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The Dying Continues


Seventeen years ago, almost exactly as I sit typing this terrorists flew two planes into the World Trade Center towers in New York City. This was followed shortly after by a plane crashing into the Pentagon. The passengers of United Airways Flight 93 stopped a similar attack on the Capitol building in Washington, DC. They did that at the cost of their lives.

America was suddenly at war with an enemy few really understood. We’re still at war, and still many people don’t seem to understand with who or why.

I’m not going to go into that today, because today is a day to reflect on the start of the current war, not to discuss it’s tortuous route ever since.

The attacks on the WTC killed almost 3,000 people including people in the towers, police, fire, EMS, and the people on the airplanes.

That was just the first day. I say that because people who were in the area where the towers stood that day are still dying and will continue to die for years to come.

Still Counting: 9/11’s toxic legacy haunts first responders

It’s not too long an article and has a lot of good information. There is some use of the “Retrospectroscope” to talk about what was done that shouldn’t have been and wasn’t done that should have been.

As a country we’ve learned a lot about emergency response to a large scale terrorist event. The people who died that day and are dying to this day paid for those lessons with their lives. Another part of the cost of this war that we are in.

Thousands of firefighters, police, construction workers and people who worked or lived near Ground Zero have become sick since then. Hundreds have since died after breathing in a witch’s brew of asbestos and other toxins. Counting the dead will continue for years to come.


“I think it’s in some ways our Chernobyl. The difference with Chernobyl is that there, vast swatches of land are not habitable because of radiation,” Dr. Jacqueline Moline, director of the Queens World Trade Center Clinical Center, said. “Chernobyl was not a terrorist attack. Most terrorist attacks don’t have a death toll that has a lasting impact in terms of health impact.”

When the World Trade Center tumbled, it didn’t simply fall to the ground or vanish. The conflagration filled the air with toxic particles.

“You’re talking 220 stories of office building on top of the other buildings that collapsed, with computers, fluorescent lightbulbs, phones, desks, metal chairs,” said Michael O’Connell, a 25-year-old firefighter on 9/11. “All of that was incinerated into pure dust. All we found was concrete, steel and rebar. You didn’t find a telephone, a lightbulb, a chair. Nothing.”

A now deceased friend of mine was there and took time to send out an email a couple of days later while he was finally taking a break. He described a landscape from another planet. Something not to be believed. Yet it was all real.

Within a few years, he too was sick and he died about five years ago. He never mentioned it, but reading this article, I’m confident that he died as a result of the toxic mix in the air.

Someone else I know less well will soon die from stomach cancer. I have other friends who were there in the first days and I fear that some of them will suffer and died as well.

Another friend worked for the New York City Office of Emergency Management. His office was in the WTC complex and he was right there when the planes hit. He didn’t evacuate until right before the towers fell and he almost didn’t get out alive.

He now has Sacoidosis and is waiting and hoping.

If you were at the World Trade Center and don’t know about the World Trade Center Health Program, then go to the link and read. If you qualify, sign up.

The dying started on September 11, 2001. It will continue for decades.

Prostate Cancer Awareness Month (PCAM)


September is Prostate Cancer Awareness Month. Prostate Cancer is the second most frequency cancer among men. It kills far more men than Breast Cancer does women.

There are no good cancers, so eradicating them all is the goal. The first step is awareness. If you’re a man and over 40, then you need to have your prostate checked. The studies go back and forth on whether a PSA or digital rectal exam in better. Maybe someday a better blood test will come along and men won’t have to go through the other process.

As for the past several years, some fellow bloggers will be participating in Kilted to Kick Cancer. My good friend JB on the Rocks, has a post about the contest with a link to the Kilted to Kick Cancer site.

Go over there and donate to one of the teams. Or, if you prefer, just make a generic donation. Either way, go, donate, get your prostate checked.

Take it like a man.

Just remember, as unpleasant as it is, it’s better than dying of a treatable disease.

Keep in mind, that it’s not the highlight of your doctors day either.

Here is a little gallows humor to go along with the serious message.

Yesterday In History


A friend who is also a blog follower sent me an interesting Youtube link yesterday.

The video series on Youtube will, over the next six years, cover World War II in real time. Weekly installments will cover significant events during the course of the war. “WW 2 in Real Time” looks to be an interesting and informative series.

Americans are America centric, just as British are British centric, Germans are German centric, and so on.

For America, the invasion of Poland by Germany on September 1, 1939 was mildly interesting. As it was 3,000 or so miles away meant that most Americans didn’t really care what happened over there. Most people probably paid even less attention on September 17, 1939 when the Soviet Army invaded Poland from the east.

Great Britain and France took the threat far more seriously. Both nations declared war on Germany on September 7, 1939. Not that it was of any help to Poland which was conquered by both the USSR and Germany in short order.

September 1 marks the official start of WW II, but the warning signs were there well before that. Fascist Italy invaded Ethiopia in 1935 could be considered the first phase of the war, although it had little impact outside of Africa.

Japan started it’s part of the war in July of 1937 in China. In December of 1937, Japanese aircraft sank the USS Panay on the Yangtze River. The Japanese claimed mistaken identity by it’s pilots and paid compensation.

So, there is room for debate over exactly when WW II started.

Back to the video link. I’m looking forward to this six year project and encourage everyone to follow it’s course. This should be interesting.


A New Firearm And A New Blog Link


Those of you who read this blog regularly, know that I’m very fond of the Smith & Wesson all metal “Third Generation” semi automatic pistols.

The “3rd Gen” guns were in regular production and cataloged from 1988 until 2006. They were produced for law enforcement use until approximately 2013 or so.

They were well built, reliable, accurate, and had a very low rate of breakage. They were also very easy to shoot well because they had a very smooth trigger pull. Available in 9mm, .40 S&W, and .45ACP, they found a lot of use among police agencies in the U.S. and even some foreign nations.

Because the receivers were made of forged metal, they required considerable machine work to produce. This made them expensive to produce and thus they were expensive to buy.

That became a problem once Glock introduced their “Safe Action” semi automatics with polymer frames. An injection molded receiver is a lot less expensive to manufacture and since government agencies at all levels are generally required to purchase the least expensive product that meets the required specifications, a lot of Glocks were adopted by law enforcement agencies around the world.

After a couple of less than successful attempts, in 2006 S&W introduced the “M&P semi automatics for both the law enforcement and civilian markets. Using an action similar in concept to the Glock pistols and made with a polymer frame, the company was able to be competitive with Glock in the LE market.

At the same time, 1911 pattern hand guns started to see renewed popularity with the civilian and to an extent the LE markets. S&W still sold a fair number of revolvers with metal frames.

Something had to go, and for Smith & Wesson “something” was the Third Generation semi automatic pistols. A few larger agencies, NYPD, the RCMP, LAPD, and the California Highway Patrol were big enough customers that S&W continued to produce the “3rd Gen firearms for them after civilian sales of these fine firearms ended.

That was good for civilian owners as the factory had to maintain a supply of replacement parts for agency armorers and the company repair facilities to make necessary repairs and do routine maintenance.

All good things must eventually come to an end, and so Smith decided that they were going to end production for even LE agencies and reduce the number of parts available to the civilian market.

As a result, the firearms see only spotty factory support. If you are a civilian with an alloy framed Third Generation gun and the frame cracks, the company will not repair it because they just don’t have the frames any longer and are not willing to make more.

That doesn’t stop many people, including me, from carrying and shooting these guns. We do that knowing that a major breakdown, while rare, is going to be the end of that gun.

It also means that if the firearm is lost, stolen, or taken as evidence for an investigation, it could be impossible to replace. The odds of that are small, but not negligible.

Since I carry a firearm just about anywhere that does not forbid or make that impractical, the odds are a bit higher. Especially when traveling out of state.

All of which brings me to today’s subject.

A few years ago Springfield Armory introduced their XD line of polymer framed semi automatics. Since they were striker fired semi automatics, I didn’t pay a lot of attention to them as that mode is of no interest to me.

At one time I owned a Glock and a M&P. Both were reliable and accurate, but I just didn’t warm to them.

Then, last year Springfield introduced the XD-E. Polymer framed, but it functioned very much like the Third Generation firearms.

Late last year I read a review of the XD-E by Tamara Keel in “Shooting Illustrated” . Like all of her articles, this one is well written and I encourage you to read it. She covers a lot of points that I have made, but in much more detail.

Based on her article, I made it a point to go to the Springfield display at the NRA Annual Meetings and handle one of the XD-E. I liked what I saw and felt. The only thing that was not quite as good was the double action trigger pull compared to my Model 3913. Still, I was interested and thought that this might make a good “travel” firearm in that it was similar to what I was used to in function and how the controls operated.

I waited until one of the local gun shops received a supply of the new firearms and listed them for sale at a very attractive price. Now, if I was traveling and something happened to my firearm, it would be easy and relatively inexpensive to replace. I headed to the shop, handled a XD-E and decided to buy it. For $392.00 I walked out of the shop carrying my new XD-E.

I got home, field stripped, cleaned, and lubricated my new acquisition and headed out to the range. I brought along my 3913 and did a comparison.

I still like the 3913 better because of the double action trigger pull, but the XD-E is pretty close. Keep in mind that the 3913 is older and has been shot a lot more. I expect that the XD-E trigger pull will improve the more I shoot it.

Here is a picture of the XD-E and an early 3913TSW.

As you can see, they are close is size and similar in layout. The safety/decocker levers on the two firearms work in a slightly different fashion, but they are close enough that the transition from one to the other is easy to learn.

Here is another picture, showing how close they are in size.

The upper of the XD-E is bit shorter and the grip is a bit longer front to back than the 3913. I like the grip of the XD-E just a little bit more than the 3913TSW. It just feels a bit more comfortable in my hand. That, of course, is personal preference and others will no doubt feel differently.

I’m still a bit iffy about the spurred hammer and the lack of a magazine disconnect. Neither are deal breakers and both are a matter of personal preference.

I put about 100 rounds through each gun, and the accuracy wasn’t very different. Both shot without a hiccup, other than one slight annoyance. The XD-E ejected the brass of the box of 147gr Browning FMJ back and to the right. When I put a box of American Eagle 147gr FMJ, two empty cases came straight back and bonked me on the forehead.

I then put a magazine worth of Federal HST 147gr JHP through the XD-E and it ejected without issue.

I had half a box of 115gr FMJ left over from when that was all that I could find in stores during the 2013/14 ammunition shortage. From prior experience, I know that the 3913TSW shoots below point of aim with that ammunition. The XD-E just didn’t care. It shot to point of aim just fine.

Score one point for the XD-E, although I don’t plan to carry that bullet weight in it.

All in all, this is a very suitable substitute for carry when I travel. Reliable, accurate, easy to shoot, and readily available if it ever needs to be replaced. It’s a winner.

A final, side note on magazine disconnects. I like the concept, but I also keep in mind that any mechanical device can fail so I never, ever, rely on that alone. Always make sure that the chamber of any firearm you plan to handle is empty before you handle it. There is very little that is scarier to a shooter than a boom when you expect a click.

As always, follow the Four Rules when handling a firearm.

A New Blog Link

While reading an article at Instapundit about the annoying problem of what do when answering the call of nature while carry a firearm, I came across a link to Eastern Iowa Firearms  Training. This article is better than the one at the Instapundit link. At least I think so. While reading the comments there, I noticed one from OldNFO. If he reads the blog, it’s definitely good enough for me to add to the blog roll.

Duly added.

Speaking of annoying, for my EMS readers, I’m working on a post about the 1-10 “Faces” pain scale. I expect to have that up in a day or so.




Back in February, the acting Mayor of Dallas, TX suggested that the NRA should cancel their Annual Meeting and Exposition scheduled for early May. That was an idiotic and impossible idea. Those meetings are planned two or three years in advance, just as all large conferences are.

I’m not sure what, other than rank politics was in his mind. Maybe just making a virtue signalling statement for the press and his constituents. It doesn’t really matter.

Tonight, I saw this story.

Politican who protested Dallas NRA show pleads guilty to corruption charges

The outspoken Dallas mayor pro tem who balked at the National Rifle Association coming to town earlier this year resigned on Thursday after entering a guilty plea in federal court.

The U.S. Attorney’s Office announced that Dallas City Council Member and Mayor Pro Tem Dwaine Caraway pleaded guilty to conspiracy and tax evasion charges involving $450,000 in bribe and kickback payments stemming from securing a city school bus stop-arm camera contract for a Louisiana company. The Dallas Morning News later reported that Caraway resigned his public position in the aftermath of the revelations.

This is the press release from the US Attorney for the Northern District of Texas.

“Today’s guilty pleas are the results of a sensitive and complex investigation conducted by FBI Dallas’ Public Corruption Investigative Team with assistance from the Internal Revenue Service. The conspirators utilized their position of access and financial means to defraud the citizens of Dallas County,” said Eric K. Jackson, Special Agent-in-Charge of the Dallas Division. “The FBI will continue to aggressively investigate any public servant who abuses their official position and access to benefit themselves financially at the taxpayer’s expense. Additionally, those who seek to exploit public servants with financial or material support will be identified and held accountable for their actions.”

“IRS Criminal Investigation uses financial investigative expertise to pursue those individuals who engage in corruption and tax fraud,” said Tamera Cantu, IRS Special Agent in Charge of the Dallas Field Office. “Merging the unique skills of each agency makes a formidable team as we investigate those who violate the public’s trust. Today’s actions underscore that the law applies to everyone, regardless of position or power.”

The press release is long, but well worth the read.

Taking a bribe is stupid, especially if you involve a bunch of people. Two of whom already plead guilty. Which means that they are now going to be looking for a way to get a shorter prison term.

Of course committing tax fraud isn’t particular bright either. That’s how the government finally put Al Capone away over 90 years ago.

I can’t say I feel particularly bad for this guy, although I do feel sympathy for his family.

Sentencing will take place sometime later this year, I suppose. I also won’t be surprised if this goes deeper and Mr. Caraway doesn’t decide to cooperate with the FBI and IRS.

These are the types of investigations that the FBI built it’s reputation on, and the type that they should focus on.

Another Great Idea Fails To Prove Its Worth


A little over four years ago, I wrote about a mobile Stroke unit being launched out of a Houston hospital. The idea was to speed up diagnosis and treatment of Stroke patients.

I didn’t think much of the idea then and nothing that has transpired in the four years since has change my mind.

Here is the original article for those who care to read or reread it. Stroke Job.

Here is a quote from the article I cited in the post,


Grotta, co-principal investigator of the study, said: “We know we can speed up treatment but we don’t know how much that speed will affect recovery.” .“We really don’t have data on how receiving tPA within the first hour after symptoms start affects patient outcomes, including the amount of disability. This study will help us determine how much more helpful it is to receive tPA within that first hour.”


Apparently we have an answer now. It doesn’t improve outcomes.

They’re a hot idea and spreading rapidly: Since the U.S.’ first mobile stroke ambulance hit the streets in Houston in 2014, at least a dozen have followed in other cities, with more planned.1 There’s just one catch: There’s no data that shows they actually improve patient outcomes. And given their cost, that’s leading an increasing number of docs and other emergency leaders to question whether they really represent the best use of limited dollars.
So, here is an expensive treatment/transport modality that doesn’t improve outcomes in patients. It’s likely that the money can be put into other efforts that will benefit patients.
How expensive? Here is one estimate.
Here’s the math: MSUs cost roughly a million bucks.2,3 “That’s what’s been quoted to us in Louisville,” says Tim Price, MD, an associate professor in the University of Louisville’s Department of Emergency Medicine who argued against MSUs in a pro/con debate at the NAEMSP’s 2018 annual meeting, “and that’s without the telemedicine piece.” Yearly operation may cost half a million to a million more.3,4
That’s a million dollars for the ambulance and modifications to install a mobile CT unit. Then there are the operating costs on top of that. To try to speed up what should be an in hospital process. It still seems to be that working on in hospital issues and educating EMS providers, who really should know this by now, on Stroke recognition and notification, would be money better spent.
For those who don’t come here via Facebook and haven’t seen the featured image for this post there, this is what one of the MSUs looks like,

Yeah, I’d say that would cost close to $1,000,000.00. Plus staffing costs.

The article goes on to talk about the efficacy of tPA in any setting,
This may be startling to providers holding the impression that fast tPA is a wonder drug for stroke. At http://www.thennt.com/nnt/thrombolytics-for-stroke/, author David Newman, MD, overviews 12 key studies that collectively depict something much different: Only two showed clear benefit. Ten were negative, and four of those indeed had to be terminated early.11
An EM physician who I’ve known for some years told me about a year ago that she was very skeptical about the entire stroke treatment paradigm. She said that her experience was that tPA was rarely given and that at that it didn’t have a great track record on reversing the signs and symptoms or restoring pre Stroke function.
Which is too bad as I’m entering the age where I have to add a Stroke to the things I need to worry about.
This also extends to the Mobile Stroke Units that are in operation,
And whether or not tPA works for acute ischemic strokes, early data shows that even mobile stroke units intended for its early delivery just aren’t getting tPA to that many patients. Of the first 100 patients treated by Cleveland’s MSU, just 16 ultimately received tPA—5% of those for whom it was dispatched.3,7 A study of information systems around New York Presbyterian Hospital’s unit found 16 administrations in seven months.17 Calgary’s unit gave it 16 times in its first year.18 And in Houston, now site of the most comprehensive look yet at MSUs’ impact (the BEST-MSU study), a run-in phase revealed an administration rate of 1.5 a week.19

There is a lot more in the article, it’s well worth reading just for the tPA information, regardless of where it was given (or not given).

Finally, is there a role for MSUs in diagnosis and speeding treatment of Large Vessel Occlusions? Maybe. But, the number needed to treat (NNT) seems to be very high even for a diagnosis and transport only approach.

The emphasis in prehospital stroke care today lies less on smaller strokes than large-vessel occlusions. Is there a role for MSUs in identifying these and routing patients to comprehensive stroke centers for fast thrombectomies?

Some recent studies have concluded that’s feasible.22,23 But at NAEMSP Price explored some limitations to that data too. He looked specifically at the conclusions of a Cleveland piece that found the MSU “may help in early triage and shorten the time to IAT (intra-arterial therapy) for AIS (acute ischemic stroke).”24

The data on this is far less than clear and will likely remain so for some time. For that matter, even thrombectomy for LVO, as promising as it appears hasn’t fully proven itself.

Sometimes what seem like great ideas don’t pan out as hoped. The problem is getting the proponents to admit that and move on to something else.

It seems like it’s time to abandon the MSU approach and find something that will improve outcomes.

The science, it seems, is never settled.

Well, That Is Stupid


Kelly Grayson has a very nice article over at EMS1 regarding the Paramedic 2 epinephrine is cardiac arrest study. Cute name, that.

I read it and wanted to put in a comment, so I registered under the name “EMS Artifact.”

Then I went to comment and got a notice that read,

EMS1 comments can only be accessed by verified law enforcement professionals.
If you are a law enforcement professional and wish to be verified, please contact our customer support team.

Yeah, that makes a lot of sense. Only verified police officers can comment on EMS1 topics. I wonder if only verified plumbers can comment on topics at Police1?

The people who run EMS1 seem to be doing their absolute best to run that website into the ground.

Here’s hoping that they succeed.

I can’t swear that that is video of an editorial board meeting, but then again I can’t swear that it isn’t.

I’ll post my comments over at Kelly’s blog, which I should have done in the first place.

She Should Know Better


The Constitution of the United States is the frame work for our nation. It is not a tremendously long document, but it is incredibly important.

Justices to the Supreme Court of the United States have to take two oaths before assuming office. This is one of them, the other is not pertinent to today’s post.

“I, _________, do solemnly swear (or affirm) that I will support and defend the Constitution of the United States against all enemies, foreign and domestic; that I will bear true faith and allegiance to the same; that I take this obligation freely, without any mental reservation or purpose of evasion; and that I will well and faithfully discharge the duties of the office on which I am about to enter. So help me God.”

One would think that having raised their hand and sworn the oath as above, a Justice would understand what the Constitution is about as well as what’s written in it and the first ten amendments thereto.

One would be wrong, I guess.

Ruth Bader Ginsburg apparently has decided that the Constitution is some outdated piece of parchment and should be discarded like a used tissue.

At least that’s what she seemed to say in this interview from 2012. She was asked about a new constitution for Egypt which had recently voted out it’s long time leader and installed a member of the Muslim Brotherhood as President. For those who don’t know, the Muslim Brotherhood is an international organization that has as it’s primary goal the imposition of an Islamic Caliphate. Not just in Egypt or other Muslim countries, but across the length and breadth of the planet.

Here is the interview. There are a number of frankly stupid comments and suggestions. From a woman who is supposed to be one of the best judges in the world, but sounds more like someone’s slightly “off” grandmother.

I’m going to take some of the quotes from this article and comment on them. I have to say that Justice Ginsburg really seems clueless at many points.

“I can’t speak to what the Egyptian experience should be…”

I can. Mohamed Morsi was elected President in June of 2012. He quickly moved to turn Egypt into a theocratic state and there was concern he wanted to reignite ware with Israel.  Within a year there were massive protests of the new government and in July of 2013 the military seized control of the government. Morsi was arrested and is currently in prison. The new constitution was suspended by the government and remains so.

All of which is far less likely to happen under our antiquated Constitution.

“… and yet we have the oldest written Constitution still in force in the world.”

There is a reason for that. It works. Many civilized nations don’t have written Constitutions, and some of the most barbaric ones on the planet do.

The reason that ours is different and works is because it has provisions for amendment. When the main body of the Constitution was drafted, there was serious concern that while it provided a framework for how the government would run, it did nothing to protect individual rights. As a result, the first ten amendments “The Bill of Rights” were added to the main body. The rights enumerated in them were meant to limit the power of the federal government, leave most matters to the individual states, and to protect individuals in their expression of their rights.

For those interested, here is the language laying out how to amend the Constitution.

Article V (Article 5 – Mode of Amendment)

The Congress, whenever two thirds of both Houses shall deem it necessary, shall propose Amendments to this Constitution, or, on the Application of the Legislatures of two thirds of the several States, shall call a Convention for proposing Amendments, which, in either Case, shall be valid to all Intents and Purposes, as Part of this Constitution, when ratified by the Legislatures of three fourths of the several States, or by Conventions in three fourths thereof, as the one or the other Mode of Ratification may be proposed by the Congress; Provided that no Amendment which may be made prior to the Year One thousand eight hundred and eight shall in any Manner affect the first and fourth Clauses in the Ninth Section of the first Article; and that no State, without its Consent, shall be deprived of its equal Suffrage in the Senate.

It’s not particularly easy to amend the Constitution, nor should it be. Only matters of great importance should impel the nation to alter it’s basic framework. Which has happened 27 times so far, including once when a silly amendment outlawing the possession, manufacturer, and use of alcoholic beverages was repealed. Silly that.

“So the spirit of liberty has to be in the population.”

I agree with her in this and her immediately previous statement. The problem being that many people have never experienced liberty and don’t understand the concept. That is more problematic in some parts of the world where the ordinary person has never experienced liberty or been taught about it. Liberty is a high level aspiration and often falls by the wayside for any number of reasons.

“I would not look to the US Constitution if I were drafting a constitution in the year 2012.”

Why not? It works well. It is why we are the nation we are.

“I might look at the constitution of South Africa.”

Really. Of course this interview was in early 2012, but what has been happening in South Africa over the past several years isn’t a grand endorsement of their government.

Here is a link to Section 25 of the South African Bill of Rights. This deals with property rights. Read through it and then read this,

‘The time for reconciliation is over’: South Africa votes to confiscate white-owned land without compensation

SOUTH Africa’s parliament has voted in favour of a motion that will begin the process of amending the country’s Constitution to allow for the confiscation of white-owned land without compensation.

The motion was brought by Julius Malema, leader of the radical Marxist opposition party the Economic Freedom Fighters, and passed overwhelmingly by 241 votes to 83 against. The only parties who did not support the motion were the Democratic Alliance, Freedom Front Plus, Cope and the African Christian Democratic Party.

It was amended but supported by the ruling African National Congress and new president Cyril Ramaphosa, who made land expropriation a key pillar of his policy platform after taking over from ousted PM Jacob Zuma earlier this month.

“The time for reconciliation is over. Now is the time for justice,” Mr Malema was quoted by News24 as telling parliament. “We must ensure that we restore the dignity of our people without compensating the criminals who stole our land.”

This is the form of government that Justice Ginsburg wants emerging nations to emulate. How’s that working out in South Africa?

She goes on to talk about the Canadian Charter of Human Rights and Freedoms from 1982. Canada, where you can be charged and convicted by a “Human Rights Commission” without being able to mount an effective defense. Where you can be jailed for “hate speech” which is any speech that someone unelected bureaucrat doesn’t like.

Then she cites the European Convention on Human Rights. Keep in mind that nowhere in the European Union is there anything resembling either the First or Second Amendments. In all of those countries you can be put in jail for “hate speech” and the press can be censored or gagged by the courts. While that can happen in the United States, it’s rare and subject to appeal in a higher court.

The Constitutions that she professes to love are documents that concentrate power in the hands of the government. They can decide, mostly on a whim, that certain speech is “hateful” and thus prohibited.

Not to mention the  total lack of anything resembling the Second Amendment.

No thanks, Justice Ginsburg. I’ll take my ancient Constitution with it’s funny spelling and arcane wording. It works just fine for me.

Bougie All Night


The Bougie, has been around for a number of years now. Actually, bougie is a generic name for a number of devices that are shaped like an Algerian candle. Don’t ask.

The one I am talking about today is more formally known as the tracheal tube introducer. Originally developed as an easy way to change ET Tubes in ICU and other units. At some point, about 15 years or so ago the device made it’s way to EMS. Anyone who practiced in the days before any sort of video laryngoscopes were around knows that it can be tough, sometimes impossible to intubate some patients in the field.

As a rule, paramedics are pretty good at intubating under less than ideal circumstances. When we learned to intubate actual patients in the hospital we generally did so in the Operating Room. Conditions in the operating room are ideal for intubation. At least most of the time when the surgery is pre scheduled and the patient has been fully prepped.

The patient has been evaluated prior to going into the OR, so you have a good idea of what difficulties you might face. The light is great, and adjustable. The height of the patient and the person intubating can be adjusted. The patient has been medicated. The patient’s head has been put on a cute little pillow to put the patient’s head at the right angle. It’s nice and clean in there, well sterile actually. Oh, you have trained help standing literally at your shoulder to do anything you need. Did I mention that the patient hasn’t eaten in the 6-8 hours before the surgery is scheduled.

Mostly you don’t have those advantages in the field. I won’t go into stories of intubating patients trapped in an upside down burning car, that is floating down a river towards a waterfall or BS like that. I think I intubated one patient sitting up right in a car in my career. Or maybe it was my partner, I really don’t remember. I did intubate a patient inside a building that was on fire. The Sorta Big City FD had dragged her out of a smoke filled room, down a flight of stairs, and dropped her in the hallway for us to treat. I’m not sure why I elected to intubate her there, but since the fire was two floors above us, the risk wasn’t all that high.

Anyway my point, to the extent I have one, is that field intubations are much different than in hospital intubations. More challenging for the most part. Which is why paramedics who work in busy systems generally have very good airway management skills.

Back to the Bougie. When my former system first adopted them, a lot of us were skeptical to say the least. Since individually each paramedic usually had more than one intubation a month, we were pretty proficient. Since we were one of the very few systems in the state allowed to use drugs to facilitate intubation, every intubation attempt was reviewed by our medical director. That was every one of them, whether medications were used or not.

What’s a good word for scrutiny?


While we were beating our chests about how great we were at intubation and airway control, something happened. Well, a couple of things. First we had some promotions, resignations, and retirements among paramedics. Some of the more senior people were no longer treating patients, so they weren’t intubating. The people promoted to replace them weren’t as experienced or proficient.

So, our success rate dropped.

Then, one of the other great innovations in EMS, CPAP was finally approved by the clerks and secretaries who seem to determine medical policy in my state. We were just about the last state in the union to allow paramedics to use CPAP. Even though in about half of the other states, it was considered a BLS level skill, our clerks and secretaries wanted more studies because as you know, human anatomy and physiology differ once you cross state lines.

Once the administrivia was out of the way, we started using CPAP. We liked it, the patient’s liked it, the hospitals liked it. The insurance companies loved it because CPAP resulted in fewer hospital days and complications than intubation. Winners all around.

The only problem was that we were intubating fewer patients, especially fewer living patients. While good for the patients, it was bad for intubation proficiency.

Which brings us back to the Bougie. We started to use it and our success rate went up. Some people, including yours truly, initially only used it on difficult patients. Which meant that we were making a second attempt since we had failed on the first.

After a little bit of time passed, more medics started using the Bougie on the first attempt for every patient. That really improved our first attempt success rate. In addition to being a number, intubating on the first pass is likely to be better for the patient.

Eventually, most of us started using the Bougie and stopped using stylets. Which I generally didn’t use, but stopped using completely once I mastered the not that difficult task of using the Bougie.

Which brings me to this link,

Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial.

Among 757 patients who were randomized (mean age, 46 years; women, 230 [30%]), 757 patients (100%) completed the trial. Among the 380 patients with at least 1 difficult airway characteristic, first-attempt intubation success was higher in the bougie group (96%) than in the endotracheal tube + stylet group (82%) (absolute between-group difference, 14% [95% CI, 8% to 20%]). Among all patients, first-attempt intubation success in the bougie group (98%) was higher than the endotracheal tube + stylet group (87%) (absolute difference, 11% [95% CI, 7% to 14%]). The median duration of the first intubation attempt (38 seconds vs 36 seconds) and the incidence of hypoxemia (13% vs 14%) did not differ significantly between the bougie and endotracheal tube + stylet groups.

This was an Emergency Department study, not an EMS study. EDs intubations are somewhere between OR and field intubations in terms of conditions and difficulty. Will these results transfer into the field?

I’m not sure it matters. The Bougie is a great airway management tool. It helps in the pre hospital setting, even now when video laryngoscopes are readily available and not insanely expensive.

It’s a simple and inexpensive device, yet it can have a huge impact on patients and makes providers lives far easier.

There are far more expensive devices in EMS that do far less for patients. They might be cool and sexy, but they really don’t improve patient outcomes.

Which, in medicine is the measure of the true value of a device.


Sorry For The Outage


I didn’t quit in a huff. Or a minute and a huff as Groucho Marx once said.

I just forgot to renew the domain. That’s all fixed now, as you can see.

I’ll try to find time for an EMS related post tomorrow. Time might be tight as I’ll be going on vacation soon.

How does a guy that’s retired go on vacation? I know, it’s silly.

Kevin Bacon assures us that all is well,



All About Me

After a long career as a field EMS provider, I'm now doing all that back office stuff I used to laugh at. Life is full of ironies, isn't it?

I still live in the Northeast corner of the United States, although I hope to change that to another part of the country more in tune with my values and beliefs.

I still write about EMS, but I'm adding more and more non-EMS subject matter.

Thanks for visiting.

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