All posts by Mike Schadone

Academia, Clinical, Culture, Emergency Medical Services, Health Care, Society

Quality and Safety Measurement

In regards to the incident surrounding the death of Josie King (Josie King Foundation, 2002), there have been many great improvements in the delivery of care at Johns Hopkins (Niedowski, 2003; Zimmerman, 2004). Those aside, and if I was faced with having to develop performance measures of quality and safety in the context of such a tragedy, I would strive to ensure that my measures were accurate and valid to identify areas of grave concern where Johns Hopkins would do good to improve.

First, I would consider measuring the structure of the care delivered. In Josie’s case, a medical response team responded when it was identified that she was in the midst of a medical crisis. The first measurement would serve to identify the availability of such teams and the adequacy of the team’s staffing. The measure would indicate the response time of the team and the licensing and certification level of each team member.

Second, I would consider measuring processes that might have contributed to the death of Josie King. In this instance, Josie was administered a narcotic while suffering acute dehydration. The administration of this medication was contrary to the physician’s orders regarding pain medication for this patient. This measure would indicate the appropriate use of narcotic analgesia in patients faced with contraindications, such as acute dehydration or shock. This measure would be a cross tabulation of recent vital signs and laboratory results.

Third, I would consider measuring outcomes. In cases where pediatric patients are downgraded from the pediatric intensive care unit (PICU) to a general ward, any adverse condition should prompt an upgrade back to the PICU. This measure would identify the number of cases in each reporting period that any recently downgraded patient was upgraded back to the PICU. This measure should account for the time between a crisis and upgrade along with a statement indicating the cause of the crisis and resultant upgrade. This measure should be augmented by a mortality and morbidity subset involving any patients who were downgraded from PICU.

My considerations for these processes are to determine if general ward nurses should be administering any medications on standing order or if there should be a requirement to ensure that any medication administered to a general ward patient is explicitly written in the patient’s chart at the time of administration. Also, nurses should be acutely aware of the contraindications of any medications that they are administering. The process measure will, hopefully, identify misuse of narcotic analgesia and any failure to assess the patient for other possible causes of distress before assuming the distress is in response to pain. Ultimately, a more timely and efficient use of medical response teams should result, which would avail physicians and more experienced nurses to the original patient care team. This should lead to an open discussion of how to better manage the patient post crisis. Also, a greater understanding of medication administration concepts should result, benefiting all patients.

References

Josie King Foundation. (2002). About: What happened. Retrieved from http://www.josieking.org/page.cfm?pageID=10

Niedowski, E. (2003, December 15). From tragedy, a quest for safer care; Cause: After medical mistakes led to her little girl’s death, Sorrel King joined with Johns Hopkins in a campaign to spare other families such anguish. The Sun, pp. 1A. Retrieved from http://teacherweb.com/NY/StBarnabas/Quality/JohnsHopkinsErrors.pdf

Zimmerman, R. (2004, May 18). Doctors’ new tool to fight lawsuits: Saying ‘I’m sorry’. Wall Street Journal, pp. A1. Retrieved from http://www.theoma.org/files/wsj%20-%20medical%20error%20-%2005-18-2004.pdf

Emergency Management, Politics, Society, Technology

Using the U.S. Patriot Act to Fight Terrorism

Many of the fundamental tenets of a free American society are founded on the basis of liberty. Americans enjoy liberty, but I surmise that many are unfamiliar with term. We as Americans can enjoy certain freedoms because of liberty. Liberty describes the condition of man to be able to govern him- or herself with regard only to the consequences of actions and decisions, the responsibility of liberty. Merriam-Webster (2011) defines liberty as “freedom from arbitrary or despotic control, the positive enjoyment of various social, political, or economic rights and privileges, and the power of choice” (para. 1). Using liberty as a foundational political philosophy, our forefathers prescribed our abilities as citizens in our freedom.

Faced with horrible, vicious, and unfamiliar terror, our society became frightened and called on our lawmakers to ease this fear. Without a full understanding of that which we were facing, the knee-jerk reaction that is the USA PATRIOT Act (2001) was signed into law. The unfortunate reality is that this law violates almost every libertarian prescription codified in the U.S. Constitution and those of the many states. No longer are we, as citizens, free to travel interstate by a common means of the day (air travel) without undue and warrantless searches and seizures. No longer can an American citizen be knowingly free to have private phone conversations without the fear of wiretaps, save for those that are reviewed by a judge to be warranted.

It would indeed be ironic if, in the name of national defense, we would sanction the subversion of . . . those liberties . . . which make[s] the defense of the Nation worthwhile” (U.S. v. Robel, 1967, pp. 258, 264). (as cited in Strossen, 2004, p. 368)

America is resilient because of the liberties enjoyed by every citizen. Legislation, such as the USA PATRIOT ACT (2001), undermines these liberties and creates a weaker nation as the focus turns towards government for the protection of the individual instead of the individual protecting the government as it has been since America’s inception. Focusing more on our freedoms and liberties while restating the need for each citizen to take an active role in their personal security and that of their community would go much farther than any knee-jerk legislation could ever hope to. I agree with Strossen (2004) that the USA PATRIOT Act is unnecessary, overreaching, and counterproductive the security of our free State.

References

Liberty. (2011). The Free Merriam-Webster Dictionary. Retrieved from http://www.merriam-webster.com/dictionary/liberty

Strossen, N. (2004). Terrorism’s toll on civil liberties. Journal of Aggression, Maltreatment & Trauma, 9(3), 365–377. doi:10.1300/J146v09n03_07

USA PATRIOT Act of 2001, Pub. L. No. 107-56, 115 Stat. 272 (2001).

Academia, Culture, Health Care, Society

The Patient Perspective: Patient Safety

The Speak Up materials provided by The Joint Commission (2011a, 2011b) do a great service in succinctly illustrating the need to be educated about health care issues. Patients and their families have a unique perspective to understanding their (or, their family member’s) health (Vincent & Coulter, 2002). Although physicians, nurses, and allied health providers are responsible for providing quality care, it remains the domain of the patient to express uncertainty or provide additional information to guide the provider. Ultimately, the patient or surrogate decision-maker must provide consent for treatment and must do so with full understanding. There are times, however, that the scope of treatment is so drastic, emergent, or specialized that the patient may not have the facilities to gain a full understanding of care needing to be rendered (Vincent & Coulter, 2002). This is the exception.

In the case of Josie King (Josie King Foundation, 2002; Niedowski, 2003; Zimmerman, 2004), which I elaborated on last week, Sorrel King, Josie’s mother, was educated about her daughter’s condition and spoke up as The Joint Commission recommends. Unfortunately, this case turned into tragedy not because Sorrel King did wrong but because the nurse disregarded her apprehension. This was tantamount to malpractice and no patient or family member could have prevented this, save for using force to physically prevent the administration of medicine. According to MacDonald (2009), there are nurses that believe “[patients] have no say and that medications are the domain of doctors, leaving the nurse and the patient to trust that the doctors would do the right thing” (p. 29).

Perhaps things were slightly different, however. As MacDonald (2009) explains, patient’s who are knowledgeable of their illness and take an active role in their health care decisions add another layer of safety, especially when considering medication action, reaction, and interaction. Medication prescription errors are numerous within health care, and as in the case of Josie King, improved communication between the physicians, nurses, and Sorrel King might have prevented Josie from being administered the narcotic and instead receiving the fluid she so desparately needed (Vincent & Coulter, 2002).

Health care should be patient-centric as it remains the responsibility of the patient to be educated about the care they receive and to provide consent for that care and treatment to be rendered. An uneducated patient does add risk, but sometimes this is unavoidable. It is in these instances that special care should be taken until a full medical history can be attained.

References

The Joint Commission. (2011a, March 7). Speak up: Prevent errors in your care [Video podcast]. Retrieved from http://www.jointcommission.org/multimedia/speak-up-prevent-errors-in-your-care-/

The Joint Commission. (2011b, April 5). Speak up: Prevent the spread of infection [Video podcast]. Retrieved from http://www.jointcommission.org/multimedia/speak-up–prevent-the-spread-of-infection/

Josie King Foundation. (2002). About: What happened. Retrieved from http://www.josieking.org/page.cfm?pageID=10

Macdonald, M. (2009). Pilot study: The role of the hospitalized patient in medication administration safety. Patient Safety & Quality Healthcare, 6(3), 28-31. Retrieved from http://www.psqh.com/

Niedowski, E. (2003, December 15). From tragedy, a quest for safer care; Cause: After medical mistakes led to her little girl’s death, Sorrel King joined with Johns Hopkins in a campaign to spare other families such anguish. The Sun, pp. 1A. Retrieved from http://teacherweb.com/NY/StBarnabas/Quality/JohnsHopkinsErrors.pdf

Vincent, C. A. & Coulter, A. (2002). Patient safety: what about the patient? Quality & Safety in Health Care, 11(1), 76–80. doi:10.1136/qhc.11.1.76

Zimmerman, R. (2004, May 18). Doctors’ new tool to fight lawsuits: Saying ‘I’m sorry’. Wall Street Journal, pp. A1. Retrieved from http://www.theoma.org/files/wsj%20-%20medical%20error%20-%2005-18-2004.pdf

Criminal Justice, Emergency Management, Politics, Society, Technology

Hacking Cyberterrorism

Although not particular to cyberterrorism, for this discussion I have chosen hacking as a type, or means, of cyberterrorism. Hacking covers virus loading and denial of service attacks, also. In order to carry out a cyberterrorism attack, it must be based on some sort of hacking. First, however, we must agree on the definitions of hacking and cyberterrorism. US Legal, a website dedicated to providing legal reference, broadly defines hacking as “intentionally accesses a computer without authorization or exceeds authorized access” (Computer hacking law & legal definition, n.d., para 1). Cyberterrorism is, according to Denning (2006):

…[H]ighly damaging computer-based attacks or threats of attack by non-state actors against information systems when conducted to intimidate or coerce governments or societies in pursuit of goals that are political or social. It is the convergence of terrorism with cyberspace, where cyberspace becomes the means of conducting the terrorist act. Rather than committing acts of violence against persons or physical property, the cyberterrorist commits acts of destruction or disruption against digital property. (p. 124)

Arguably, in order to use a computer system to do any of the above, it involves hacking, but without hacking, there can be no cyber- component to cyberterrorism, which leaves mere terrorism. Fortunately, using these definitions, there has never been a cyberterrorism attack ever in history (Brunst, 2008; Conway, 2011). Brunst (2008) goes further using the term terrorism to include the planning (and, even pre-planning) phases of an event. I disagree with this tact in scholarship. Brunst fails to provide the distinction between cybercrime and cyberterrorism. Thinking simply, having a Facebook account in order for ease of communication does not amount to meeting for coffee. Messaging a friend on Facebook and organizing a meeting does not constitute meeting for coffee. The act of two or more persons meeting for coffee is a conventional one, however it was planned. This is the same with terrorism. I argue that, although much planning and radicalization can occur using computer networking (e.g. Facebook, MySpace, general information websites, et al.), any terroristic act that stems from such organization would still be considered conventional terrorism unless the act, itself, is described as being technological in nature (Conway, 2011).

There is potential for a cyber-attack to generate fear, economic impact, and the loss of life. This is why we concentrate on security measures to ensure difficulty in accessing systems without proper credentialing, rapid identification and response to active intrusions and threats, and recovery techniques to identify and repair data, networks, and nodes that were involved. For this reason, networks are designed with human redundancy. Human redundancy, as Clarke (2005) explains, integrates human decision points within a technological operational structure in order to detect, indicate, explain, and correct an error. Additionally, infrastructure, a commonly regarded target by the experts, tends to be resilient by its own nature making cyber-attacks inefficient and ineffectual (Conway, 2011; Lewis, 2002; Wilson, 2005)

References

Brunst, P. W. (2008). Use of the internet by terrorists: A threat analysis. Responses to Cyber Terrorism, 34(1), 34–60.

Clarke, D. M. (2005). Human redundancy in complex, hazardous systems: A theoretical framework. Safety Science, 43(9), 655-677. doi:10.1016/j.ssci.2005.05.003

Computer hacking law & legal definition. (n.d.). US Legal. Retrieved from http://definitions.uslegal.com/c/computer-hacking/

Conway, M. (2011). Against cyberterrorism: Why cyber-based terrorist attacks are unlikely to occur. Communications of the ACM, 54(2), 26-28. doi:10.1145/1897816.1897829

Denning, D. (2006). A view of cyberterrorism five years later. In K. E. Himma (Ed.), Internet security: hacking, counterhacking, and society (pp. 123-139). Sudbury, MA: Jones and Bartlett.

Lewis, J. A. (2002, December). Assessing the risks of cyber terrorism, cyber war and other cyber threats. Washington, DC: Center for Strategic and International Studies. Retrieved from http://www.steptoe.com/publications/231a.pdf

Wilson, C. (2005, April 1). Computer attack and cyberterrorism: Vulnerabilities and policy issues for Congress (CRS Congressional report No. RL32114). Retrieved from http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA444799&Location=U2&doc=GetTRDoc.pdf

Criminal Justice, Emergency Management, Politics, Technology

Cyberterrorism vs. WMD

Perhaps in an Orwellian society where computers are independant and there is very little human-to-computer interaction could a cyberterrorist cause such an impact as to be equal with a weapon of mass destruction. This is not true, however, regarding the technology of today. According to James Lewis (2002) from the Center for Strategic and International Studies, “cyber attacks are less effective and less disruptive than physical attacks. Their only advantage is that they are cheaper and easier to carry out than a physical attack” (p. 2). Studies of the implementation of efforts to reduce the effectiveness of infrastructure during war show a resiliency that is poorly respected. Redundant systems in conjunction with a focused human response provides mitigation to reduce the impact of disruptive efforts on infrastructure (Wilson, 2005). It seems the more important the system, the larger and focalized the response.

The northeast blackout of 2003 provides a decent case study, although the cause was a systems failure and not related to terrorism. According to the article by Minkle (2008), within an hour and a half, 50-million subscribers lost power in eight states and parts of Canada for a few days, yet it only contributed to about 11 deaths within the affected area. While the impact was significant, geographically, it was more or less a nuisance for most people.

References

Lewis, J. A. (2002, December). Assessing the risks of cyber terrorism, cyber war and other cyber threats. Washington, DC: Center for Strategic and International Studies. Retrieved from http://www.steptoe.com/publications/231a.pdf

Minkle, J. R. (2008, August 13). The 2003 northeast blackout — five years later. Scientific American. Retrieved from http://www.scientificamerican.com/

Wilson, C. (2005, April 1). Computer attack and cyberterrorism: Vulnerabilities and policy issues for Congress (CRS Congressional report No. RL32114). Retrieved from http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA444799&Location=U2&doc=GetTRDoc.pdf

Academia, Health Care, Public Health

Comparing Hospital Care in My Area

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

Bioweapons of Mass Destruction: Actual Use or Hoax

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

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

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

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

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

References

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

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

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

Walsh, D. W., Christen, H. T., Callsen, C. E., Miller, G. T., Maniscalco, P. M., Lord, G. C., & Dolan, N. J. (2012). National Incident Management System: principles and practice (2nd ed.). Sudbury, MA: Jones & Bartlett.

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

Medical Error: The Josie King Story

Josie King’s story (Josie King Foundation, 2002; Niedowski, 2003; Zimmerman, 2004) is heartbreaking, but the events told herein empowered Sorrel King, Josie’s mother, to take on a mission responsible for numerous patient care recommendations that have enhanced the safety of pediatric patients throughout the country. Josie King was only 18 months old when she climbed into a hot bath and suffered 1st and 2nd degree burns which led to her being admitted to Johns Hopkins pediatric intensive care unit (PICU). Within 10 days, Josie was released from the PICU and brought to the intermediate floor with all assurances that she was making a remarkable recovery and would be released home in a few days. Josie did not continue her remarkable recovery, however.

According to Sorrel King (Josie King Foundation, 2002), Josie began acting strangely, exhibiting extreme thirst and lethargy, after her central intravenous line had been removed. After much demanding by Sorrel, a medication was administered to Josie to counteract the narcotic analgesia she had been administered. Josie was also allowed to drink, which she did fervently. Josie, again, began recovering quickly. Unfortunately, the next day, a nurse administered methadone, a narcotic, to Josie as Sorrel told her that Josie was not supposed to have any narcotics… that the order had been removed. Josie became limp and the medical team had to rush to her aid. Josie was moved back up to the PICU and placed on life support, but it was fruitless. Josie died two days later and was taken off life support.

The Institute of Medicine (2001) published six dimensions of health care: safety, effectiveness, patient-centered, timeliness, efficiency, and equality. In Josie’s case, the care was not delivered efficiently, effectively, safely, or in a patient- or family-centered fashion. The overuse of narcotics in Josie’s case was certainly not effective or safe. Additionally, withholding fluids and allowing her to become dehydrated was detrimental to her recovery, which was neither safe nor effective. As Josie exhibited extreme thirst, her symptoms were dismissed, which does not follow patient-centeredness. Moreso, when the nurse administered the narcotic to Josie despite the pleadings of her mother, it demonstrated a lack of family-centered care, safety (in that, the order should have been double checked), efficacy (further demonstrating overuse of narcotic analgesia), and efficiency, as medication orders were either unclearly written or removed.

This story is clearly a demonstration that mistakes can happen at even the best of hospitals.

References

Institute of Medicine. (2001, July). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

Josie King Foundation. (2002). About: What happened. Retrieved from http://www.josieking.org/page.cfm?pageID=10

Niedowski, E. (2003, December 15). From tragedy, a quest for safer care; Cause: After medical mistakes led to her little girl’s death, Sorrel King joined with Johns Hopkins in a campaign to spare other families such anguish. The Sun, pp. 1A. Retrieved from http://teacherweb.com/NY/StBarnabas/Quality/JohnsHopkinsErrors.pdf

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

Criminal Justice, Emergency Management, Politics, Society, Technology

Planning a Terrorist Attack

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

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

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

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

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

References

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

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

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

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

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

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

Emergency Management, Emergency Medical Services

Ethics and Decision Making During Critical Incidents

As a paramedic, I am faced with ethical decisions fairly frequently. As an example, I am usually the sole responding paramedic to an incident that might involve a number of seriously ill or injured patients (e.g. car accidents, fires, carbon monoxide). These incidents are challenging in that I have to choose which patient(s) will be treated at the higher level of care that I can provide versus the lower level of care that the basic life support units can provide. Typically, I base my decision merely on which patient is more ill or injured; however, many times I am faced with a number of critical patients and must decide based on ethical criteria, such as who would benefit more from my care in the long run, including the fact that adolescent and adult patients tend to fair better than elderly and infant patients (Broos, D’Hoore, Vanderschot, Rommens, & Stappaerts, 1993; Kypri, Chalmers, Langley, & Wrigh, 2000; McGwin, Melton, May, & Rue, 2000).

One of the problems with attempting to remain ethical while decisions during an emergency response is that the situational picture is almost never as clear as you need it. This is especially true as the scope and scale of the incident increases. As the magnitude of an incident grows, the incident command team become inundated with information, and it is common to be overwhelmed. We do, though, try our best to be just and fair in our determinations. We need to make our decisions based on the current information and not dwell on if they were right or wrong (Walsh et al., 2012), only if we could have approached the problem more effectively and efficiently, and this should be done only in the debriefing.

References

Broos, P. L. O., D’Hoore, A., Vanderschot, P., Rommens, P. M., & Stappaerts, K. H. (1993). Multiple trauma in elderly patients. Factors influencing outcome: importance of aggressive care. Injury, 24(6), 365-368. doi:10.1016/0020-1383(93)90096-O

Kypri, K., Chalmers, D. J., Langley, J. D., & Wrigh, C. S. (2000). Child injury mortality in New Zealand 1986–95. Journal of Paediatrics and Child Health, 36(5), 431–439. doi:10.1046/j.1440-1754.2000.00559.x

McGwin, G., Melton, S. M., May, A. K., & Rue, L. W. (2000). Long-term survival in the elderly after trauma. Journal of Trauma, Injury, Infection, & Critical Care, 49(3), 470-476.

Walsh, D. W., Christen, H. T., Callsen, C. E., Miller, G. T., Maniscalco, P. M., Lord, G. C., & Dolan, N. J. (2012). National Incident Management System: principles and practice (2nd ed.). Sudbury, MA: Jones & Bartlett.