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

- Rogue Medic

Why Can’t Medics Intubate?

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

A study of prehospital intubation[1] was just published. The surprising result is that in the system studied they are able to intubate 3 out of 4 patients they try to intubate.

I will write another post with more detail on this. From that study, there are some quotes worth reading.

Compliance with documentation of ETCO2 was poor.

This suggests that the medics do not understand the connection between exhaled CO2 and intubation.

Let me rephrase that. This suggests that the medical directors have been unaware of the lack of documentation of ETCO2.


The medical directors appear not to have done a good job of explaining the importance of assessing CO2 in tube placement confirmation.

There you go blaming the medical directors, again.

Yes. How do you provide oversight of paramedics and not notice that there is no documentation of, or that there is less than adequate documentation of, exhaled CO2?

I give up.

I don’t know the answer to that one either, but there is good news.

Since the completion of the study, training and education on the use of capnography interpretation and documentation have been emphasized by the group of supervising EMS medical directors, and continuous-waveform capnography is now incorporated into the airway management protocol.

That is reason to celebrate!


Maybe they learned from the study, but why did it take a study to get them to notice that The Gang That Couldn’t Shoot Straight needs remediation?

Why do the medics not understand the importance of capnography?

Why do the medical directors not understand the importance of capnography?

Here is one partial answer:

Our finding that EMS providers reported only 70% of attempted intubations suggests that self-reported rates of intubation may underestimate the number of intubation attempts and therefore overestimate success rates.


^ 1 A prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region.
Denver Metro Airway Study Group.
Prehosp Emerg Care. 2009 Jul-Sep;13(3):304-10.
PMID: 19499465 [PubMed – in process]
All quotes are from this study.


Overdose Treatment – One Perspective

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

Wandering a bit from the recent All Cardiac – All of the Time drift of Paramedicine 101, but not entirely, I must point out an excellent post on Heroin Overdoses by a blogger, who really is much more imaginative than that post title suggests – Too Old To Work, Too Young to Retire. He is just as direct as the title suggests.

Here is an example of education on junkie slang. It is both translated to everyday English and comes with an explanation of the most effective and most appropriate treatment.

commonly known as “nodding off” or being “on the nod”. The person is usually easily woken up by either a shake on their shoulder or speaking to them loudly. Despite what some in EMS think, this is NOT an overdose. Because it is the desired effect, I refer to this as “a dose”.

He describes the protocol that is in place where he works. His protocol uses respiratory depression as the criterion for treatment with naloxone (Narcan). Some of us have protocols that require treatment with naloxone for Altered Mental Status. I am not in favor of treating opioid overdoses under Altered Mental Status protocols, because this discourages the medic from delivering appropriate care. In stead, the medic ends up delivering vending machine care.

Enter minimal diagnostic criteria _____, remember to use only approved EMS terminology (the protocol vending machine does not recognize unapproved terminology), press Enter, and out pops a treatment. Eureka! No Fuss, No Muss, No Thought, No Possibility For Error. At least, this is the way that many seem to design protocols. Of course, the word diagnostic would not be in the list of approved terminology.

If we are designing a protocol with Foolproof in mind, aren’t we designing protocols to encourage the hiring of fools? How can we deny that we expect fools to use the protocols, if we are designing the protocols with fools in mind? We are designing protocols to prevent fools from doing too much damage, while using those protocols. Wouldn’t it be better to just keep the fools from being authorized to poison patients?

There is a great article by Dr. Bledsoe on the error of using a set treatment for every unconscious patient.[1]

TOTWTYTR points out the use of other diagnostic information in coming to the conclusion of heroin overdose. In addition to the respiratory depression, needle marks, pinpoint pupils, being in a shooting gallery, the presence of injection supplies, . . . are just some of the information that would lead a competent medic to use naloxone in treating this patient. Pennsylvania has a pretty good example of this in their protocols.[2]

With such a patient, my goal is not awake and alert, but breathing adequately. True, they will not have a GCS[3] of 15, but that is where the word competent becomes important. Were we called to the scene because a heroin user was sleeping (not awake), or because a heroin user could not go out and steal something to pay for more drugs (not alert enough to act as a lookout), or because a heroin user was not breathing adequately?

How awake do we want the patient to be?

How alert do we want the patient to be?

How much do we want to endanger EMS crews, just to have the vital signs part of the paperwork look pretty?

Is it possible that an HOD (Heroin OverDose) has a stroke at the same time? Gosh, injecting various impure and not exactly FDA approved solutions into the veins could result in something that should not be in the brain, ending up in the brain. And I am not referring to the heroin, but particles that do not become fully dissolved in the solution that is injected, or particles that precipitate out of solution at some point. These would not be described as good in the brain. What is baseline function of the addicted brain? Is it always GCS = 15? Can we identify signs of a stroke, even if the patient’s GCS 15? Yes. Why do we think we could not?

Reading TOTWTYTR’s blog is a good way to avoid the dumbing down of EMS. He does not only mention the shortcomings of EMS in this post, but points out the abuse of pulse oximetry in the hands of a nurse. Is he just looking for an opportunity to criticize nurses? No. He is pointing out that this is somebody who should not be a nurse – perhaps a Faux Nurse. No more representative of competent nurses than a Faux Paramedic (Medic X) would be representative of competent medics.

Anyway. Go read the whole thing. It is longer than his usual post (bad kettle), but it is very informative and entertaining.


[1] No more coma cocktails. Using science to dispel myths & improve patient care.
Bledsoe BE.
JEMS. 2002 Nov;27(11):54-60.
PMID: 12483195 [PubMed – indexed for MEDLINE]
The Pubmed link is to the abstract. For the full article as a pdf, click below.
Free PDF

[2] Altered Level of Consciousness
Pennsylvania Adult Statewide ALS Protocol Nov. 2008
Note # 6
Pages 78/121 and 79/121 enter 78 in the page count window.
Page with link to the full text PDF of the protocols.

[3] Glasgow Coma Scale/Score


Zero Tolerance V – Autopilot Oversight – Sparrowmict comment

sparrowmict left a comment on the post Zero Tolerance I – Basic EMT Oversight of Paramedics. I apologize for taking so long to respond. These are not unimportant points. They get to the heart of what is wrong with a lot of EMS. I just have not felt satisfied with my response:

I am disheartened that my company has also succumbed to the lets record everything rather than take care of the patient. We have fallen onto the capnography bandwagon and unless we have a square waveform in spite of the fact that I just saw the cords as the tube went past them and have chest rise and clear bilateral lung sounds and no epigastric sounds they want me to pull the tube.

First, I think that waveform capnography is the single most important assessment for tube placement. Better than seeing the tube go through the vocal cords, which is probably the single most misleading assessment of tube placement and the most common excuse for an esophageal tube.[1], [2]

Katz and Falk39 evaluated 108 paramedic endotracheal intubation patients arriving at a regional trauma center in Florida. The authors used a systematic physician approach to confirm proper tube placement on ED arrival, including the selected use of direct revisualization. The authors found that more than 25% of the endotracheal tubes were misplaced, two thirds of these in the esophagus. The authors partially attributed the results to noncompliance with out-of-hospital protocols requiring placement confirmation using carbon dioxide detection. Jemmett et al40 conducted a similar study of 109 paramedic endotracheal intubation patients in Maine (an emergency medical services [EMS] system with no carbon dioxide detection protocol) and found a similar tube misplacement rate of 12%. Jones et al41 reported a lower (5.8%) tube misplacement rate for 208 paramedic endotracheal intubation in Indianapolis, but this study occurred in a region serviced primarily by a single EMS agency with close medical oversight.[3]

These are examples of the diversity of medical oversight. I think that the best indicator of medical director oversight may be the intubation success rate. No competent medical director should tolerate low success rate, but many do. Some medical directors do not even know what the success rates of their paramedics is.

Here is a different approach. these medics were excellent at intubation before they used capnography. After capnography, they were even better. After capnography the only esophageal tube was due to the medic ignoring capnography

Prior to 1990, tube placement was confirmed by visualization of the tube passing through the vocal cords and auscultation of the chest, axilla, and abdomen. Confirmation of tube placement after 1990 was assisted with portable mainstream capnography . . . .

Six (0.36%) unrecognized esophageal intubations were discovered in the emergency department or at autopsy. Only one (0.06%) of these occurred since this addition of capnography and a tube aspiration device in 1990. In this patient, a zero reading on the capnograph was ignored and not verified by a tube aspiration device or by removing the tube and re-intubating the patient.[4]

Second, I think that waveform capnography may be the most important tool that is available in EMS. 12 lead ECG is the main competition. Since they tend to come together in the same machine – the monitor/defibrillator/cardioverter/pacer/12-lead/waveform capnography/pulse oximetry/non-invasive blood pressure/et cetera – I am very fond of the combination monitor/automated paramedic. I do not believe that it should be used as an autopilot for EMS.

As much as I like waveform capnography, it is still only one part of the assessment of the airway. To have one assessment automatically superior to all others demonstrates a lack of understanding of airway management.

So much of what we do has to do with keeping an electronic record of what we did rather then what we do to help the patient.

There are people who believe that the most important thing that can be done is to remove the human from important decisions. If humans are fallible, and we all are, then no human decision can be perfect.

Since humans are imperfect, we must eliminate that imperfection from important decisions.

What they do not realize is that computers are incapable of recognizing the difference between valid data and data errors. For example, if a person is being ventilated with good chest rise, equal lung sounds, no belly sounds, and improving skin signs – increasingly pink, warm, and dry; moving away from cyanotic, cool, and moist – then that is a good thing. Even if the data from the capnography is telling a different story.

The capnography sensor can malfunction, especially if the patient has vomited and some of that vomit is in the tube. The connector might not be tightened properly. The sensor might not even be between the tube and the bag. The tubing from the sensor to the monitor may be kinked, preventing sampling of the exhaled gasses. There are many possible failures. Some will have a malfunction warning, but some will just indicate no CO2.

While some of these are operator errors, some are only malfunctions that can be corrected by a human operator. Proper application and interpretation of the information requires an intelligent human operator.

How can a human operator be responsible for application of the device (both the endotracheal tube and the waveform capnography sensor), yet not be allowed to override the cases of equipment malfunction. Even if the malfunction is due to misapplication of the equipment, the trained operator should be able to recognize that there is a problem of bad data.

To prevent the human operator from making these decisions, as your QA/QI/CYA department appears to, is the worst decision QA/QI/CYA could have made. It is great that they have chosen to use waveform capnography. That is an important and very smart decision. That is a decision made by a human, or a group of humans. It is not great that they decided to try to prevent, as much as possible, decision making by the humans trained in airway management.

We no longer have OLMC requirements but that was because none of the hospitals wanted to be saddled with it and our own Medical Director you see when you start our academy then never again.

EMS by autopilot does not work.

High quality EMS depends on well trained providers who care about their patients.

You might get so see one of his cronies when they choose to yell at you and suspend your clinical privileges because you didn’t get the capnography on within 60 seconds. Our protocols are 1.5 inches thick and have 126 sections and 26 pages alone just for a destination protocol. And don’t even get me started on the hospital divert system or the Level 2 trauma rotation that the State cooked up.

If George Orwell[5] were to write a book about an EMS dystopia, he might write about this kind of lack of oversight. EMS should never be the occupation for unthinking and uncaring people.

One last thing, our new incoming Medical Director (who I had high hopes for because he started out as a medic) has decided that because we do not carry LP12’s on our bike team that we can no longer intubate because we cannot capture that magic waveform for the reports that QI generates.

One of the most important decisions a medic can make is – should I intubate this patient?

That is a decision that may change during the treatment of the patient. Maybe the patient is not responding to treatment. Maybe the patient responds so well to treatment, that the decision to intubate is changed. The waveform capnography cannot make that decision.

One of the big problems with RSI (Rapid Sequence Induction/Intubation) is that some places seem to be making this decision to intubate far too often, just because they can. RSI, as with helicopter transport, is something that can be abused by overuse. That is not something that waveform capnography will recognize.

We do have a lot of nifty toys, but it seems that we are taking steps further backward. Yes we can import all of the data from the LP12 better remember to event scroll push everything you do. 12 lead ECG, but have to transmit all of them to the hospitals (BOY DID PHYSIO CONTROL MAKE A FORTUNE OFF OF THIS DEAL) I still have yet to figure out how they got our medical director to say that we cannot use any other electrodes then Physio control brand.

We all have our biases. Biases that allow us to believe that what we are doing is not bad. Hanlon’s Razor is possibly a much more powerful force than any evil –

Never attribute to malice that which can be adequately explained by stupidity.[6]

Maybe they offered him a pen.[7], [8]

I have talked to, and written to, many doctors who care very much about EMS. Some just do not get it. They believe that certain things prevent paramedics from being allowed to make decisions. They just do not understand EMS. Some of these doctors are smart enough that eventually they will realize that there are better ways to provide emergency patient care. Some will never learn. Some already do understand and spend a tremendous amount of time trying to get others to understand.

Unfortunately, there will probably always be a place for the medical director, who feels comfortable being told what to do by a CEO, a hospital administrator, or a fire chief. Some of them justify this by saying, If I don’t do it, then they will get somebody worse. That is so dangerous, it deserves a post of its own. Too bad that attitude is not uncommon.

I also agree that the National Registry has not helped advance us in any way, so far it just seems to be a method that the state uses to not have to come up with testing or recertification requirements of their own and we still have to pay both the state and the NR license fees.

The NR is the embodiment of what your medical director is doing.

Eliminate the human from the equation, since humans are fallible.

Here is an example of a medical director, who does understand EMS oversight.

Following didactic training, each student must successfully complete a minimum of 20 intubations, in the operating room, under the supervision of a board-certified anesthesiologist. Additionally, paramedics are required to successfully intubate at least one patient monthly for three years, post certification, and one per quarter thereafter. At least one intubation, annually, must be performed under an anesthesiologist’s supervision.[9]

Their success rate?

Trauma patients – 1,110 patients – 94.1% successful endotracheal tubes.

Nontrauma patients – 547 – 98.3% successful endotracheal tubes.

Total patients (trauma and nontrauma combined) – 1,657 patients – 95.5% successful endotracheal tubes. The rest managed by alternative airways, except as indicted in the first quote. Footnote [4] and Footnote [9].

I know the complaints that most people will come up with. We can’t afford that. That’s too expensive. Our people are that good without all of that practice.

Never attribute to malice that which can be adequately explained by stupidity.

These are examples of stupidity. As TOTWTYTR likes to point out – There is no cure for stupid.

Any discussion of airway management is incomplete without Kelly Grayson’s article on how to think about airway management.[10]

Some other writing on these topics. If you want to read more of my ranting, and Yes ranting is appropriate for the topic:

Prehospital Advanced Airway – Should Paramedics Be Intubating? – comment II

Prehospital Advanced Airway – Should Paramedics Be Intubating? – comment

Prehospital Advanced Airway – Should Paramedics Be Intubating?

Waveform Capnography vs. Hubris.

RSI, Risk Management, and Rocket Science


^ 1 Waveform Capnography vs. Hubris
Rogue Medic

^ 2 Prehospital Advanced Airway – Should Paramedics Be Intubating?
Rogue Medic
This is commenting on an EMS Garage segment and has 2 follow-up posts.

^ 3 Out-of-hospital endotracheal intubation: where are we?
Wang HE, Yealy DM.
Ann Emerg Med. 2006 Jun;47(6):532-41. Epub 2006 Feb 28.
PMID: 16713780 [PubMed – indexed for MEDLINE]

^ 4 Prehospital use of succinylcholine: a 20-year review.
Wayne MA, Friedland E.
Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.
PMID: 10225641 [PubMed – indexed for MEDLINE]

^ 5 George Orwell

^ 6 Hanlon’s Razor

^ 7 Medtronic unwraps gifts. But some say vendor’s role not clearly defined.
Rhea S.
Mod Healthc. 2008 Sep 15;38(37):8-9. No abstract available.
PMID: 18810822 [PubMed – indexed for MEDLINE]

Other industry watchers expressed greater skepticism, saying Medtronic’s disclosure highlights the still deeply entrenched practice of vendors gifting to bolster their sales influence. “Their gifting follows areas of their financial interests,” said David Rothman, president of the Institute on Medicine as a Profession.

^ 8 A great gesture on the part of pharmaceutical companies indeed…
The Pump Handle

^ 9 Prehospital use of succinylcholine: a 20-year review.
Wayne MA, Friedland E.
Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.
PMID: 10225641 [PubMed – indexed for MEDLINE]
This is the same as Footnote [4].

^ 10 The Airway Continuum
Kelly Grayson

^ 39 Misplaced endotracheal tubes by paramedics in an urban emergency medical services system.
Katz SH, Falk JL.
Ann Emerg Med. 2001 Jan;37(1):32-7.
PMID: 11145768 [PubMed – indexed for MEDLINE]

^ 40 Unrecognized misplacement of endotracheal tubes in a mixed urban to rural emergency medical services setting.
Jemmett ME, Kendal KM, Fourre MW, Burton JH.
Acad Emerg Med. 2003 Sep;10(9):961-5.
PMID: 12957980 [PubMed – indexed for MEDLINE]

^ 41 Emergency physician-verified out-of-hospital intubation: miss rates by paramedics.
Jones JH, Murphy MP, Dickson RL, Somerville GG, Brizendine EJ.
Acad Emerg Med. 2004 Jun;11(6):707-9.
PMID: 15175215 [PubMed – indexed for MEDLINE]


EMS Garage, CPR, Continuous Compressions, and Resuscitation

I have a bunch of comments I should be responding to with posts. At least to do justice to the topics raised. Since today is yesterday was official procrastination day, I am getting a bit side tracked. I was listening to EMS Garage Episode 29: Traction Control, which has a lot of interesting things to say about resuscitation, rather than traction. The social networking takes up about 7 minutes of the beginning of the show, which is not unusual for The View The EMS Garage.

The host(?) of the show is discussing mechanical resuscitation devices. He referred to one device as the Geezer Squeezer, because . . . . Well, I don’t know why they used this terminology. Maybe they figured they had scared off all of the non-EMS listeners and this is like sitting in a bar and swapping stories. Never mind, that probably is how the show was started. Anyway, the host(?) is trying to get Skip Kirkwood to say that this mechanical compression device improves outcomes. The host(?) appears to be shocked when he is told that these devices have not been shown to improve outcomes. Skip Kirkwood, talking about the good resuscitation rates in his system states –

Yes, we have good results. No, you got the Geezer Squeezer. That’s when I said, “No we don’t.” We have a chest compression adjunct that we believe to be far superior to any mechanical device that costs a lot of money. That’s a high speed, low drag City of Raleigh Fire Fighter, with whom we have worked since day one to do uninterrupted compressions, hard and fast, and to apply defibrillators. We attribute the vast majority of our pretty successful cardiac resuscitation numbers to quick, very effective Basic Life Support (BLS).

There is mention of a few resuscitations by BLS-only CPR (CardioPulmonary Resuscitation) and one of the people on the show keeps saying –

That’s incredible.

To quote Inigo Montoya, You keep using that word. I do not think it means what you think it means. Incredible means beyond belief or understanding. Anybody familiar with EMS should not be surprised by these results.

There is no good research to show improved outcomes from ALS (Advanced Life Support) interventions. What is surprising is that people in EMS still have trouble understanding the uselessness of ALS in resuscitation. We keep making progress, but grudgingly. The progress is slow. The progress comes from minimizing/delaying/abandoning ALS treatments.

There was a paper written, following one of the ACLS (Advanced Cardiac Life Support) revisions, a couple of revisions ago. I do not remember the paper, but a quote from it essentially stated, These ALS treatments are based on expert opinions. Not a level of evidence that would be given much weight today. Why does it take large scale randomized placebo controlled trials – the highest level of evidence – to remove these lowest level of evidence treatments from the guidelines?

These treatments have no valid research to support them, but have become standards of care. Because they are standards of care, IRBs (Institutional Review Boards) and the FDA (Food and Drug Administration) have suggested that it is unethical to deprive patients of these standards of care, to find out how much harm we are causing to patients with these standards of care.

ACLS has become a cult. We do not question the standards of care. We do not evaluate the standards of care.

Even though we have no ethical reason to believe that these standards of care are effective.

Even though we have evidence to show that these standards of care are harmful.

ALS is not just useless. ALS is harmful in resuscitation. ALS is one of the excuses for interrupting compressions. Interrupting compressions is probably the most harmful thing we can do in resuscitation. The other harmful thing that we interrupt compressions for, aside from ALS, is to move the patient. Other than to create room to be able to do effective compressions on scene, there is almost never a reason to move a dead body. But we are EMS, and if we are not transporting, we somehow feel inadequate.

EMS is not just transport.

EMS is not giving treatments just because we can.

Viewing EMS as either of those makes for bad EMS.

Medicare reimbursement policies encourage both of those dangerous approaches.

Here is what I think about mechanical CPR devices:

Why have a mechanical CPR device?

  • Our people do not know how to do CPR.
  • Our people are too lazy to do CPR.
  • Our medical director does not allow field pronouncement.
  • We get a kick-back from the company and this money goes to my retirement plan.

If these describe your department, maybe you do need a CPR machine.

One participant does mention that there is no reason to transport patients with CPR in progress, except in the most unusual of circumstances. Somebody else questions this. Obviously, if the patient is responding intermittently, you transport, but you aren’t continuously performing CPR under those circumstances. You are only performing CPR during the time that the patient has no spontaneous pulse.

Later, one of the participants mentions putting dead bodies in helicopters, as long as the dead body had been a police officer. That is before the police officer died. Fortunately, the majority pointed out the mistake of endangering a lot of people, just to make it seem that we did all that we could.

Did we fire the officer’s gun in the air, disregarding where the bullets would land?


Then we did not do everything we could do.

But that is not something that has a chance of improving the outcome.

Putting a dead body in a helicopter is not going to improve outcomes, either. Sure, in the case of a child drowning in freezing conditions, there is a reason. Unless this is a cold, drowned very junior police officer, there is no reason to fly the officer, just to put on a show. Hey, look at this. We even used the Whangdoodle. The Whangdoodle means we really, really, really tried. And then some.

If we are doing things just so we look good, we need to stop doing them. We should be limiting ourselves to things that work. We need to stop doing things that some magical thinker believes will make EMS look good. We need to get rid of these magical thinkers. Perhaps even drive a stake through some of their hearts, if we can find their hearts. We should not consider the results of research to be incredible. Research is how we determine what is credible.

These believers in showy ineffective treatments are the people, who have been keeping resuscitation rates down. These are the people, who have been harming EMS.

The rest of the show has a lot to write about, as well. That will have to be another time.


NTSB HEMS Hearings – Helicopter Association International

Yesterday, I wrote Observations on the NTSB HEMS Hearings. After Dr. Blumen gave his presentation, Mr. Matthew Zuccaro[1] gave a presentation. While Dr. Blumen’s had been about the negative outcomes of HEMS (Helicopter EMS), Mr. Zuccaro, President of HAI (Helicopter Association International) presented ideas for improving safety.

Wait. That really isn’t what he said. The link to his presentation makes a startling demand – we need to reduce the international helicopter accident rate by 80% over the next 10 years.


As I have mentioned in earlier posts, HAI seems to have the right attitude about safety. They do not try to hide, or excuse, the problems in the helicopter industry. They face these problems and try to figure out how to minimize them.

If only EMS had an organization that took such an aggressive approach. Yes, we have several very good organizations, but even the NAEMSP (National Association of EMS Physicians) seems to be too comfortable with things the way they are. EMSunites.com can only address so much. We need somebody with HAI’s kind of foresight to dramatically change our approach to EMS patient safety. At Emergency Physicians Monthly, there is a review of the OPALS Major Trauma Study[2] that completely misses the failure of quality in EMS. This article has not yet received any comments, except from me. Perhaps my obvious displeasure has discouraged others.

Nonetheless, an argument against inferior training as a reason why these findings might not be applicable in the US is countered by the OPALS paramedic procedural success rates: intubation 72% and IV 90%. These skills compare favorably with US paramedics.[3]

A Tourette’s inducing claim.

How can 72% intubation success be viewed as comparing favorably with US paramedics, by this emergency physician? Are we trying to encourage incompetence? That is one of the great things about HAI. They do not look at the rate of helicopters falling out of the sky, and say something like:

“Whenever someone says they want to ratchet it back,” says Dr. Thomas M. Scalea, physician in chief at Shock Trauma, “I tell them ‘OK, how many people can die next year to make that worthwhile?'”[4]

Almost as if we have not evolved the capacity to plan for adversity. Flight crews have a job that, averaged over the last 10 years, is the most dangerous job in America. This is not just based on data from the recent most deadly year in HEMS history, but a 10 year average. Dr. Scalea’s response is to start singing, Hakuna Matata. Where is the evidence that the overuse of HEMS saves more than it kills? Where?

This is not acceptable.

Should I be more subtle? I sometimes get a bit, sort of carried away.

Right! And the 72% intubation success rate?

This is not acceptable, either.

Two peas in the same pod. Tolerance of these conditions is tolerance of behavior that kills. Why be subtle? Oh. It’s only a moderate amount of death. All things in moderation, you know.

We have become tolerant of experts telling us what we should put up with. We have no reason to accept these moderately expert approaches to safety.

If you look at an earlier OPALS study,[5] they kicked 3 paramedic services out of the study for failure to maintain a 90% intubation success rate. Most of the paramedic services remained in the study, because most of the paramedic services were able to maintain at least a 90% intubation success rate.

Finally, paramedics trained to provide advanced care had to successfully perform endotracheal intubation for 90% of patients. These criteria were monitored regularly, and data collection for the advanced-life-support phase of the study in each community did not begin until the criteria were met. The three communities that did not meet the standards were excluded from the study.[5]

Clearly, this can be done. But is 90% even the right number for the low end of tolerable? No, but it is a start. First, we need to re-educate the medical directors of the parts of the US that consider Two Out of Three Ain’t Bad to be an acceptable approach to airway. Then, we can push for even higher criteria – everywhere.

Maybe we should have the medics practice intubation on the medical directors. Maybe that would change their moderate approaches to airway management success.

Look at that. I went and hijacked my own post, diverted it from where i started, which was the presentation by Mr. Zuccaro.

• Safety As a First Priority
• Safety Above All Else
• Fly To a Higher Standard[6]

Then, if you scroll down to page 11 in the pdf page counter, you will see a chart. If you read this blog on a regular basis, it should look a bit familiar.

This is a chart of 43 years of vaccine progress.[7] Now, look at the charts of earlier HEMS crash rates from Dr. Blumen.[8] Déjà vu all over again. In my post, I show the way each drop in polio is similar to the previous time period. The improvement was at an exponential scale, until there was no more polio in the US. I don’t expect that we will completely eliminate HEMS accidents or missed intubations, but we shouldn’t stop trying or admit defeat.

Page 12 looks the same as page 11, but if you look at the dates, you will see that this projects the decrease in accident rates with the application of better technology and procedures. The charts look the same, but the scale is different. This is an exponential improvement in safety. This is not a fantasy.

OK. If the Defenders Of Tradition oppose it, then the time scale is fantastic, but it will happen eventually. How many people do you want the Defenders Of Tradition to kill?

Do other aircraft have better safety rates? Yes, so we can improve HEMS crash rates by a lot.

Do anesthesiologists have better intubation success rates? Yes, so we can improve intubation success rates a lot.

What? It is unreasonable to expect medics to intubate at that level of proficiency?

No. It is unreasonable to accept 72% intubation success.

72% is blind squirrel territory. If I could get a blind squirrel to manipulate a laryngoscope with any kind of dexterity, I could get that blind squirrel to intubate at better than 72%. I might have to teach him to use a bougie, but it could be done.

H/t to CrzeGrl for another site with a similar approach to HEMS safety is Vision Zero from the Association of Air Medical Services.


^ 1 Witness #2 Matthew Zuccaro,
President, Helicopter Association International, Alexandria, Virginia
Mr. Zuccaro has been active in the helicopter industry for nearly 40 years. He was president of Zuccaro Industries, LLC, which provided aviation consultation services and specialized in helicopter-related issues. He holds airline transport pilot and instrument flight instructor certificates for both airplanes and helicopters. Mr. Zuccaro has also held several executive and operations management positions, with commercial, corporate, scheduled airlines, and public service helicopter operations in the northeastern United States. Mr. Zuccaro is a past president and chairman of the Eastern Region Helicopter Council. He received his initial helicopter flight training as a U.S. Army aviator and served with the 7/17 Air Cavalry unit in Vietnam. During his tour, Mr. Zuccaro earned several commendations, including 2 Distinguished Flying Crosses, 3 Bronze Stars, and 19 Air Medals.

Matthew Zuccaro’s slide presentation is Helicopter Association International Presentation on Industry Safety Initiatives
National Transportation Safety Board
Washington D.C.
Free PDF from NTSB of what was a PowerPoint presentation by Mr. Zuccaro.

^ 2 The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity.
Stiell IG, Nesbitt LP, Pickett W, Munkley D, Spaite DW, Banek J, Field B, Luinstra-Toohey L, Maloney J, Dreyer J, Lyver M, Campeau T, Wells GA; OPALS Study Group.
CMAJ. 2008 Apr 22;178(9):1141-52.
PMID: 18427089 [PubMed – indexed for MEDLINE]
Free Full Text . . . . Free PDF

^ 3 The Evidence Against “Stay and Play” Pre-Hospital Care
by James E. Brown, MD, is on the faculty of BEEM (Best Evidence in Emergency Medicine) and is the vice-chair & residency director at the Wright State University department of emergency medicine
Free Article

^ 4 Advantages of medevac transport challenged
Baltimore Sun
October 5, 2008

^ 5 Advanced life support for out-of-hospital respiratory distress.
Stiell IG, Spaite DW, Field B, Nesbitt LP, Munkley D, Maloney J, Dreyer J, Toohey LL, Campeau T, Dagnone E, Lyver M, Wells GA; OPALS Study Group.
N Engl J Med. 2007 May 24;356(21):2156-64.
PMID: 17522399 [PubMed – indexed for MEDLINE]
Free Full Text . . . . Free PDF

^ 6 National Transportation Safety Board
Washington D.C.
Free PDF
Page 4 in the pdf page counter. Yes, this is the same pdf from footnote [1].
There is no good reason not to go through this presentation carefully. The safety information applies to all areas of risk management. Only some of it is specific to helicopters.

^ 7 11/10 Anti-Vaccinationists Are Smarter Than Scientists
MMWR Summary of Notifiable Diseases, United States, 1993
October 21, 1994/42(53);1-73
Free Full Text

^ 8 Dr. Blumen’s slide presentation is An Analysis of HEMS Accidents and Accident Rates
Free PDF from NTSB of what was a PowerPoint presentation by Dr. Blumen.


To Restrain or Not To Restrain, But That’s Just the Beginning of the Question – comment

In the comments to To Restrain or Not To Restrain, But That’s Just the Beginning of the Question, jeg43 wrote,

I am astonished that restraint is an issue in this day and age.

Restraint should not be an issue, but it still is. Pennsylvania actually has better protocols than many other states/localities.

Wait! I do see the legal components.

There are many legal components of this, but consider the first footnote I showed in the chemical restraint protocol –

2. Do not permit patient to continue to struggle against restraints. This can lead to death due to severe rhabdomyolysis, acidosis, dysrhythmia, or respiratory failure. Medical command should be contacted for possible chemical restraint with sedative medication.[1]

I think the suggestion that medical command be contacted, is one that appeals to a medical director who does not have to physically get involved in restraining patients. Dr. Kupas is the state medical director for Pennsylvania, the one who has his name attached to these protocols. He was (probably still is) a paramedic. He has to convince a committee of regional medical directors of the appropriateness of these protocols. Or, it could be the other way around.

I have only briefly talked with him about pain management protocols, something that could have progressed into a conversation on sedation. It would be a natural progression of such a conversation. In stead the conversation was quickly terminated by Dr. Kupas. He stated that he was trying to change the pain management protocols to get the regions that prohibit standing orders for pain management, to be more aggressive.

He also stated that he wanted to reign in the more aggressive regions. These regions had standing orders that are only dangerous if the medical directors are authorizing incompetent paramedics to treat patients. Of course, any protocol can be dangerous in the hands of an incompetent paramedic, but these medical directors really, really believe in the magical powers of OLMC (On Line Medical Command requirements for permission to treat). He ended the conversation right there. Then went to stand in the back of the conference room.

I never had the opportunity to ask him the relevant questions.

Why do EMS patients not deserve appropriate pain management in Pennsylvania?

Why do EMS patients not deserve appropriate sedation in Pennsylvania?

Why is this at the whim of the doctor answering the phone?

It all does depend on the mood of the doctor answering the medical command phone, their approach to pain management, the culture at that particular hospital, . . . . Some doctors are great and give appropriate orders for the patient. Some act as if the patient is unimportant and they are doing me a favor by giving me orders to treat the patient appropriately.

My patient vs the doctor’s patient. Is there a real distinction, when I am following the doctor’s orders? Of course, my patient is also their patient. So by doing me this wonderful favor, they are allowing me to prevent them from mistreating their patients. Try getting some of the doctors to understand that.

Eventually, some lawyers will recognize that inadequate prehospital pain management and inadequate prehospital sedation are areas of medical direction malpractice that will probably be gold mines in the courtroom.

The doctor has an obligation to the patient.

The doctor ignores that obligation, perhaps out of some infantile attitude that the patient’s pain does not matter until the doctor sees the patient. Maybe the doctor is overworked. Maybe the doctor just has no competence in pain management. Maybe the doctor just authorizes a lot of incompetent paramedics, and thinks this provides some safety for the patients. It does not.

After reading most of your linked posts I have another reaction: Self, never, never let anyone put you in an ambulance. Wait! Bad idea. I may not be able to make that decision and may need help urgently. Another thought: This is information I really did not want to have. And: Damn. The EMS have issues of clusterf**kedness just like the rest of reality.

Yes, there are many problems, but things are improving. As more physicians have more experience with EMS, and with pain management and sedation, the competence level improves. There are still hospitals that do not allow emergency physicians to use fentanyl or propofol in the management of patients. These are considered anesthesia-only drugs in some hospitals. The research on the use of fentanyl and propofol by emergency physicians is extensive. This research demonstrates the safety of administration by emergency physicians without an anesthesiologist holding their hand.

As there is research to show that emergency physicians can safely administer these medications. Anesthesiologists are becoming much more comfortable with emergency physicians using these drugs.[2] There is less extensive, but similar research showing the safety of aggressive pain management and sedation by EMS. Some emergency physicians are becoming more comfortable with EMS treating these patients without the, OLMC holding their hand, Mother-May-I call.[3]

Both examples are in the interest of improving patient care. Some physicians will use the irrelevant distinction that medics are not doctors. Of course medics are not doctors. If we are treating patients according to EBM (Evidence-Based Medicine, or as some prefer – SBM or Science-Based Medicine), then the critical part is, What is best for the patient?

The question is not, What is best for maintaining the customary hierarchy? The question is not about the status or authority of the emergency physician. Appropriately aggressive oversight requires an involved competent medical director. It does not require polling the local OLMC to see what mood the doctor is in, or to see if Dr. Just Transport is working, or any other random factor, factors that are irrelevant to what is going on with the patient. Factors that are irrelevant to patient care.

The evidence is clear. EMS can aggressively manage sedation and pain without ED doctors holding their hand. This hand holding only serves to delay appropriate care, not to improve it. For these patients, delayed care is worse care. For these patients, delayed care is bad care.

Then: You mean to tell me that there are incompetent medics actually treating emergency patients? And OLMC is in place because no one will fire the incompetent medics thus adding to the problems of timely emergency care/treatment?

Maybe I should phrase it – OLMC is in place, because of a poor understanding of risk management, a poor understanding of EMS, and a lot of other responsibilities. I have spent a lot of time trying to convince medical directors of the safety of standing orders and of the importance of aggressive oversight. They deny that there is a problem. They deny that there is a better solution. They see the problem as other medical directors approving dangerous medics and they have to protect patients from those medics. this only perpetuates the problem. As the state changes to more liberal standing orders – appropriately liberal – medical directors will need to adapt.

Yes, there is a problem of inappropriately liberal standing orders. The medical director, who says, Do whatever you want, yet does not provide aggressive oversight. This does nothing to manage the quality of care, either.

Two things more:
1) Each time I read one of your posts, my respect and appreciation for who you are and what you do increases. Thank you, sincerely, for your effort.
2) Is there anything a civilian, not in any way connected to the field of medicine, can do to help you other than shoot identified incompetents?

Thank you. EMS is a job that appeals to several different types of people. Many of us in EMS would not fit in in a M-F 9-5 world. I am glad there are people, other than me, to do those jobs. I could write a lot of posts on EMS personalities and finding the right niche to fit into.

Unfortunately, as a civilian, there is not much you can do. If there are hearings on any changes in EMS, where you live, go find out what you can. Ask questions. Get involved in the discussions. Unfortunately, even those in EMS have a poor understanding of how to best provide EMS. People in EMS do want to help patients, but we often disagree about what is best.


[1] Pennsylvania EMS Statewide ALS Protocols
Effective November 2008
Pages 100/121 to 102/121 in the pdf page counter
Page with link to the full text PDF of the protocols.

[2] “Poachers and Dabblers?”: ASA President’s Incautious Comment Riles Emergency Physicians
George Flynn
Special Contributor to Annals News & Perspective
Ann Emerg Med. 2007 Sep;50(3):264-7. No abstract available.
PMID: 17712877 [PubMed – indexed for MEDLINE]

[3] Safety and effectiveness of fentanyl administration for prehospital pain management.
Kanowitz A, Dunn TM, Kanowitz EM, Dunn WW, Vanbuskirk K.
Prehosp Emerg Care. 2006 Jan-Mar;10(1):1-7.
PMID: 16418084 [PubMed – indexed for MEDLINE]

This is just one example of the appropriately aggressive and safe use of fentanyl in EMS. This is much larger than the rest of the research on the topic combined. I wrote about the study, in more detail, in Public Perception of Pain Management.


Bad Oversight – Part I

Once upon a time, in an EMS system far, far away, there was a brand spanking new medic. No, I did not spank him, but some others did. This is the story of how they were wrong. A story of how they were the ones, who needed to be spanked.

In this system, the medic is all by his lonesome, in a fly car, in the middle of nowhere. Our hero, Spanky, is brand new as a medic, is not familiar with the area, and has not even had a real orientation to the system. In other words, this situation is just made of WIN!

In this moderately busy system, there are 911 calls. Dispatch sends out the ambulance and medic for the particular location of the call. So far, so good. Spanky is dispatched, not to his own territory, the nowhere that he does not even know his way around. Spanky is dispatched to the next medic’s territory, a whole different nowhere, a nowhere that he did not even know existed prior to being dispatched. This nowhere is between 10 minutes and 20 minutes away. That time is assuming that one proceeds directly to the location.

Spanky is driving like he is at Daytona, because that is the way he sees other medics driving. He is reading the map at the same time, because that is what the other medics do, too. Texting while driving would only improve driving ability, here. Spanky is kind of lost, but after some assistance from dispatch, he does arrive on scene.

The dispatch was for cardiac arrest. This is back before the concentration on not interrupting compressions. The main reason for a medic to drive 10 – 20 minutes to a cardiac arrest is in case the person turns into a vampire. The medic is the only one authorized to drive a stake into the vampire’s heart. It is an invasive procedure, after all. Hospitals become upset if ambulances transport vampires without staking them, first.

Spanky arrives, parks, grabs his gear, and goes to the ambulance. The ambulance is sitting there, lights flashing, maybe the siren is also on, and the driver is sitting in the driver’s seat, ready to go. Spanky opens the doors to the back of the ambulance, where the patient is. As soon as the door closes, before Spanky has a chance to grab a seat, a history, a patient assessment, or even to catch his breath, Ricky Bobby takes off.

Now, to properly understand the benefit provided by Mr. Toad’s Wild Ride, while you are reading, you should bounce up and down and side to side, occasionally throw yourself into the wall. If no wall is handy, throwing yourself off of a balcony might be a reasonable substitute. You should imagine that you are trying to deliver patient care, while this is happening. I even tried to type this post, while using this method, but I crashed the computer.

Anyway, the low-guy-on-the-ambulance-totem-pole is in back with the patient, performing one person CPR. Ricky Bobby has to be up front gunning the engine, waiting for the starting gun. If you remember how goofy one person CPR was back before it was realized that the ventilations make things worse, you can picture the circus atmosphere in the back of this ambulance. But, now our hero is there. Things can only get better, right?

If the CPR had been tolerable, while the ambulance was not moving, it only became worse, when the roller coaster ride began. En route, Spanky intubated the dead patient. They soon arrived at the hospital.

Perhaps, some of the irregularities need to be addressed here.

What did the BLS crew do?

Apparently, they just moved the patient from the residence to the ambulance.

Why move the patient?

Because they don’t know what else to do. If it is embarrassing to be just doing CPR in front of the family, at least they can go hide in the ambulance. And Ricky Bobby can tell the bottom-of-the-2-person-totem-pole guy to do CPR by himself. Ricky Bobby has to drive. Vroom-vroom. Besides it is easy to do one person CPR while moving the patient (no, Ricky Bobby does not participate in the CPR, Ricky Bobby just lifts and drives).

What about an AED[1]?

Yes, the ambulance crew had an AED. I do not know if they brought the AED into the home, but it appears that it was never attached to the patient. The medic will be here soon. We’ll use his defibrillator pads, so we don’t have to restock.

Is there anything the medic or the hospital can do that is more important than defibrillation?

They can bill at a higher rate, but not much else.

It seems as if the ride to the hospital was short. Why didn’t they just transport, in stead of waiting for the medic?

One reason is that in this area, the doctors and nurses will throw a super-duper hissy fit. Screaming, Why didn’t you wait for the medic? This criticism is not at all uncommon, although it is unreasonable and just plain stupid. The closest ALS was the hospital. If the ambulance crew decided to move the patient to the ambulance, they should have continued moving to the hospital without the medic.

In other words, ignoring the AED (as they did), they had 3 choices. Treat the patient on scene. Move the patient to the hospital. Move the patient to the ambulance and treat the patient there. They made the worst choice, as far as patient care is concerned. Best choice – stay on scene delivering the best CPR that they can (and use the AED). Second best choice – if they are foolish enough to move this patient, they should keep going, until they are at the hospital. Worst choice – just move the patient to anyplace where they can hide their ignorance (in this case, the back of the ambulance).

Now, I don’t mean to cast any doubt on the accuracy of the tale recounted by Spanky. That would be wrong. According to Spanky, he properly intubated the patient, but forgot about defibrillation. When they arrived at the ED, the patient was in fine VF (Ventricular Fibrillation, one of the rhythms the AED is designed to shock automatically, preferably before it deteriorates to fine), the patient was shocked into asystole, and eventually the patient was pronounced still dead.

End of story?

Not a chance. Everybody has to have their input on how to punish this medic for being put in a position he never should have been put in.

Management wants to make an example, so that people will not suggest that their irresponsible scheduling and lack of orientation had anything to do with this. Spanky was not there because of any particular trust in his abilities. He had a card and a pulse. He had been signed off by the medical director. He could not refuse to work this shift. Spanky was not there because of any ability to charm people. No way. No how. Not Spanky.

The ambulance crew wants the focus on the inaction of the medic, not on their inability to provide basic CPR and their inability to use an AED appropriately. The crew did have an AED. Of course, they only have to convince their fire chief that they did nothing wrong. They point out that it was a medical problem and the chief immediately loses interest. Don’t bother him with that medical stuff. So they skate. They may even get some street cred for putting up with such a dangerous medic.

The hospital didn’t have much of a problem, but they had not done anything that they needed to cover up.

To atone, Spanky is told he must ride along with an EMS agency, but it may not be his employer, because that would make too much sense. He has a few weeks to complete all of the ride along time. He has to arrange for everything himself. Well, surprisingly Spanky does manage to arrange this with one of the competitors.

The ALS Chairman for that agency is convinced that because Spanky was a respiratory therapist, Spanky thought of airway first and will always think of airway first. The Chairman sees this as a fatal flaw, that can never be repaired. This was one of the big disagreements I had with The Chairman. I wasn’t defending the skills of Spanky. There was not much to defend. I was advocating for him to have a fair shot of demonstrating whether he actually had any skills.

If anything, a problem with EMS is we do not have enough people with respiratory backgrounds. We could learn a lot from respiratory therapists.

Anyway, Spanky did not complete everything to the satisfaction of all involved. After riding with the competition, he would be a pariah, anyway. From what I hear, he moved on to several other companies, and is no longer in EMS. Next time you are at Micky D’s, or Double D’s, ask if the guy there knows the story of Spanky and Ricky Bobby. You just may be getting a Coolata hand made by Spanky.

Rather than try to remediate someone, who might have learned from his mistake – a mistake that probably had nothing to do with the outcome – we reinforce the idiotic way EMS is delivered in this area.

Spanky delivered no Sparky.

But that was the least significant of the problems on that call.


^ 1 AED = Automated External Defibrillator


Star of Death

Vince writes about a shocking unexpected rare not exactly every day occurrence in EMS. Star of Death is a criticism of the approach to patient care in a large EMS agency.

Vince’s post raises several questions.

First, here is his summary of the events that were described in the article.[1]

A 39 year old man who was having chest pain and shortness of breath had complete resolution of his symptoms after about 6 hours. The bad news is that the symptoms went away right along with that nagging heartbeat he had.

Does it seem as if he left out some detail? Something that might show the paramedics in a more favorable light?

It sure does seem that way. Vince can be a rather harsh critic Vince can be a rather harsh observer. Reading the entire article does not make things look any better. The point of view is mainly from the family, but most of what I copy is attributed to people speaking for EMS. This incident has not been fully investigated. There has not yet been an article that I have read, about an incident I was involved in, that did not have inaccuracies.

Paramedics are required by department protocol to transport by ambulance a patient who asks to go to a hospital, said Alan Etter, a spokesman for D.C. Fire and Emergency Medical Services.[1]

This may surprise some people, but that is the job. That and providing patient care.

checked his vital signs and performed an electrocardiogram, the results of which they said were normal.[1]

If they actually said that, who trained these clowns? Who is providing oversight to allow such idiocy to persist.

The term Normal Sinus Rhythm is one I do not believe should be used in the patient care setting. The word normal is inappropriate in describing anything about a patient with a medical complaint. To say that it may be normal is entirely different.

People get upset with EMS using the word diagnose. Even though we diagnose and treat all of the time. We use a bit of medical terminology sleight of hand to change it to working diagnosis, or some other demonstration of placing appearances before substance.

If diagnosis is outside of the scope of practice of EMS, why is it that so many in EMS are comfortable pronouncing a diagnosis of normal? Pronouncing does appear to be the wrong word in this case.

The EMTs asked Givens whether he had eaten or had anything to drink that evening, and he said he had eaten a burger, Givens said. They told him and his mother that he probably was suffering from acid reflux and suggested he take antacid.[1]

As long as he isn’t on a starvation diet, we’re out of here and back to bed in 5 minutes!

Why is it that doctors, medics, and nurses are so quick to ignore the serious condition and focus on something that means less work? The job is to prepare for the worst and hope for the best. To approach patient care in any other way, is just plain wrong. This does not mean that you follow the defensive medicine approach of a CAT scan for every head ache, but that you fully assess the patient in the way that a competent professional would. Jumping to the conclusion, that a patient does not have a legitimate cardiac complaint, without a full assessment is wrong. Too bad it isn’t rare.

“As per protocol, we are conducting a thorough quality assurance case review, and we will determine whether proper care was provided and if the two medical events are related,” Rubin said in a written statement.[1]

Rubin is Fire Chief Dennis L. Rubin. How would the two be unrelated? If they had transported him to the hospital, he might have died in the hospital. He may have had a heart attack or it may have been something not cardiac. If he had been transported, there would have been some documentation to help them come to a conclusion. They cannot prove that the 911 call and his death are unrelated. Will they try?

Is 39 too young to have a heart attack?

Should 39 be considered young? Since I am older than 39, I say yes. The question should be, is any age too young to have a heart attack? Since I have treated teenagers who have had heart attacks, I say no.

Conversely, there is no age at which a heart attack becomes mandatory. We are dealing with likelihoods. Knowing just the age, I would say a heart attack is unlikely. When you add chest pain and difficulty breathing, I would have to be a fool to say a heart attack is unlikely.

Jack Benny claimed to be 39 years old for most of his life, so it isn’t a bad age, but it does not rule out heart attack. And heart attack vs indigestion is not the extent of the differential diagnosis. Did EMS get a thorough history? I do not know, but I do not suggest to a patient that chest pain is probably just indigestion.

Is there any research to suggest that 39 year olds, with chest pain and difficulty breathing, should be considered to have agita, rather than angina?

I’d ask them how comfortable they are with saying, Would you like fries with that? I would, but they would probably try to discourage the customer from purchasing the fries, since fries might cause indigestion.

On L & D calls, does the medic suggest, You probably just need to sit on the toilet and have a good bowel movement?

On CHF calls, You’re hyperventilating. Just breathe into this paper bag.

On amputations, Pull yourself together?


^ 1 Man Dies at Home After Paramedics Diagnose Acid Reflux
By Elissa Silverman
Washington Post Staff Writer
Thursday, December 4, 2008; Page B04