of years (or every year) for the skills considered most important. If we care about our patients’ outcomes, we need to do better.

Not only have varying rates of skill acquisition been documented after traditional American Heart Association (AHA) training classes, but also universally poor skill performance of varying providers 3 to 6 months after CPR training has been established.11,–,15 [2]


Supervised on-line mannequin practice may be the most practical way for us to increase the rate of providing hands-on practice. As cameras become cheaper and smaller, as cell phones become much more interactive, we may have a way to do the same for intubation. Is there any good reason for practicing intubation less than once a month?

We need to improve our intubation, but everyone seems to think that the problem is with other medics and they do not need any practice. When the research is done, the problems continue. We like to intubate. We assume we are good at it. We hate to practice. we really like to make excuses. Our patients are the ones who are harmed. Other than bad assessment, bad intubation is probably the most deadly skill we have.

Training sessions occurred at entry into the study (time 0: initial skill acquisition) and then 1, 3, and 6 months after study entry.[2]


Each training session was less than five minutes long (one minute of testing, then two minutes of training), so the interference with work would be minimal, while the benefit would be significant.

In this study, lower rates of retention were observed in the training group that did not use a live instructor (automated defibrillator feedback only) compared with the group that used an instructor without automated feedback (instructor-only training).[2]


They suggest that the participants relied on the feedback from the automated devices and may not have learned to assess their performance themselves. During testing, the lack of machine feedback may have put them at a disadvantage. If machine feedback can be provided at the time of initiating compressions, The machine feedback could help. currently, that does not seem likely, so the use of only machine feedback is not as good an option as feedback from an instructor or from an instructor and a machine.

Although the automated feedback provided was targeted to CPR psychomotor skill errors, these systems do not provide constructive positive feedback. Instructors have an advantage: they were able to comment not only on skills done incorrectly, but also praise good performance.[2]


How well would this work in EMS?

We could make this something that is done once a week, or even at the beginning of each shift, on a different skill each time. Intubation/Airway management is the weak spot of EMS, so we could use this to improve.

If are only retraining on intubation/airway management once a year, or once every other year, we obviously are not taking patient care seriously and are trusting our luck, rather than any skill.

Go listen to the podcast on the Single Use Manikin Option (SUMO™) and consider if that would be a better way of recertifying. Maybe it is one way of implementing brief low-dose, high-frequency booster training in addition to recertification.

Also check out the site –



[1] SUMO Remote CPR Skills Testing Online and Episode 392
By podmedic
June 30, 2014
Podcast/videocast page

[2] Low-dose, high-frequency CPR training improves skill retention of in-hospital pediatric providers.
Sutton RM, Niles D, Meaney PA, Aplenc R, French B, Abella BS, Lengetti EL, Berg RA, Helfaer MA, Nadkarni V.
Pediatrics. 2011 Jul;128(1):e145-51. doi: 10.1542/peds.2010-2105. Epub 2011 Jun 6.
PMID: 21646262 [PubMed – indexed for MEDLINE]

Free Full Text from Pediatrics.

Sutton RM, Niles D, Meaney PA, Aplenc R, French B, Abella BS, Lengetti EL, Berg RA, Helfaer MA, Nadkarni V. (2011). Low-Dose, High-Frequency CPR Training Improves Skill Retention of In-Hospital Pediatric Providers PEDIATRICS, 128 (1) DOI: 10.1542/peds.2010-2105d


FREE Webinar from Annals of Emergency Medicine, the AHA, Dr. Bentley Bobrow, Dr. Christopher Crowe, Dr. Ashish Kumar Aggarwal, and Mark Venuti (paramedic)


Do you have questions about the best way to perform CPR?

If this FREE webinar does not answer them, there will be time to ask questions at the end.

Tuesday, July 8th 2014, 1pm EST (17:00 Universal Time).

Register for FREE at this link.


Dr. Bobrow is one of the people who has been focusing on improving the quality of chest compressions and minimizing interruptions. Two things that we know about CPR are that improving the quality of compressions and minimizing pauses in compressions make a big difference in neurologically intact survival.

These two improvements may be responsible for most of the improvement in survival since the 2005 ACLS guidelines.

That is the difference between the old focus on ALS (Advanced Life Support) because everybody knows the paramedic/nurse/doctor makes all of the difference and the new focus on compressions and keep the paramedics/nurses/doctors from doing things that interfere with compressions.

We are still waiting for some evidence that resuscitation rates would not increase even more if we just kept the paramedics/nurses/doctors away from the patient until after ROSC (Return Of Spontaneous Compressions).

You can read the guidelines, and the protocols, and the research at any time, but there are not many times when you are able to ask the experts responsible for creating all of them.

Register for FREE at this link.

Tuesday, July 8th 2014, 1pm EST (17:00 Universal Time).

Is a 48 Hour Paramedic Class Possible?


Maybe the Is this going to be on the test? people are in charge.

Is this a case of bad reporting, is Brownsville, TX trying to find a way to force people out of the fire department, is Brownsville, TX trying to suggest that a 48 hour paramedic refresher course is an acceptable initial paramedic course?

Well over 20 years ago, my paramedic class was around a thousand hours long. A few years earlier, my EMT class was over a hundred fifty hours long.

Oakerson claims he is being retaliated against because of an expert opinion he offered that stated firefighters needed more than a two-week refresher course to take and pass the National Registry Exam to become paramedics.[1]


If someone does not know the difference between a refresher course, which assumes the successful completion of initial paramedic education and experience as a paramedic, and an initial course, should we trust them to make any important decisions?

BFFA president Carlos Elizondo said the union sued Brownsville over allegations that Fire Chief Lenny Perez was forcing 13 firefighters to take a 48-hour refresher course over two weeks before taking the National Registry Exam to become paramedics, which is a condition of employment set out in the collective bargaining agreement.

That lawsuit was settled and dismissed March 13.[1]


If you know nothing about EMS, a 48 hour course might sound reasonable to become a paramedic, but this is not a feel good movie, or The Secret,[2] or something that Deepak Chopra is selling as quantum[3] education.

These charlatans take advantage of misunderstanding.

Maybe we need to develop more understanding of what medicine/EMS is, if only to protect the public from those who would harm them.


[1] Lawsuit alleges retaliation – EMS service takes action against city
Monday, April 21, 2014 10:21 pm.
The Brownsville Herald
Mark Reagan

[2] The Secret is wishful thinking nonsense that claims positive thinking causes positive results and the cause of our misfortunes are negative thoughts.

In other words, children born with birth defects, or cancer, are the victims of their own negative thoughts, but they could be cured by positive thinking.

This works in movies – actually started out as a movie and was later adapted to a book. Unfortunately, many of us think this way. We ignore the bad things that happen and claim that the good things that happen are proof. This is self-deception.

[3] Deepak Chopra is just as ridiculous, only he throws in the word quantum to explain everything. People do not understand quantum, so they will be afraid to challenge him. I do not understand quantum, but I do recognize a scam and this is as much of a scam as when electricity was new and the frauds described their scams as electric. The words change, but the dishonesty remains.


Belly flops with cliches, proves he’s a Satirist (You have a dirty mind if you’re thinking what I think you’re thinking this means)


What happens when EMS becomes so distorted that it is embarrassing?

Things get silly.

Image credit.

By silly, I mean the satire starts off simply, but then becomes a multi-layered satire that deserves its own Wikipedia page. There is no page, yet, or is there?

Kelly Grayson started us off with an article about EMS cliches.

From the blank stares I got from all assembled, I realized that none of them had ever seen Bull Durham. So while I educated them in the Tao of Crash Davis, I started thinking about the clichés we spout in EMS. Every cliché has at its root a central truth; that’s how they get to be clichés in the first place.

But nothing is so good as a well-placed cliché as a substitute for real wisdom and knowledge. Just insert one of these babies into a social media comment thread and watch the “Likes” pile up!

. . .

If you learn to use these simple EMS clichés, I guarantee that you will develop a reputation as a paramedic sage in no time. Especially to people who don’t know better.[1]


You’re going to have to read the full article yourself. Polonius would have been skewered several acts earlier if Kelly had been there, but this gets better.

Then Happy Medic turns up the satire by responding to Kelly.


8. “We cheat death.” We do, daily! I have a T-shirt with the Grim Reaper being slapped in the face by a bad ass medic with sunglasses and everything. You are so narrow minded you can’t see how we bring the dead back everyday. Epi works Kelly![2]


Go read the rest, too.

Ridicule is the only weapon which can be used against unintelligible propositions. Ideas must be distinct before reason can act upon them; – Thomas Jefferson.

Finally, Tor eckman takes it to Eleventy!!11!!! in the comments.

I also teach them to think and look for clues on scene, like just last week I got to see the lights come on in this “newb” Paramedic when he wasn’t going to spinal a patient in a MVC until I had him walk down the bank and look at the car, after seeing the mechanism he came back up, told the patient that he was lucky he wasnt paralyzed for walking up the bank. We did a standing take-down right then and there. By the time we got to the hospital the pt had pretty bad back pain, can you imagine if we hadn’t put him on the backboard? lawsuit. So go ahead and make fun of the noobs, I’ll take them and teach them.[3]


I think that someone should Call the Cops for all of this abuse of the witless, because the giggles just keep on coming.

Maybe this is an example of Poe’s law (a legitimate comment from some person who is so blind to their bias that they do not notice the self-parody)?[4],[5]

Maybe, but Tor eckman[6] is a character from Seinfeld. Tor eckman is a ridiculous alternative medicine practitioner, much like our ridiculous EMS providers who do not understand what it means for a treatment to improve outcomes.

Go spend some time reading the comments on social sites and you will see that this might not be satire, but somebody should take credit for it if it is satire – and somebody should be ridiculed for it if it is not satire.


[1] The stupid EMS cliche usage guide – Using phrases like ‘We cheat death’ is so much easier than actually thinking
September 30, 2013
The Ambulance Driver’s Perspective
by Kelly Grayson

[2] Kelly Grayson belly flops with cliches, proves he’s a Noob
Happy Medic
October 3, 2013

[3] Tor eckman’s comment
Kelly Grayson belly flops with cliches, proves he’s a Noob
Happy Medic
October 3, 2013

[4] Poe’s law

Without a blatant display of humor, it is impossible to create a parody of extremism or fundamentalism that someone won’t mistake for the real thing.


[5] Poe’s law

The site’s description of Poe’s law appears to qualify as a parody of extremism or fundamentalism that someone won’t mistake for the real thing. Or is it the real thing that someone will mistake for parody?

Will Andrew Schlafly wait until his mother is dead before he admits that he was just trying to please his mother, just not as violently as Norman Bates? Or is he the real thing that someone will mistake for parody?

[6] The Heart Attack


Bad Patient Care – Literalists


There are many ways that we harm patients.

One way is by claiming that we need to literally interpret some rule, such as a protocol.

Once we start to try to do this, we come across contradictions.

What is most important in patient care?

Doing what is best for the patient?

What is most important in literal interpretation of anything?

Protecting the literal interpretation.

But it is literally what is written, it is not open to interpretation.

All writing is open to interpretation. We can try to simplify it as much as possible. We can try to make it as clear as possible. Someone will read the writing as meaning something else. Some of those people will have valid points about what the writing means.

For EMS protocols, are all penetrating injury patients the same?

Of course not, so we try to be specific.

Are all penetrating injuries to the neck the same?

Of course not. When I shave, I occasionally penetrate the skin of my neck with the razor, thus lightly slashing my neck.

Should that be treated the same as the slashed neck of someone who is slashed with a knife in an attempt to kill the person?

Of course not.

You may claim that I am being ridiculous.

That is the point. Literal interpretation is ridiculous.

That is why protocols should be written as guidelines that are flexible enough to deal with the real world.

Assessment is the way we determine the difference between a penetrating injury to the neck that needs a trauma center and the minor injury that does not.

Competent assessment does not work with attempts at literal interpretation.

Literal interpretation is an excuse to lower standards so that the least intelligent people can participate.

We need to raise our standards.

If raising our standards mean that some people cannot play with the lives of others, that is a real shame. 😳

How little do we care about our patients that we are more worried about offending dangerous instructors and dangerous medics, rather than worried about protecting patients from the results of dangerous instructors and protecting patients from dangerous medics?


One Laceration, Two Helicopters, Third Part


There is also a comment from steve mauch on Two Children Abducted by EMS Helicopter for One Laceration that deserves comment.

Rouge, I see what you’re getting at, but the problem is not so much with the medic, its what/how he was taught. If in his area they are taught if you see skull you fly, then he did everything right.



That is what I am criticizing.

We are supposed to be doing what is best for the patient.

We are not supposed to be blindly following protocol, nor blindly following the local culture of fly everyone and let the trauma center discharge them right away.

We need to hold the medical directors and the EMS agencies accountable for this ridiculous approach to patient care.

Where is your outcry against the flight crew that made the decision to fly the second child?? Why not crucify the flight nurse too?!


It was not my intent to crucify the medic.

It is my intent to crucify the system.

I just need some people with hammers and nails and we can nail the system to a Star of Life. 😉

OK. I will settle for metaphorical crucifixion, but we didn’t have to settle for metaphor in the good old days.

I agree with rick in the fact that we should not be ridiculing each other, we get enough of that.


Sometimes ridicule is an excellent way to expose a problem.

Again, I was not focused on the medic, but on the actions that are commonplace in EMS.

Look at that mechanism!

We can’t be out of service for an hour! What if a call comes in and our dangerous neighboring service has to cover for us? Many of the people in the neighboring service work for both EMS services, because that is the way EMS works. So how dangerous is the neighboring service, if they have the same employees?

This encourages us to take a helicopter out of service for real emergencies, so that we can fly someone for vehicular damage, yet vehicles are designed to deform to protect the occupants of the vehicle – and that kind of design works very well.

My response to the doctors in the trauma center who have questioned me about why I did not fly a patient, why I did not call for a trauma alert, and/or why we took our time driving with traffic, rather than using lights and sirens is this –

Assess the patient and tell me what you find that is unstable, then we will talk.

I also am familiar with the research. There is no valid research that supports flying patients within a 45 minute drive of a trauma center.

There is no valid research supporting the idea that we are not using HEMS enough.

The helicopters are often in the wrong place. Many are close enough to the trauma centers that EMS should be driving patients, but that is not where a helicopter would make a difference in outcomes. Helicopters make a difference in outcomes for unstable patients who are well over an hour drive time from the trauma centers.

We are encouraging the helicopters to flock near the trauma centers, so that they can service the medical directors who write mechanism-only flight protocols that endanger patients.

Maryland changed their protocols so that medical command permission is required for a mechanism-only flight. Helicopter transports were cut by over half. Where are the dead bodies that Dr. Thomas Scalea predicted would be the result of this cut in flights?

But I agree with you that issues DO need to be addressed, but we need to look at the initial educators. As a fairly recent paramedic graduate, I can tell you that medics are being taught to be cookbook medics, we are not taught to think.


I agree.

But, each paramedic program is different.

We need to encourage those medic programs that do a great job. There are many out there.

We need to discourage those medic programs that teach people to be protocol technicians, IV technicians, monitor technicians, alarm technicians – Oh, look! The asystole alarm is going off. I need to start CPR. There are many out there.


How much have we changed from the days of calling for orders and being told to give one amp of the yellow box?

If we do not understand pharmacology, we do not understand the most important part of pharmacology – when not to give a drug.

The same is true for procedures. We need to understand when not to use a procedure. Defibrillation, as in the video, or cricothyrotomy, or intubation, or synchronized cardioversion, . . . .

When needle decompression is used, the use almost always appears to be inappropriate.

Needle decompression does save lives when used appropriately.

Click on the image to make it larger.[1]

The chart is for all patients stuck in the chest at least once with a needle in an attempt to decompress a suspected tension pneumothorax.

Many patients never had any kind of pneumothorax.

Was needle decompression used appropriately on any of these patients?

Maybe. Maybe not. We do not know.

It seems that many in EMS need a lot of work in learning when not to attempt needle decompression.

One of the biggest things I recall is SVT. I was “taught” greater than 150=SVT. I went on thinking this was fact. I was not taught svt is a class of rhythms, not a rhythm by itself.


SVT – SupraVentricular Tachycardia.

The sinus node is supraventricular.

Sinus rhythms do not benefit from adenosine or synchronized cardioversion.

Do not blame the medic for not knowing what someone else never took the time to pass along.


Yes and No.

We need to take responsibility for our own education.

Education does not stop once we put on a patch or get authorized to work on our own.

I was supposed to be writing about the presentations at EMS Expo this week, but it is looking as if that will be next week. If we attend EMS conferences, we can learn about the things our instructors misinformed us about.

Backboards probably do more harm than good, especially for the patients with unstable spinal injuries.

Helicopters do save lives, but probably only for unstable trauma patients over an hour from the trauma center.

How to interpret 12 lead (and 15 lead and 18 lead, . . .) ECGs and how to identify unusual rhythms.

Now I am off to once again demonstrate that a heart rate faster than my calculated maximum heart rate is possible and can still be sinus tachycardia. When I wake up, my heart rate will be a respiratory arrhythmia sinus bradycardia. All of these are arrhythmias/dysrhythmias, but they are not bad rhythms and they are not the absence of rhythm.[2]

These arrhythmias/dysrhythmias are better than normal sinus rhythm.

Arrhythmias/dysrhythmias are treatable, but most do not benefit from treatment.

Should anyone ever use the term normal sinus rhythm?

What do we base normal on?

Does that mean that the patient’s heart is healthy?

How much beat-to-beat irregularity is permitted while still calling the rhythm normal?

What is the difference between normal and healthy?

If a patient is having a normal episode of angina, is that a good thing?

If a patient is having a normal seizure, is that a good thing?

If a patient is having a normal case of hypoglycemia, is that a good thing?

Based on what?

We often use terms we do not think about. Does that mean that it is not normal for us to think?

Is normal good?

In all of that I forgot to mention, I agree that they should not have been flown, ESPECIALLY since mom was against it, but I wasn’t there and it wasn’t my call. I do think way too many people are flow, and even more people are backboarded that don’t require it. We need to improve critical thinking and assessments BEFORE applying devices and treatments, but that’s a whole new blog!


Again, this is about highlighting the problem, not the person.

We have a big problem. Making a scapegoat out of one individual does not change the problem.


[1] Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study.
Blaivas M.
J Ultrasound Med. 2010 Sep;29(9):1285-9.
PMID: 20733183 [PubMed – in process]

Free Full Text from J Ultrasound Med.

When Should EMS Use Needle Decompression
Rogue Medic
Thu, 10 Nov 2011

Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – Full paper
Rogue Medic
Mon, 14 Feb 2011

Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – abstract
Rogue Medic
Tue, 07 Sep 2010

[2] dys-
The Free Dictionary

       1. Abnormal: dysplasia.
               a. Impaired: dysgraphia.
               b. Difficult: dysphonia.
       3. Bad: dyslogistic.
[Latin dys-, bad, from Greek dus-; see dus- in Indo-European roots.]
The American Heritage® Dictionary of the English Language, Fourth Edition copyright ©2000 by Houghton Mifflin Company. Updated in 2009. Published by Houghton Mifflin Company. All rights reserved.