I was reading the news the other day and came across an article entitled 'San Antonio paramedic didn't check pulse before declaring wreck victim dead'. Naturally we only have a portion of the real story however when cases like this occur it puts Incident Response in to perspective.
1) We don't deal in life or death situations. We deal with computers. Granted, depending on the particular system it could create a life or death situation but generally speaking it's about a computer that someone somewhere views as "important" - more often than not because it's a revenue stream.
2) Not checking vital signs of a victim can lead to disastrous results. This points to a live response. At the very least, check the vitals of the victim system before you pull the plug and 'pronounce' them dead.
3) Never just pronounce the victim dead. Granted there are some situations where presumptions can be made pretty easily -but generally, paramedics don't do that, it's not their job. Their job is to save lives. The coroner or medical examiner pronounces. Incident Responders should not just pull the plug.
4) Even with years of experience, training can be forgotten in the heat of the moment. Living a life of 'trials by fire' can lead to overconfident and sloppy behavior that can result in poor performance when it matters most. Regardless of how busy you or your team are, make time to step back and review and refine procedures and policies.
5) Beware the fog of war. After long hours or during a particularly hectic scene the fog of war can be thick and hazardous. Situational awareness must be maintained.
6) Incidents occur because of multiple layers of failure. When incidents occur it's easy to point the finger at the lowest person on the totem pole, but rarely is the fault solely theirs.
7) It takes a catastrophe for change to occur. Sometimes it's not such a bad thing when executives get slapped in the face. Unfortunately this is what it takes to wake them up.
This case is a tragedy to be sure but there is always a lesson to be learned.
Saturday, January 12, 2008
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