Jwade

CH, That is why I asked for clarification, I simply provided the article as a refresher just in case.... Respectfully, JW

Speedy, Can you clarify the above for me please? Not sure I understand? Femoral pulse checks are pretty worthless. See below... Respectfully, JW (Circulation. 2005;112:IV-78 – IV-83.) © 2005 American Heart Association, Inc. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care 8. Connick M, Berg RA. Femoral venous pulsations during open-chest cardiac massage. Ann Emerg Med. 1994; 24: 1176–1179. Assessment During CPR At present there are no reliable clinical criteria that clinicians can use to assess the efficacy of CPR. Although end-tidal CO2 serves as an indicator of cardiac output produced by chest compressions and may indicate return of spontaneous circulation (ROSC),1,2 there is little other technology available to provide real-time feedback on the effectiveness of CPR. Assessment of Hemodynamics Coronary Perfusion Pressure Coronary perfusion pressure (CPP = aortic relaxation [diastolic] pressure minus right atrial relaxation phase blood pressure) during CPR correlates with both myocardial blood flow and ROSC (LOE 3).3,4 A CPP of 15 mm Hg is predictive of ROSC. Increased CPP correlates with improved 24-hour survival rates in animal studies (LOE 6)5 and is associated with improved myocardial blood flow and ROSC in animal studies of epinephrine, vasopressin, and angiotensin II (LOE 6).5–7 When intra-arterial monitoring is in place during the resuscitative effort (eg, in an intensive care setting), the clinician should try to maximize arterial diastolic pressures to achieve an optimal CPP. Assuming a right atrial diastolic pressure of 10 mm Hg means that the aortic diastolic pressure should ideally be at least 30 mm Hg to maintain a CPP of 20 mm Hg during CPR. Unfortunately such monitoring is rarely available outside the intensive care environment. Pulses Clinicians frequently try to palpate arterial pulses during chest compressions to assess the effectiveness of compressions. No studies have shown the validity or clinical utility of checking pulses during ongoing CPR. Because there are no valves in the inferior vena cava, retrograde blood flow into the venous system produce femoral vein pulsations.8 Thus palpation of a pulse in the femoral triangle may indicate venous rather than arterial blood flow. Carotid pulsations during CPR do not indicate the efficacy of coronary blood flow or myocardial or cerebral perfusion during CPR. Assessment of Respiratory Gases Arterial Blood Gases Arterial blood gas monitoring during cardiac arrest is not a reliable indicator of the severity of tissue hypoxemia, hypercarbia (and therefore the adequacy of ventilation during CPR), or tissue acidosis. This conclusion is supported by 1 case series (LOE 5)9 and 10 case reports10–19 that showed that arterial blood gas values are an inaccurate indicator of the magnitude of tissue acidosis during cardiac arrest and CPR both in and out of hospital. Oximetry During cardiac arrest, pulse oximetry will not function because pulsatile blood flow is inadequate in peripheral tissue beds. But pulse oximetry is commonly used in emergency departments and critical care units for monitoring patients who are not in arrest because it provides a simple, continuous method of tracking oxyhemoglobin saturation. Normal pulse oximetry saturation, however, does not ensure adequate systemic oxygen delivery because it does not calculate the total oxygen content (O2 bound to hemoglobin + dissolved O2) and adequacy of blood flow (cardiac output). Tissue oxygen tension is not commonly evaluated during CPR, but it may provide a mechanism to assess tissue perfusion because transconjunctival oxygen tension falls rapidly with cardiac arrest and returns to baseline when spontaneous circulation is restored.20,21 End-Tidal CO2 Monitoring End-tidal CO2 monitoring is a safe and effective noninvasive indicator of cardiac output during CPR and may be an early indicator of ROSC in intubated patients. During cardiac arrest CO2 continues to be generated throughout the body. The major determinant of CO2 excretion is its rate of delivery from the peripheral production sites to the lungs. In the low-flow state during CPR, ventilation is relatively high compared with blood flow, so that the end-tidal CO2 concentration is low. If ventilation is reasonably constant, then changes in end-tidal CO2 concentration reflect changes in cardiac output. Eight case series have shown that patients who were successfully resuscitated from cardiac arrest had significantly higher end-tidal CO2 levels than patients who could not be resuscitated (LOE 5).2,22–28 Capnometry can also be used as an early indicator of ROSC (LOE 529,30; LOE 631). In case series totaling 744 intubated adults in cardiac arrest receiving CPR who had a maximum end-tidal CO2 of <10 mm Hg, the prognosis was poor even if CPR was optimized (LOE 5).1,2,24,25,32,33 But this prognostic indicator was unreliable immediately after starting CPR in 4 studies (LOE 5)1,2,32,33 that showed no difference in rates of ROSC and survival in those with an initial end-tidal CO2 of <10 mm Hg compared with higher end-tidal CO2. Five patients achieved ROSC (one survived to discharge) despite an initial end-tidal CO2 of <10 mm Hg. In summary, end-tidal CO2 monitoring during cardiac arrest can be useful as a noninvasive indicator of cardiac output generated during CPR (Class IIa). Further research is needed to define the capability of end-tidal CO2 monitoring to guide more aggressive interventions or a decision to abandon resuscitative efforts. In the patient with ROSC, continuous or intermittent monitoring of end-tidal CO2 provides assurance that the endotracheal tube is maintained in the trachea. End-tidal CO2 can guide ventilation, especially when correlated with the PaCO2 from an arterial blood gas measurement.

Well, you will see two schools of thought from people on this, some will say yes try it, others such as myself will say no... In my 19 years experience in EMS, the PROBABILITY of pacing working is NOT statistically significant. Also, there is case law to support the medic D/C compressions based on sheer exhaustion...... Respectfully, JW

Well, Short answer, NO and it depends.... First, to answer your question accurately, please " qualify" arrest? If the patient is in V-Fib or Pulseless V-tach, the answer is NO. If your patient is in symptomatic bradycardia, refractory to medication , then obviously pacing and or CPR are indicated. ( This is also making the assumption one has figured out WHY the patient is in arrest and is instituting specific TX modalities. Respectfully, JW

You said the key word in this entire scenario..." WALK AROUND" As a pilot, this is something I do EVERY single time before every leg of a flight...........As a Flight Paramedic, this is something I did as well, EVERY SINGLE TIME........Complacency Kills! Honestly, how hard would it have been to open the door and put it on the seat? Seriously.......MAJOR FAIL........ JW

Just wanted to elaborate a little more on how " Negligence" is actually proven in a court of law. Just finished up a law class, so this is pretty fresh in my mind! Negligence claims require the plaintiff to prove 5 elements: 1. Duty of care owed to the victim, and 2. Breach of that duty of care, and was the 3. Actual Cause of the damages or injuries, and was 4. Proximate Cause of the damages or injuries, and 5. Damages or Injuries resulted. Duty of Care owed? The basic premise of the law of negligence is that each person has a duty to conduct their affairs in a manner which avoids an unreasonable risk of harm to others. But one doesn’t owe a duty of care to just anyone. Courts look at fairness and public policy to determine whether a duty is owed, also whether there’s a special relationship e.g. doctor/patient, attorney/client, also whether there is a statute that creates a duty of care to that person, e.,g. traffic laws. Generally, a promise made to another person is not sufficient to create a duty of care. Breach of Duty of Care? The standard by which a person's actions will be measured is that of a hypothetical reasonably prudent person. The standard is thus objective, but is also flexible by assuming the reasonably prudent person has the knowledge of the defendant and is viewed in the circumstances of the defendant as of the time of the objectionable conduct. If the conduct falls below the minimum standard of care, then a tort will be found to have been committed. Thus, a specific intent to commit the tort is not required -- merely to have failed to exercise that degree of care that would have been exercised by a reasonably prudent person. Actual Cause? Courts use the “but for” test where one person is at fault. If more than one person is at fault, then courts generally use the “substantial factor” test. Proximate Cause? Even if the defendant owed a duty of care, and breached that duty, and actually caused the damage or injury, the defendant must also be the proximate cause. That means that the actual consequences were reasonably foreseeable. Damages or Injuries? Courts require more than emotional distress. They require some evidence of property damage or physical injury. Here are some special negligence doctrines: 1. Negligence per se. A statute or ordinance establishes the duty of care. A violation of the statute or ordinance constitutes a breach of this duty of care. 2. Res ipsa loquitur. A presumption of negligence is established if the defendant had exclusive control of the instrumentality or situation that caused the plaintiff's injury and the injury would not have ordinarily occurred but for someone's negligence. The defendants may rebut this presumption. 3. Dram Shop Acts. State statutes that make taverns and bartenders liable for injuries caused to or by patrons who are served too much alcohol and cause injury to themselves or others. 4. Social host liability. Some states make social hosts liable for injuries caused by guests who are served alcohol at a social function and later cause injury because they are intoxicated. 5. Guest statutes. Provide that a driver of a vehicle is not liable for ordinary negligence to passengers he or she gratuitously transports. The driver is liable for gross negligence. 6. Good Samaritan laws. Relieve doctors and other medical professionals from liability for ordinary negligence when rendering medical aid in emergency situations. 7. Fireman's rule. Fire fighters, police officers, and other government employees who are injured in the performance of their duties cannot sue the person who negligently caused the dangerous situation that caused the injury. 8. "Danger invites rescue" doctrine. A person who is injured while going to someone's rescue may sue the person who caused the dangerous situation. 9. Common carriers and innkeepers. Owe a duty of utmost care, rather than the duty of ordinary care, to protect their passengers and patrons from injury. 10. Landowners. Landowners (and tenants) owe the following duties to persons who come upon their property: a. Invitees. Duty of ordinary care b. Licensees. Duty of ordinary care c. Trespassers. Duty not to willfully and wantonly injure trespassers. Respectfully, JW

I would not go as far and say no good option....... MIT ( Massachusetts Institue of Technology) provides many outstanding lectures and video courses online free of charge...I have literally watched 2 semesters worth of various MBA and Health courses..... MIT LINK Just click on the Health Sciences and Technology link, or go to the video courses, or whatever else you need..... Many top rated schools have put their lectures and courses online for free. One just has to know where to look... Respectfully, JW EDIT......In fact, I just went through HST 151 Principles of Pharmacology, ( found under the Health Sciences link) The lecture notes are all in PDF form and are VERY GOOD! Let me know what you think...

Richard, Good info about the radio stuff......The cost structure you outlined above SHOULD be covered ad nauseum in a well written Business Plan...As a Pilot, Paramedic, and someone who holds an MBA, I certainly agree with you the chances of startup and making it past year 1 are slim at best without proper leadership and capital..... Respectfully, John Wade MBA, FP-C

Dart, Here is the REAL, NO BULLSHIT deal answers to your questions... FIRST AND FOREMOST...... 1. You and Your Friend need to write a BUSINESS PLAN for your future Helicopter Service.... For Example I am currently in the process of starting a fixed wing operation with a friend of mine, and the business plan we wrote was 35 pages, with 15 of those pages being nothing but FINANCIAL INDICATORS. This will be the HEART and SOUL of the operation and not something that can be thrown together quickly or done mediocre. For example, 1. Personnel Plan 2. Profitability % 3. Activity Ratios 4. Leverage Ratios 5. Liquidity Ratios 6. EBITDA 7. Debt to Asset Ratios 8. Revenue Forecast - Broken down monthly 9. Revenue Forecast - yearly 10. Break Even Analysis for 1st year 11. Pro Forma P&L ( Profit and Loss) Statements, Must Pro Forma out 5 years 12. Gross Margin & Monthly Profit 13. Pro Forma Cash Flow - 5 years Projected 14. Pro Forma Balance Sheet - 5 years = Assets & Liabilities / Shareholders Equity 15. Sensitivity Analysis The above was just my financial section alone, and it took us months just to write the plan, revise, revise, revise, etc......We are now in the process of dealing with Angel Investors for our initial startup funds..... With your limited experience in the air-medical industry and limited formal business education, I would say you have your work cut out for you indeed, not impossible, but, you're going to need the right help from the right people.... Once, you get this done and perfected, you then need to decide if you are going with a specific Vendor, and whose Part 135 certificate you will be using. This is also something that must be planned for, as the FAA just doesnt give these out like candy....They are VERY EXPENSIVE and time consuming to get one....and without one, you do not fly anywhere..... Now, after those things are done, you must think about aircraft type, Single vs Twin, VFR vs IFR, Single Pilot vs Dual Pilot, Medical Crew Configuration, training, continuing education, maintenance, Night Vision Goggles..., etc..... Where are you going to base the helicopter, Hospital, airport, or some other option? Medical Director....You must have a medical director for the program. These are just some of the very basic things you must have done to even remotely have a chance to get this thing off the ground......again, Not impossible, but highly improbable with what I have read so far..... Let us know more. John Wade, MBA, CCEMT-P, FP-C

Seems like EMS is not the only people who can't agree on entry level standards......Thoughts? Nursing Tug of War

Exactly, I heard this EXACT same quote from 2 different ER nurses today while I was teaching ACLS........ The paramedics who would be capable of working in an ICU would be considered statistical outliers. ( Yes, there are some) However, definitely not the mean of the population... Respectfully, JW

Course Requirements for AAS Degree Paramedic Courses Required All courses with the PAR prefix must be passed with a "B-" or better in order for a student to progress through the paramedic program sequence. PAR 1000 EMT Basic (2) PAR 1001 EMT Basic Lab (4) PAR 2000 Intro to Paramedic Practice (4) PAR 2010 Medical Emergencies (6) PAR 2020 Traumatic Emergencies (3) PAR 2030 Special Considerations in Paramedic Practice (3) PAR 2040 Paramedic Clinical I (4) PAR 2100 Advanced Paramedic Practice (4) PAR 2110 Paramedic Clinical II (3) PAR 2120 Paramedic Internship (9) Students participating in the distance education “Skills Camps” will also complete the following: PAR 1011 EMT Intermediate Intro Lab (2) PAR 1021 EMT Intermediate Lab (2) PAR 1031 Advanced Cardiac Life Support (ACLS) (1) Biomedical core courses required (or acceptable equivalent) HTHS 1101 Medical Terminology (2) Must be taken in sequence HTHS LS1110 Health Sciences (Biomedical Core) (4) HTHS 1111 Health Sciences (lab) (4) Acceptable Equivalent to completing the anatomy and physiology requirement ZOOL 2100 Human Anatomy (4) ZOOL 2200 Human Physiology (4) or HTHS 1115 Biomedical Principles for Certificate of Completion for Paramedics (4) Support Courses Required (15 credit hours) COMM HU2110 Interpersonal & Small Group Communication (3) HLTH 3400 Substance Abuse Prevention (3) HTHS 2230 Pathophysiology (3) PSY SS1010 Psychology (3) SOC SS/DV1020 Social Problems (3) This is how the program stands now, as compared to when I started 20 years ago. Most of the same requirements still in place. The differences from my day are I don't see any specific Pharm I,II classes, and the Chemistry, Micro have been combined into the year long Bio-Medical core classes, which give you A&P, Micro, Organic/Inorganic Chem over the course of a year, minus summer semester. Obviously, on top of the above are all the general requirements as well, English, Psych, College Algebra, etc....... The chemistry was required for the AAS when I started, again, the chem is still in the program if the student takes the BioMed Core classes. This was NOT in michigan. Respectfully, I guess it depends on how you "qualify" normal? This was my world when i started, so for me, that was my normal. Now, what has happened over the last 20 years is up for debate obviously. In looking at UMSTUDENT list of schools, seems there are still some doing it correctly..... Mine has clearly changed somewhat from when I was going to school there. However, for the most part, this program is still clearly a few standard deviations above the mean! :-) Respectfully, JW

CCMEDOC, My paramedic program REQUIRED A&P I,II, Microbiology, Organic Chemistry, Inorganic Chemistry, Pathophysiology, Pharmacology I,II, All these classes were taken in a 300 seat auditorium at a very big University, where all the students of Nursing, EMS, RT, PRE-MED, all sat together for these classes.....Only when we went for our " core" classes did we break up into our respective fields......... So, after reading this last 2 pages of the thread, both sides present strong and valid points. Unfortunately, politics and ego continue to dominate the efforts needed to make meaningful change. I love EMS and being a paramedic with all my heart, I have NEVER wanted to be a Nurse, but, I went to Graduate School to pursue an education that will hopefully allow me at some point to cut through all the BS on both sides and make some change..... Respectfully, JW

Agree with CHBARE i do!!!! ( My best YODA impersona) Go to the APP store and search for iRESQ. I downloaded it tonight, and it is amazing...by far the best out there.... Also, the author is a friend of mine, and if you have any issues or problems, he will take care of them ASAP for you..... JW

Vent, My cousin is a PT in Michigan and her program was a Masters in Science. I am pretty sure just about all PT programs are all Graduate level now? We could take a lesson from these guys and the Pharm people i think! JW

Vent, My apologies, I must have misread your statement earlier. I stand corrected on the Hospital Admin and education issue! :-) From what I have read about MBA programs from the early 80's compared to programs currently, the focus seems to have changed dramatically, and just like nursing, has expanded to encompass areas as you have pointed out in the previous responses. Dust, I have also heard some friends of mine express the same thing about RT school being much more difficult than nursing school. One of my close friends who was a 2 year degree medic first, said nursing school was just beyond boring and mundane. He really enjoyed RT school after 2 years as an RN, and was happy he made the change. CHbare, Here in Arizona, there are very long wait lists for nursing school due to the lack of qualified Nursing instructors. Respectfully, JW

Dust, Very well stated! HEMS is overrated, and people take themselves way too seriously. You would think with some of the EGO's involved, they were curing cancer or something! JW Vent, In the MHA classes we look at a variety of different models that are being taught to various other allied health providers, including BSN, NP, PA, CRNA ( including the new DNP, DNAP), MD, DO, PT, PharmD. We have done many statistical analyses to see which models have proven effective based on a variety of variables. However, this would clearly be beyond the scope of this conversation. Do you honestly think that Hospital CEO's and Administrators have NO clue as to what other professions require for education? I agree Nursing is a very expansive profession, I do believe I stated that in a previous post somewhere. I think we are just looking at it from two different spectrums clinical versus business. Respectfully, JW

Maverick, Have you checked into Wayne States CD2 BSN program? This is a 1 yearish ( 16 months) BSN program for students with a previous Bachelors and all prereqs completed. I have had at least 5 friends of mine go through this program when I lived in Detroit, and all were successful and anecdotally stated it was not really all that difficult. Granted, most had previous medical experience as well. Wayne State University / CD2 BSN Program Again, Follow your heart! Good Luck, JW

Trust me, I am not missing the point.... I understand he was not in ST, that is pretty easy to figure out, however, I still would NOT have pushed adenocard. Based on the anecdotal info you have provided, this patient would have been provided O2, serial 12 leads in route, depending on timeframe, possibly pain control, and I would have insisted his Cardiac Surgeon been called from his PCP's office. I still would not classify him as " Unstable" so, I would have waited to see some labs before I started him on any drips. Just because someone is in A Flutter, does not make one immediately deemed unstable.... Respectfully, JW

No offense taken. Excellent reply. I will qualify " anecdotal " as your initial post stated " YOU WERE TALKING TO A PARAMEDIC". This in and of itself makes the entire scenario anecdotal. It would be completely different if this was your patient, you looked at the 12 lead etc...... Second, Having spent 8 years as a Surgical First Assistant, I can tell you, S/P CABG patients can have these symptoms for months. They can be caused by a variety of reasons, including spasms of the graft, I have seen this firsthand looking into many open chests during my time in the Heart rooms. I am not saying one way or the other, stable or unstable due to the inherent nature of the information provided. This patient could very well be unstable, however, with the info provided in this manner, I would be hesitant to call this patient unstable and have that prompt me to push adenocard. AND, No offense, But I certainly would not allow any PCP to determine my 12 lead, I would insist on having the cardiologist on call or the cardiac surgeon who had his or her hands in the patients chest to determine this info....To each their own though! Most Respectfully, JW

CCMEDOC, Good info, Thank you. I would have to read each study independently to verify the validity of the study and see what variables were excluded to reach their conclusions. It is often not what was included in the study which makes it valid, often times these are manipulated by leaving certain demographics out, as you probably already know being an MSN. Again, I think you are taking my point out of context. In fact, even though I am NOT a BSN, in my MHA classes we have studied these programs quite extensively for reasons such as you provided in your post. So, I have a very in depth understanding of what these BSN Management classes are teaching, and they are a very basic level. I will qualify basic by saying they only teach a broad overview of concepts such as accounting, finance, stats, healthcare law, etc......Very few offer entire semesters of these classes as I stated would be a beneficial track if made available to the BSN students for those interested in future leadership opportunities. As it stands now, most are poor leaders being held back by a lack of formal education in this area. Of course there will always be outliers, but most in my experience tend to operate at two standard deviations below the mean. :-) Just to clarify, I am certainly not against a BSN by any means, one must compare apples to apples in order to be swayed, for which, I am always open. Just not through a bunch of anecdotal evidence. Respectfully, JW

Kaisu, Take the above advice quickly. One of my previous employers tried to do the same thing to me with some comments I posted on Flightweb. Unfortunately, Upper Management was completely inept and did not do their homework before opening their mouths to me. So, I called my lawyer, I had her print off the thread in question, and then proceed to call the Program Director and explain the finer points of our constitution to him and a few other business law statutes. Needless to say, My base supervisor called with an apology very quickly, and the Program Director refused to even make eye contact the next time I saw him. ( You really have to love the uneducated!) Don't worry about HIPPA, 99% of the people who talk about HIPPA violations have not even read the entire document. Their opinions are almost always anecdotal... JW EDIT---( P.S.) I don't like lawyers either, but they are worth their weight in gold when you really need one, so, my advice would be to NOT shut that door automatically! Keep your options open.

Vent, Agreed, on the state license issue! You are correct, good point! As with Nursing some time ago, many diploma RN's did not have a degree and still able to get a license. EMS just needs to get with the program and force out all of the medic mills, volunteers, etc.....I personally think they should all be 2-4 year degree programs such like the one I provided a few posts ago. There would be ZERO arguments anymore as to which profession has the more basic knowledge base! Did Oregon finally institute this requirement? Now, again you make huge assumptions, which, any decent critical thinking course would frown upon as you well know! I am NOT defending the warm body interview style at all...The issue is and has been, you have mostly RN's with zero to very basic business / mgt background running these programs and making poor hiring decisions. This is a fact, not fiction. Trying to compare an MBA to a BSN MGT 101 course is ludicrous. Contrary to your statement, I personally would push for some upper division MGT courses as a track available to the BSN students. Giving someone a broad overview of basic accounting, finance, business law, HR, maybe stats, does very little to prepare someone to be a manager, much less a leader of a program / business / etc......I would make the educational track for mgt where an entire course in the aforementioned classes would have to be taken. This would be a gigantic step in the right direction. Respectfully, JW

Vent, You are killing me here...LOL.... Agreed some people just exist for 10 years.....HOWEVER, this is where someone such as myself who understands the business side of things and has extensive knowledge in business management would be able to " WEED OUT" those " Just Exist" people during the application review process and at the furthest during the interview process. So, they would never make it on to my team to begin with! This is where a lot of Nurse Managers fail because they do not have the advanced business education from which to base sound hiring and business practices! Their very basic MGT classes in the BSN program are not sufficient by any means. Again, I am all for education, and to get back on the OP questions, follow your heart, it does NOT matter how much education you have if you hate your job! I have friends who went to law school, passed the bar, and now went to med school, and one took up being a fly-fishing guide! Follow your heart! Respectfully, JW

VENT, Let me start by correcting you. I have both, license and certification! As I think you well know, Paramedics are LICENSED in the state of Michigan and others. Second, It drives me absolutely crazy when people start throwing the licensure versus certification argument around with their limited knowledge. Having taken a few semesters of graduate level business law, criminal law, and healthcare law, the Case Law and courts have shown no distinction between licensure and certification. Without either one, an individual such as you or me does not partake in the taking care of others. This whole stupid debate was started by RN's trying to protect their EGO's and Turf..... Seriously, they make people who cut your hair have a license! Third, My undergrads are in Physiology and Business Management, My Masters Degrees are an MBA and soon to be completed MHA. Not sure where you are going with that. Fourth, I do believe i said the BSN classes include community health and so forth. I agree with everything else you said about the BSN, although I have my doubts about how many BSN's could show me how to do a statistical research analysis. My point was that a BSN nurse does not provide an education any more suited for taking care of patients straight out of school than a traditional ADN program. Again, I realize there are statistical outliers, however, we never base any decisions on an outlier! I disagree completely with your last paragraph. My liking over a 10 year ICU ADN nurse versus a 3 year BSN nurse is obvious, based strictly on experience. If I am hiring for a clinical position, then 9 out of 10 I am taking the experience versus 3 years...( Assuming all other things are equal)...It has nothing to do from the business side of the equation. Most Respectfully, JW (edited for a spelling error)