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

- Rogue Medic

A Conversation on Mechanism of Injury

I was talking with one of the long time, weekend, night shift nurses. The people I count on to do what is right for the patient, because the administrators are not around.

Well, I mentioned in passing – I thought it was going to be just in passing – about the recent comment kerfuffle about MOI (Mechanism Of Injury criteria for trauma triage, or just mechanism). This is the assessment skill substitute for assessment that people use as a justification for flying uninjured patients in helicopters.

As if that is safe.

All of a sudden, the nurse started a little tirade about a medic who brought in a patient to this non-trauma center ED (Emergency Department) because he did not bother to report on the MOI when calling for medical command destination decision.

I do not remember what the mechanism was, but it was something vehicular and must have sounded bad, because that’s what MOI means –

The 911 call sounds bad!


That dent looks like it is going to cost a lot to repair!.

That has nothing to do with the patient, except that the mechanism suggests things to be more careful in assessing for.

This is all that mechanism means.

You might want to pay extra attention to these things suggested by mechanism.

Mechanism is not assessment.

Mechanism is the equivalent of stereotype, or prejudice, or bias, or racism.

Mechanism is not about understanding.

Mechanism is a shortcut that encourages ignorance.

Mechanism is just a superficial substitute for a patient assessment.

Mechanism is for those who cannot assess real patients.

Anyway, being the blunt person that I am, I interrupted the nurse’s rant, because my shift is only 12 hours long and her rant was looking like a filibuster. I didn’t even have to ask the obvious question about what a simple assessment showed, because the nurse mentioned over a dozen rib fractures and a flail chest.

Clearly, this is not a patient who should have been transported to the local ED with several trauma centers less than 20 minutes away by ground. This is a case, if reported accurately, of an incompetent medic. And not just a little bit incompetent.

Back to mechanism.

What does mechanism add to the assessment of a patient with a flail chest?

A flail chest is a portion of the ribs acting like a trap door. The ribs are broken in so many places that there is no resistance to pressure, except when the patient exhales.

Breathing is not very complicated. The diaphragm creates negative pressure. On inhalation, the diaphragm pulls away from the chest and the accessory muscles also cause the chest to expand. This sucks air in.

On exhalation, the diaphragm and accessory muscles relax and create pressure. This forces air out.

With a flail chest segment, breathing mechanics are mostly normal for everything except the flail segment. The rest of the chest is creating a pressure difference that moves the air. As long as the ribs are intact, they will all move together. When there is a flail segment (2, or more, ribs broken in 2, or more, places is the textbook definition) that broken part of the ribs will move the opposite direction from the rest of the ribs. The flail segment will move in the opposite direction from the intact part of the ribs.

When the ribs are expanding out to create negative pressure, the negative pressure is pulling air into the chest, but the negative pressure is also pulling the broken ribs inward.

When the ribs are relaxing and creating positive pressure, the positive pressure is  forcing the air out of the chest, but the positive pressure is also forcing the broken ribs outward.

This is one of those assessment findings that is hard to miss. The patient may be trying to keep you from assessing that part of the chest, because . . . well . . . it hurts. It doesn’t hurt a little bit. This isn’t just a hairline fracture that hurts a lot. This is a bunch of broken bones that are moving around – a lot – with every bit of breathing.

Not – It only hurts when I laugh.

Not – It only hurts when I move.

But – It only hurts when I breathe.

The normal response to the first two is pretty easy. If it hurts, when you do that, don’t do that.

That doesn’t work very well for breathing. Go ahead. See how long you can hold your breath. Now take a hammer and break a bunch of your ribs. Now, how long can you hold your breath? Not the same thing, at all.

The only time that a flail chest should be missed is when the ribs are not completely broken, in which case, it is not really a flail chest, except for the textbook definition of 2, or more, ribs broken in 2, or more, places. That is the textbook definition. The textbook definition should include the paradoxical movement. Paradoxical movement is what everyone is supposed to be looking for.

Paradoxical means the opposite of what we would ordinarily expect. We would ordinarily expect the ribs to all move together. With a flail chest, the flail segment is moving in the opposite direction from the rest of the ribs.

If the patient is conscious and not disoriented, the pain should be a clear clue to examine the part of the chest being protected. The patient’s arm may act as an excellent splint. Expect to use a lot of morphine/fentanyl/Dialudid. Pain will interfere with breathing more than the opioids will. Fentanyl is less likely to affect cardiac output (blood pressure), so that is my preference.

If people are missing flail chest, we need to ask Why?

We don’t need to complain that the person is ignoring mechanism.

Focusing on mechanism just ignores everything we understand about assessment.

Or do we just not understand assessment?

Mechanism Of Injury criteria for trauma triage encourage incompetence.


That’s not Klingon It’s One Word Dyspnea: EMS Garage Episode 98

We were supposed to be talking about the potential harm from the way we use oxygen in EMS, but we ended up with That’s not Klingon It’s One Word Dyspnea.

First, I mentioned that I am blogging at a new location – here. Also at EMS Blogs will be Black Hearts Incorporated, EMS Bloggers, EMS Office Hours, Medical Author Chat, Ready Fodder, The Social Medic, and Too Old To Work, Too Young To Retire. So far, EMS Office Hours, Too Old To Work, Too Young To Retire, and I are posting while things are being worked out. The blog transfer has not been fun, but it has been educational. I expect to learn a lot more. And I have to thank David Konig, who has been putting his blog, The Social Medic, on hold and guiding us through this. He has also come up with a nice simple design for my blog that I like a lot.

Then the topic turned to the recent medical helicopter crashes and Ambulance Driver’s post Is that helicopter really necessary? in response to the M.D.O.D. post Do You REALLY Need the Helicopter? Before the podcast, I wrote a post mostly about the comments on Ambulance Driver’s post. Fly Everyone, Let the NTSB Accident Investigators Sort ‘Em Out.

It should come as no surprise to people who are familiar with any of the participants, that we were very critical of the abuse of helicopter EMS by medical directors, by ED physicians, and by ground EMS personnel.

Why should we try to justify abuse?

The comments in support of helicopter abuse (on Ambulance Driver’s post) are depressing for those of us trying to improve the quality of EMS. These comments do point out the problems I wrote about in Confirmation Bias and EMS. Many of us do not appear to make any attempt to be objective in evaluating what we do in EMS. We only seem to look at things through the filter of our biases. The people writing these comments seem to have decided that helicopters always save lives and they deny that helicopter crashes are a problem.

The purpose of the helicopter is to make a significant difference in transport time for the patient who really is unstable. These patients are not as common as many suggest. They seem to be most commonly encountered by the least experienced people. In other words, as people become more skilled, they panic less and fly fewer patients. The people denying the problems with helicopters seem to be trying to demonstrate that they cannot assess patients well enough to recognize which patients are unstable, which are stable, and which were never even injured.

The people denying the problems with helicopters also seem to demonstrate that they do not understand that they are not saving significant amounts of time. They often are delaying a patient’s arrival at a trauma center just so they can put the patient in a helicopter.

Finally, we did briefly mention harm from oxygen, but that should be covered in an upcoming podcast. Preferably a show with at least one physician on it. There is a lot to discuss, when considering the over-use of oxygen, and it does appear that we use too much oxygen. We have too many patients receiving oxygen without any evidence of hypoxia.

In the absence of hypoxia, there is not evidence of benefit from oxygen, but there is evidence of harm. This goes back to at least 1950, so the idea that oxygen is harmful is not at all new. This is another example of what I write about in Confirmation Bias and EMS.


Fly Everyone, Let the NTSB Accident Investigators Sort ‘Em Out

Many people think that my posts on science and logical fallacies are not related to EMS. For a Fantastic Feast of Fallacies, head on over to A Day in the Life of an Ambulance Driver. Read his post Is that helicopter really necessary? More important is to read the comments.

Ambulance Driver is referring to a post at M.D.O.D. by the title of Do You REALLY Need the Helicopter?

First, Ambulance Driver writes this:

Over at M.D.O.D., ERdoc85 wonders if some of his patients are being transported inappropriately via helicopter.

And the answer to that question is, “Hell yes, most of them.”

Ambulance Driver does not write a lot of words in his post, but he does provide a lot of evidence.

The Cult of Mechanism
The Ambulance Driver’s Perspective
by Kelly Grayson

Mechanism of Injury in Prehospital Trauma Triage
The EMS Contrarian
by Bryan E. Bledsoe

Alright, I’ll Say It
The EMS Contrarian
by Bryan E. Bledsoe

Two Dead in Oklahoma Medevac Crash
EagleMed chopper crashed enroute to pickup a patient

by Ken Miller, Associated Press Writer
Friday, July 23, 2010

Ambulance Driver finishes up with this:

And if your primary justification for the flight is mechanism of injury, or the helicopter is the quickest way to clear an ER bed, or to allow your ground EMS crew to go back into service sooner, you’re part of the problem.

Nice and concise with a lot of evidence and some recent news about the real dangers of HEMS (Helicopter EMS).

Dr. Bryan Bledsoe, often wrongly accused of hating helicopters, hating flight crews, and just hating EMS, concluded Alright, I’ll Say It with this paragraph:

I had better bring this tirade to an end. While flying home today from Philadelphia, it hit me that I knew more people who have been killed in a medical helicopter accident than by virtually any other means. At some point in my life I have met or spoken with at least five people who later died in medical helicopter crashes. They were all great people and died doing what they loved. We owe it to their legacy to assure that not a single flight nurse, flight paramedic, pilot or patient dies unnecessarily.

The highlighting is mine. The hating is not there, no matter how much people would like to believe that the only way anyone could point out the problems with HEMS, or with EMS, is to hate HEMS, or to hate flight crews, or to hate EMS.

How many people spend as much time trying to improve EMS as Dr. Bledsoe does? Certainly not those who ignorantly criticize him.

You might think that any contrary opinions expressed in the comments would be well thought out, so that those commenting would not completely embarrass themselves. You would be a hopeless optimist. Maybe some quotes from the comments will cure you.

Reading the comments, I wonder how these Fly Everyone, Let the NTSB Accident Investigators Sort ‘Em Out types even mange to put decipherable sentences together. These comments certainly do not demonstrate anything that passes for understanding.

Even in the week since that post, there has been another fatal HEMS crash.

Arizona: Helicopter Crash Kills 3
By The Associated Press
Published: July 29, 2010

Here is a sampling of the commentary in defense of unnecessary helicopter flights and in defense of the unnecessary deaths of flight crews and patients.

I find this article insulting.

. . . and yes I have lost friends in airmedical crashes, but I still continue to fly and support our system.

Because if he were to admit that a lot of them died unnecessarily, that would really mess with his cognitive dissonance.

Did he read any of the linked articles?


Did he understand any of the articles?

Not much chance of that, assuming he did read any of them, with his cognitive dissonance protecting him from the truth.

Support our system, even if it is killing us! Go Team! Rah! Rah! Rah!

Better to be insulted, than to think.

Another writes:


This is safety?

This is not being sorry?

Then this clown accuses Ambulance Driver of being a city slicker.

Someone else criticizes a flight medic for agreeing with Ambulance Driver about the unnecessary flights.

i am sorry to hear that you get silly calls, but that is part of the job and you go when you are requested. if you dont take it then we get called as the ground crew, then you get to get back to your nap or tv show you are watching.

This one appears to think that the danger involved is limited to missing one’s favorite TV show and having to watch it later on TiVo®. He probably only remembers this bit of poetry:

Their’s not to make reply,
Their’s not to reason why,
Their’s but to do and die:

This from a raconteur wanna be:

Or better yet, when we get launched for an MVA and then declined because they end up taking the patient to the local hospital. Then invariably we’re called about 4 hours later to pick up a soup sandwhich and take them to the Level I trauma center. And what was the Rx given at the hospital, other than a cashechtomy?


in every case or on every occasion; always:

He is describing a problem. It might only be an imagined problem, since he does seem to have wandered, more than a little bit, from the path of the truth. He seems to be very interested in providing an entertaining story about how he could save the day, if only they would call him earlier. He does not seem to have much interest in improving anything for his patients, unless it involves him swooping in from the sky to rescue them.

Are any of these comments not great examples of the failure of logical thinking and the victory of bias?

Better safe than sorry imagines that transport by HEMS is not any more dangerous than transport by ground. Not only that, he claims that transport by HEMS is safer than transport by ground EMS. I do not doubt that this is the case, when he is the one treating patients in the ambulance. He does seem very dangerous.

Then he assumes that Ambulance Driver must not be familiar with rural EMS, even though Ambulance Driver regularly writes about rural EMS. Better safe than sorry seems to think that the only way anyone would not agree with him is to be unfamiliar with what he deals with. I do not know much about what he deals with, but I can tell you that it is not reality. In his mind, he redecorates reality with a Feng Shui that is pleasing to his prejudices.

Then there is the guy who thinks that the most dangerous part of HEMS is repetitive stress injury from overuse of the TV remote.

Picture Credit

A real medic would walk away from that, with the patient in one arm and the pilot over his shoulder. Piece of cake.

Just put down the remote and fly, you sissies! We need to sacrifice you on the altar of the Magic Rotor Cure! Think of the Glory!

EMS flight crew is only the most dangerous job in the US, so why not abuse them to death – the patients, too.


Double Edged Swords

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

A post at Paramedicine 101, by Medic999, raises some important questions. Chronicles of EMS – A double edged sword? This is what I think addresses the most important part of the way we do things and why we do them differently in different places.

Before all of this crazy show started, I lived and practiced in my own little bubble. I used to naively think that we were the best at what we can do.

That is the human thing to do, to assume that our leaders are making the right choices.

I take the opposite approach. I want our leaders to prove that what they are doing is good for patients. Not that their way is the best way, but that their way can be demonstrated to be good for patients.

Most of what we do in EMS fails that test.

Why should we continue to use these experimental treatments?

Why should we continue to we continue to be guided by ignorance?

Medic999 points out that he was unaware of some possible improvements to patient care. Now he wonders why his protocols do not include treatments like therapeutic hypothermia.

We often will dismiss something because it is a foreign idea. If you want to have a political idea ridiculed, one of the quickest ways is to suggest that it came from France, except if you are in France. As if the origin of an idea has anything to do with the quality of the idea.

There is nobody so perfect that he/she never produces a bad idea. Conversely, we should not assume that there is such a perfect fool, that he/she never produces a good idea. To assume that the origin of an idea is more important than the idea, is itself a bad idea.

Unfortunately, Not originated here means not used here is EMS dogma in many places.

We come up with excuses to avoid changing things.

We act as if our patients will be better served by avoiding improvements in EMS care.

If we are not here to provide the best care to our patients, shouldn’t our patients be protected from us?

One objection that I repeatedly hear from EMS traditionalists is that, We have to be able to say that we did everything we could for the patient.

The parts they leave out are –

As long as the idea originated here!

As long as we don’t have to change the way we do things!

As long as we don’t have to sit in a classroom, or read, or do anything else that would be considered learning!

As long as the patient does not expect us to provide excellent patient care!

As long as we get to spend more time stroking our egos than we spend on improving patient care!

Chronicles of EMS is a double edged sword. Through Chronicles of EMS, Medic999 has more knowledge about what EMS does in other places. Now he is less satisfied with the way things are done where he works. His satisfaction level has decreased because his knowledge level has increased. This is where the term ignorance is bliss comes from. The more we know, the less satisfied we are with traditional solutions.

But this is not about satisfaction. The decrease in satisfaction is only due to looking at things the wrong way. With more knowledge we have the ability to make improvements that make things better for patients.

When we learn that most patients flown to trauma centers did not benefit from being flown, we realize that we are contributing to the excessive death rate among flight crews when we call for more flights, which leads to more helicopters, which also leads to a greater dilution of experience for flight crews. Tradition tells us to fly patients based on mechanism of injury. This allows the blissfully ignorant EMS personnel to think that they snatched the patient from the jaws of death.

When we learn that by rushing to perform ALS procedures during CPR, we have been neglecting the quality of chest compressions. When we improve the quality of chest compressions, we triple the survival rate – the real survival rate, not the misleading and short term return of a drug induced pulse. This is the first improvement in survival to discharge. This only came by discarding the traditional way of doing things.

When we learn that intubation is performed horribly in many places, some of us work to improve our intubation skill, some move to alternative airways much more quickly, some do both, while traditionalists just claim that it is more important for them to intubate, than to provide competent airway management.

Ignorance can be bliss. Tradition can be bliss. Both can also be deadly for our patients.

Knowledge is a double edged sword, but it is much better to provide excellent patient care than to hide behind That’s the way we’ve always done things!

Medic999 is not suggesting that blissful ignorance is better. He is pointing out that the more he knows, the more problems he becomes aware of. This is not a bad thing.

If we are not aware of the problems, we will not correct the problems.

If we do not correct the problems, our patients suffer.

The more we know, the less satisfied we are with traditional solutions.

Our goal should be the protection of our patients by the destruction of our traditions.

Over at Medic999, there is a vigorous discussion in the comments to CoEMS – A Double Edged Sword.


Advance Directives

Some more writing on the topic of advance directives.

As with Dr. Boris Veysman,[1] I have begun resuscitation in the absence of awareness of a DNR.

Unlike Dr. Veysman, when I have learned after transport to the ED, I have responded with an apology and an explanation that I did not know and certainly would not have abused their family member if I had known.

Walt Trachim writes about one such situation in DNR’s: Yes or No?.

Dr. Veysman seems to have had the perverse response of – But look at what a great result I produced by abusing your loved one!

In Dr. Veysman’s defense, I do feel that it is important to point out that Dr. Veysman does advocate for very aggressive pain management.[2] I do not believe that he is at all malicious.

I think that one of the big problems with medicine is that so much harm can be done without any malice.

The most important thing mentioned in DNR’s: Yes or No? – after some undeservedly kind words (prolific could go either way), and a few cases relevant to the topic, is the main point.

And now – because of the facts and opinions that I’ve read – I have to think about it. How can I not?


One way of addressing this unintentional harm is with the POLST. Dr. Eric Widera writes about this in POLST: Standardizing End-of-Life Orders rather than Patient Communication.

Twelve states have adopted the POLST paradigm into law (CA, HI, ID, MD, NY, NC, OR, TN, UT, WA, WV), and many more are developing programs. My state (California) has signed the POLST into law, although implementation in San Francisco is spotty at best.

The Coalition for Quality at the End of Life (CQEL) is a link to more information on end of life issues.

National Health Care Decisions Day 2010 is at Pallimed.

From Happy National Health Care Decisions Day! at Asystole is the Most stable Rhythm, I picked up a link to a post by Dr. Grumpy. There are a lot of comments. Checkout time.

Finally, the most recent post, The Arrogance of Hope is the dissection of Dr. Veysman’s article at Movin’ Meat.


^ 1 ‘Shock me, tube me, line me’.
Veysman B.
Health Aff (Millwood). 2010 Feb;29(2):324-6. No abstract available.
PMID: 20348077 [PubMed – in process]

Free Full Text from Health Affairs         Free PDF from Health Affairs

^ 2 Truth hurts.
Veysman BD.
Acad Emerg Med. 2009 Apr;16(4):367-8. Epub 2009 Mar 6. No abstract available.
PMID: 19298618 [PubMed – indexed for MEDLINE]


Why is air medical transport still killing us? Comment from Samuel Kordik

In the comments to Why is air medical transport still killing us? the following comment appears from Samuel Kordik

Without a doubt, something needs done to reduce the high risks for HEMS crews. But I’m not sure how enforcing the 1 hr drive radius would help.

A one hour no fly zone is one way of measuring distance. I did not state that there should be an absolute ban on flights within a one hour drive time of a trauma center. I stated, We should then require justification for any flight within that radius.

I think that we should require justification for all flights, but that it is essential to carefully review flights within what is a reasonable drive time for unstable trauma.

Where is the evidence that there is a benefit to unstable trauma patients from HEMS transport within an hour drive of a trauma center?

We definitely need to have ground EMS justify calling for helicopters.

Where I work, anything that could remotely justify transport to a trauma center is flown by some agencies only 10 minutes drive time from a trauma center.


Well, I am not sufficiently familiar with the DSM-IV to give an accurate explanation.

Why endanger flight crews and patients for no possible benefit to the patient?

As I stated, I don’t know how many of the diagnoses in the DSM-IV apply, but the DSM-IV does seem to be the place to look for answers.

I work on a rural MICU unit about 30 minutes from a Level 1 trauma center. My service also flys 3 helicopters, and holds us to account to justify every air transport in our documentation—which makes basic sense.

It makes basic sense to have to justify flights so close to a trauma center. Why do you need 3 helicopters when the trauma center is so close? Why even one helicopter?

If the patient needs it, and the helicopter would get them there faster than we could, then I’ll fly my patient in a heartbeat.

If the patient needs it,

Define needs it. Do you follow up with the trauma center to find out how many of these patients had immediate surgery, or had an emergent intervention in the trauma room, that saved the patient’s life, or made some other significant difference in outcome?

How many of these patients meet that criteria? HIPAA does not prevent the hospital from providing that information. This is a necessary part of any flight justification.

and the helicopter would get them there faster than we could,

How much faster?

The major benefit from HEMS is to make a significant difference in transport time.

A difference of only 5 minutes in transport time, or a difference of only 10 minutes in transport time, or a difference of only 15 minutes in transport time is unlikely to make a difference in outcome.

Yes, there will be the extremely rare patient, where a decrease in travel time of 15 minutes is important, but it is extremely rare.

That is the purpose of justification. There should be an explanation of the particular threat to the patient’s life, supported by EMS assessment findings, information from the trauma center supporting or refuting the initial assessment, and whether it was reasonable based on the limited information available to EMS at the time, to conclude that there would be a dramatically worse outcome if this patient were not flown.

A worse outcome is so rare, that the research on prehospital time periods does not show any effect of these differences in prehospital time on the survival of the most seriously injured patients.

This decision is not based on my desire to go watch TV or sleep, nor is it based on some kind of fear. It comes right out of my position of being a patient advocate and wanting the best possible outcome for said patient.

I did not mean that everyone will fly patients for the same reason. However, there are plenty of people who do fly patients for purely personal reasons.

Restricting unnecessary flights is entirely about wanting the best outcome for patients.

Although I’ll watch for weather and overhead hazards, I still rely on the HEMS crew to watch out for their own safety—weather, terrain, etc.

Perhaps the best way we can protect HEMS personnel would be to require ground EMS providers to justify the flight, and then provide education followup for those providers on patient outcome and whether or not the flight was justified.


Help ground paramedics learn what is and isn’t a justified use of air transport, so that it will still be around when a patient legitimately needs it.


Let me emphasize what I believe is the most important part.

The risk to the patient is usually significantly greater when transported by helicopter.

The risk to the flight crew is definitely much greater when transporting by helicopter.

We need to decide when the benefit to a patient of a particular and significant difference in travel time is worth those risks.

There should be an explanation of the particular threat to the patient’s life, supported by EMS assessment findings, information from the trauma center supporting or refuting the initial assessment, and whether it was reasonable based on the limited information available to EMS at the time, to conclude that there would be a dramatically worse outcome if this patient were not flown.

We have at least that obligation to our patients and to the flight crews.


Anonymous Comments on the Death of Curtis Mitchell

In one comment to City may discipline EMS workers – Public Safety Director Michael Huss and in 3 comments to Where Was Public Safety Director Michael Huss during the Death of Curtis Mitchell? there is a trend. One of the comments is repeated, but maybe the authors of these comments are incapable of interpreting material rationally. Maybe they are attempting to protect themselves from criticism for their failure to prepare for this snow storm.

In any case, I will address the lies presented in the whining.

First is an anonymous comment signed as Jack E. Davis, Sr. Actually, first and second, since he/she provided the same comment on both posts.

No, Mr. Huss, it isn’t rocket science and the wheel doesn’t need to be reinvented. The EMTs are there for a reason, to save lives, if possible, and to carry out their duties as they were “HIRED” to do!

This person seems to think that sending the medics on foot to calls in the snow will help to create jobs in Pittsburgh. We don’t need to waste money on snow plows or 4 wheel drive trucks. We will just have the medics carry everyone. Then we can sit around and do some Monday morning whining and stoning. We aren’t good at anything else.

If the medics decide not to call for help, then the city will need many more medics to transport patients. How many patients would they actually have reached? How many patients with similar medical conditions, or more serious medical conditions (according to their dispatch criteria), would have been waiting for EMS for a much longer time?

The medics did not refuse to transport anyone.

The medics were dispatched 3 times.

The medics were canceled 3 times.

The investigation by the medical director did not find fault with the medics.[1]

Maybe this person is posting anonymously because of the embarrassing ignorance displayed in these comments.

Hot coffee and Krispy Kremes sound much better than a cold, wet trudge through the snow; let’s go back to the station, this guy will be alright, he’s probably just having a bad reaction to some drugs anyway.

Why presume that the medics were able to go back to the station? Because this person appears to have an overly active imagination. When it wants to make something up to suit its prejudices, it will. Why let the facts get in the way of reality?

The medics were transporting patients all day in the snow. They were digging themselves out of the snow every time they became stuck in the snow.

We know where the medics were and what they were doing.

The medics were working.

We do not know what this anonymous liar was doing.

Interesting that this abdominal pain call is presumed to be due to drugs. Where does this come from? Is this from personal experience? Is this from information that was reported after the fact? If the medics knew how the inaccurately reported story would be written, they could have told dispatch. You can’t cancel us. We know this guy is going to die. We are refusing to treat or transport anyone else, until we transport this guy, because we know he is going to die. Isn’t everyone psychic?

Prosecution for dereliction of duty sounds like the proper and justified course of action and a STERN message needs to be sent. If you’re a “public servant” and you’re not fully dedicated to the complete and proper discharge of your duties; C H A N G E J O B S !!!

Oh, the contradictions. Follow imaginary rules, but disobey actual rules.

This writer wants anarchy in Pittsburgh.

Ignore dispatch, when dispatch cancels you.

Ignore dispatch, when dispatch sends you to treat and transport patients.

Medics only need to use their psychic powers to predict which patient will die, respond only to that patient’s residence, transport only that patient, and ignore the rest of the patients.

In any case, the anonymous person posting as Jack E. Davis, Sr. is more than willing to give false testimony and cast the first stone. I don’t know what I am writing about, but I am willing to punish people because of the way I imagine things. And what an imagination it has.

Let’s not rely on facts. Let’s demand that the main stream media make all of our decisions for us. This person provides an example of what happens when our schools fail to educate. If only critical judgment were taught, we should not see so many people forfeiting their decision making to the media.

This lowest common denominator hates America and the rights that our Founding Fathers sacrificed so much for. This person just wants to lynch people. Especially the innocent. This is an example of the true American Taliban. Intolerance combined with ignorance.

Next, Melvin writes this comment.

I can not understand how we travel around the world to dig people out of destroyed rubble and assist with devestaing earthquakes, and all types of disasters, but whatever the reason our public service can not transport a man to the hospital regardless of the bad weather conditons.

3 different ambulances were dispatched. They became stuck in the snow/ice. They called for help getting to the patient.

All 3 of those ambulances were canceled. All of the help they called for was canceled, too.

The medics did not refuse to treat or transport Curtis Mitchell.

This is what they train for to be able to respond in the worst of conditions.

You would have to bring that up with Public Safety Director Michael Huss. Public Safety does not appear to have any plan to deal with these storms that happen every decade, or two. I agree that they should have some preparation for this. However, that failure is not a failure on the part of the medics.

Anyone can respond in nice summer day. My 95 year old grandmother on a wheelchair can respond.

Some modestly amusing hyperbole.

How does your 95 year old grandmother get the patients onto the stretcher?

How does your 95 year old grandmother get the patients into the ambulance?

What kind of treatment does your 95 year old grandmother provide to unstable patients?

You clearly do not know what is involved in treating and transporting patients.

Arriving at the side of the patient and transporting the patient are not even close to being the same thing. Not that your 95 year old grandmother would be able to get to the side of the patient without a wheelchair ramp and somebody to push her up the ramp.

What a shame and embarssment to not have been able to save this mans life.

I agree, Melvin. The medics were canceled each time they responded, so this is not the fault of the medics.

These EMT should be disciplined and or fired.

I think I have already established that you do not understand what you are commenting about.

The medical director reviewed this call.

The medical director found a lot of problems with the way the 911 calls were handled.

The medical director did not blame the medics for these problems.

Unlike these comments, there is a more reasonable comment. Sandra writes the following comment.

I, cannot believe that this man have lost his life after making all these calls for help and then with so many days that it took.

The medics did call for help. Each time they were stuck. Each time they were canceled. If they had not been canceled, Curtis Mitchel would have been transported. This may have required the Public Safety Director to divert a snow plow, or a supervisor, to transport the patient in a 4 wheel drive truck, but Curtis Mitchell would have arrived at the hospital.

I, also agree with Mr. Melvin it is a shame that Mr. Curtis could not get the help that he needed and these people need to be disciplined and a lawsuit needs to be filed.

I also agree that those at fault need to be held accountable. You use the term, these people. I think that the people you need to look at are those trying to blame the medics.

The medical director’s report makes it clear that the medics are not at fault.

My heart goes out to his girlfriend Sharon Edge. I, hope that this do not get swept under the table.

I agree.

Curtis Mitchell should not have died. I do not know what the cause of death was. I am assuming that the cause of death was something that would have been successfully treated in the hospital.

Sharon Edge should not have had to deal with his death.

People are trying to sweep this under the rug by blaming the medics.

The medics are the only people who have been cleared by any investigation.

Public Safety Director Michael Huss had the results of that investigation, but still made his ridiculous claim that this was all the fault of the medics. Why is Public Safety Director Michael Huss providing false information?

Podcasting on the death of Curtis Mitchell:

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

From the EMS Garage

Up to My Pips: EMS Garage Episode 75 – 03/02/10

Writing on the death of Curtis Mitchell:

From Too Old To Work, Too Young To Retire

Trouble Right Here In Three River City – 02/19/10

Comment From Someone In Pittsburgh – 02/20/10

More From Pittsburgh – 02/23/10

Update On The Pittsburgh Story – 02/28/10

And Then I Realized… – 03/01/10

Fertilizer – 03/22/10

Human Sacrifice – 3/24/10

The Tapes Don’t Lie, But People Do – 3/29/10

The Drama Continues In Pittsburgh – 5/12/10

Let The Scapegoating Begin – 01/06/11

Common Sense Prevails – 02/15/11

From David Konig

EMS Blog Rounds Edition 32 – 03/09/10

Why You Need A Social Media Presence: The Case Of Pittsburgh EMS – 02/22/10

Yes Mary, It Is A Transportation System – 02/19/10

From 9-ECHO-1

Pittsburgh…my take on it – 02/23/10

Still Don’t Make It Right… – 03/20/10

From A Day In The Life Of An Ambulance Driver

As usual the truth is somewhere between the extremes – 02/20/10

From Pittsburgh Legal Back Talk

The Power of Saying “I’m Sorry”. – 02/21/10

Medic’s Perspective on Mitchell Case. – 02/22/10

The Need for Evidence Before Assessing Guilt. – 02/23/10

The View from Foggy Goggle. – 02/25/10

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.


[1] Medical Call Review for 5161 Chaplain Way 2/6/2010
Ron Roth, MD Final 2/15/10
Medical Director, City of Pittsburgh, Department of Public Safety
Medical Director, Allegheny County Emergency Operations Center
Free Full Text


The Catch-22 of Homeopathy and Patient Choice

I have written about the fraud that is homeopathy before. Earlier this week, the British Parliament reviewed the evidence supporting on homeopathy and whether the NHS (National Health Service) should fund homeopathy. They have a lot to say. Let’s look at the area of patient choice.

Patient choice

98. Patient choice is an important concept in modern medicine. Medical practice used to be highly paternalistic, whereby the doctors would know what was best for patients and would prescribe whatever treatments they felt best. Today, doctors are trained to communicate with patients about their treatments and, while providing advice and guidance, ultimately enable patients to make informed choices, where possible, over treatment options and more control over the management of their conditions.

99. Indeed, patient choice was repeatedly cited in written submissions as a reason why homeopathy should be provided on the NHS.[120] The Minister stated:

I think there is an illiberality in saying that personal choice in an area of significant medical controversy should be completely denied, and I think the Government should be cautious about constraining that illiberality, or interfering with it. We should not take the view that patients should not be able to have homeopathic medicine when they want it.[121]

100. However, patient choice is not simply about patients being able to pick whatever treatments they like. They must understand the implications of their decisions, which means that patient choice must be informed choice. As Professor Ernst put it: “patient choice that is not guided by evidence is not choice but arbitrariness”.[122] The RPSGB echoed this view:

It is essential […] that the patient is given the appropriate information to make these informed choices and as a consequence it should be clear to the patient that there is no scientific evidence for homeopathy.[123]

101. We agree with Professor Ernst and the RPSGB. For patient choice to be real choice, patients must be adequately informed to understand the implications of treatments. For homeopathy this would certainly require an explanation that homeopathy is a placebo. When this is not done, patient choice is meaningless. When it is done, the effectiveness of the placebo—that is, homeopathy—may be diminished. We argue that the provision of homeopathy on the NHS, in effect, diminishes, not increases, informed patient choice.[1]

The bold highlighting is in the original document. The RPSGB is the Royal Pharmaceutical Society of Great Britain.

If we lie to the patient, we are not behaving ethically.

If we tell patients the truth, the placebo (homeopathy) is not likely to provide any benefit, since patients need to believe in placebos for placebos to work.


^ 1 House of Commons – Science and Technology Committee – Fourth Report – Evidence Check 2: Homeopathy
2 NHS funding and provision
The evidence check
Homeopathy on the NHS
Patient Choice