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Bougie All Night

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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?

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

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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,

 

 

The Declaration of Independence

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The Declaration of Independence is the founding document of the United States. It lays out the numerous grievances the Colonials had with their Sovereign, who lived just about 3,000 miles away. After the statement of grievances, the Colonials then stated the course of action.

They would no longer be Colonials, they would be Americans. The thirteen former colonies would become thirteen sovereign states in their own rights. Each would be independent of the others in most matters, but united for matters of great national importance.

At least that was the statement, but it really wasn’t until 1789 when the Constitution was ratified be enough states to become law. Along the way, we had a really unsatisfactory “Articles of Confederation” that eventually was replaced by the Constitution as we now have it. We also had a bit of military nastiness with our former Sovereign and his army. Which eventually learned, as many nations have since, that a well organized insurrection far from home is damnedly hard thing to put down or beat.

The Declaration was not then and is not now part of the legal framework of the nation. It is a statement of ideals which all free men and women should strive to achieve.

In reality, what we now call the Revolutionary War started over a year before the official date of the Declaration of Independence.

The Boston Massacre took place on March 5, 1770. A group of British soldiers claimed that they were attacked by a mob of protesters and shot several of them. In the end, five Colonials died and only two of the British soldiers were convicted.

The Boston Tea Party was an act of rebellion against unfair taxes and took place on December 16, 1773.

The Battle of Lexington and Concord took place on April 19, 1775. This was where the “Shot Heard ’round the World” was fired as Colonial militiamen openly resisted efforts by the British Army to seize cannons, shot, and powder from Colonial armories. Said armament was intended to be used by the militias to fight the Indians and even French invaders from Canada. The British also figured that it might be used by the traitorous scum Colonials against them, so they decided to take it.

That didn’t work out quite as they thought it would as the well regulated militiamen shot quite effectively and kept the British from seizing the material.

That set the stage for the Battle of Bunker Hill on June 17, 1775. Which, by the way, took place on Breed’s Hill. The British won, eventually. It took three waves of attack and a lot of casualties, but they won. The militiamen, again well regulated, inflicted heavy casualties on the British regulars. The Colonials eventually retreated, but with far fewer casualties than the British.

I could go on, but you get the point. When the Declaration of Independence was adopted and published, the Revolution was well underway. The Declaration was the formal instrument severing our ties with Great Britain.

To the British, it was a formal statement of Treason. Rebellion against the King is Treason.

Unless you win, of course. Then you become a nation. Which is what happened, although it was dicey for some time.

Herewith is the text, laying out the grievances and reasons for severing the bonds with England. Today, nothing in their seems radical, but at the time it was, dare I say, revolutionary.

As you read through the list of grievances, you get a clear idea of why many of the passages in the Constitution and the Bill of Rights are written as they are.

I’ll have some comments on the statements of a certain Justice of the Supreme Court on the Constitution on another day.

IN CONGRESS, JULY 4, 1776
The unanimous Declaration of the thirteen united States of America

When in the Course of human events it becomes necessary for one people to dissolve the political bands which have connected them with another and to assume among the powers of the earth, the separate and equal station to which the Laws of Nature and of Nature’s God entitle them, a decent respect to the opinions of mankind requires that they should declare the causes which impel them to the separation.

We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness. — That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed, — That whenever any Form of Government becomes destructive of these ends, it is the Right of the People to alter or to abolish it, and to institute new Government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Safety and Happiness. Prudence, indeed, will dictate that Governments long established should not be changed for light and transient causes; and accordingly all experience hath shewn that mankind are more disposed to suffer, while evils are sufferable than to right themselves by abolishing the forms to which they are accustomed. But when a long train of abuses and usurpations, pursuing invariably the same Object evinces a design to reduce them under absolute Despotism, it is their right, it is their duty, to throw off such Government, and to provide new Guards for their future security. — Such has been the patient sufferance of these Colonies; and such is now the necessity which constrains them to alter their former Systems of Government. The history of the present King of Great Britain is a history of repeated injuries and usurpations, all having in direct object the establishment of an absolute Tyranny over these States. To prove this, let Facts be submitted to a candid world.

He has refused his Assent to Laws, the most wholesome and necessary for the public good.

He has forbidden his Governors to pass Laws of immediate and pressing importance, unless suspended in their operation till his Assent should be obtained; and when so suspended, he has utterly neglected to attend to them.

He has refused to pass other Laws for the accommodation of large districts of people, unless those people would relinquish the right of Representation in the Legislature, a right inestimable to them and formidable to tyrants only.

He has called together legislative bodies at places unusual, uncomfortable, and distant from the depository of their Public Records, for the sole purpose of fatiguing them into compliance with his measures.

He has dissolved Representative Houses repeatedly, for opposing with manly firmness his invasions on the rights of the people.

He has refused for a long time, after such dissolutions, to cause others to be elected, whereby the Legislative Powers, incapable of Annihilation, have returned to the People at large for their exercise; the State remaining in the mean time exposed to all the dangers of invasion from without, and convulsions within.

He has endeavoured to prevent the population of these States; for that purpose obstructing the Laws for Naturalization of Foreigners; refusing to pass others to encourage their migrations hither, and raising the conditions of new Appropriations of Lands.

He has obstructed the Administration of Justice by refusing his Assent to Laws for establishing Judiciary Powers.

He has made Judges dependent on his Will alone for the tenure of their offices, and the amount and payment of their salaries.

He has erected a multitude of New Offices, and sent hither swarms of Officers to harass our people and eat out their substance.

He has kept among us, in times of peace, Standing Armies without the Consent of our legislatures.

He has affected to render the Military independent of and superior to the Civil Power.

He has combined with others to subject us to a jurisdiction foreign to our constitution, and unacknowledged by our laws; giving his Assent to their Acts of pretended Legislation:

For quartering large bodies of armed troops among us:

For protecting them, by a mock Trial from punishment for any Murders which they should commit on the Inhabitants of these States:

For cutting off our Trade with all parts of the world:

For imposing Taxes on us without our Consent:

For depriving us in many cases, of the benefit of Trial by Jury:

For transporting us beyond Seas to be tried for pretended offences:

For abolishing the free System of English Laws in a neighbouring Province, establishing therein an Arbitrary government, and enlarging its Boundaries so as to render it at once an example and fit instrument for introducing the same absolute rule into these Colonies

For taking away our Charters, abolishing our most valuable Laws and altering fundamentally the Forms of our Governments:

For suspending our own Legislatures, and declaring themselves invested with power to legislate for us in all cases whatsoever.

He has abdicated Government here, by declaring us out of his Protection and waging War against us.

He has plundered our seas, ravaged our coasts, burnt our towns, and destroyed the lives of our people.

He is at this time transporting large Armies of foreign Mercenaries to compleat the works of death, desolation, and tyranny, already begun with circumstances of Cruelty & Perfidy scarcely paralleled in the most barbarous ages, and totally unworthy the Head of a civilized nation.

He has constrained our fellow Citizens taken Captive on the high Seas to bear Arms against their Country, to become the executioners of their friends and Brethren, or to fall themselves by their Hands.

He has excited domestic insurrections amongst us, and has endeavoured to bring on the inhabitants of our frontiers, the merciless Indian Savages whose known rule of warfare, is an undistinguished destruction of all ages, sexes and conditions.

In every stage of these Oppressions We have Petitioned for Redress in the most humble terms: Our repeated Petitions have been answered only by repeated injury. A Prince, whose character is thus marked by every act which may define a Tyrant, is unfit to be the ruler of a free people.

Nor have We been wanting in attentions to our British brethren. We have warned them from time to time of attempts by their legislature to extend an unwarrantable jurisdiction over us. We have reminded them of the circumstances of our emigration and settlement here. We have appealed to their native justice and magnanimity, and we have conjured them by the ties of our common kindred to disavow these usurpations, which would inevitably interrupt our connections and correspondence. They too have been deaf to the voice of justice and of consanguinity. We must, therefore, acquiesce in the necessity, which denounces our Separation, and hold them, as we hold the rest of mankind, Enemies in War, in Peace Friends.

We, therefore, the Representatives of the united States of America, in General Congress, Assembled, appealing to the Supreme Judge of the world for the rectitude of our intentions, do, in the Name, and by Authority of the good People of these Colonies, solemnly publish and declare, That these united Colonies are, and of Right ought to be Free and Independent States, that they are Absolved from all Allegiance to the British Crown, and that all political connection between them and the State of Great Britain, is and ought to be totally dissolved; and that as Free and Independent States, they have full Power to levy War, conclude Peace, contract Alliances, establish Commerce, and to do all other Acts and Things which Independent States may of right do. — And for the support of this Declaration, with a firm reliance on the protection of Divine Providence, we mutually pledge to each other our Lives, our Fortunes, and our sacred Honor.

New Hampshire:
Josiah Bartlett, William Whipple, Matthew Thornton

Massachusetts:
John Hancock, Samuel Adams, John Adams, Robert Treat Paine, Elbridge Gerry

Rhode Island:
Stephen Hopkins, William Ellery

Connecticut:
Roger Sherman, Samuel Huntington, William Williams, Oliver Wolcott

New York:
William Floyd, Philip Livingston, Francis Lewis, Lewis Morris

New Jersey:
Richard Stockton, John Witherspoon, Francis Hopkinson, John Hart, Abraham Clark

Pennsylvania:
Robert Morris, Benjamin Rush, Benjamin Franklin, John Morton, George Clymer, James Smith, George Taylor, James Wilson, George Ross

Delaware:
Caesar Rodney, George Read, Thomas McKean

Maryland:
Samuel Chase, William Paca, Thomas Stone, Charles Carroll of Carrollton

Virginia:
George Wythe, Richard Henry Lee, Thomas Jefferson, Benjamin Harrison, Thomas Nelson, Jr., Francis Lightfoot Lee, Carter Braxton

North Carolina:
William Hooper, Joseph Hewes, John Penn

South Carolina:
Edward Rutledge, Thomas Heyward, Jr., Thomas Lynch, Jr., Arthur Middleton

Georgia:
Button Gwinnett, Lyman Hall, George Walton

 

(Il)literacy In EMS

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As most of my regular EMS readers know, I know work in the Quality Improvement part of EMS. The company I work for has a unique approach to the subject as we take an educational approach to working with our clients.

Unlike typical QI, we don’t do any finger wagging when we meet with a medic or EMT to discuss a call that has questions or from which an issue has arisen.

That extends to the first part of the process, which is the PCR review. Auditors are taught during their orientation to avoid pejorative words and phrases. They are instructed to take the review as an opportunity to point out issues and offer solutions.

During initial classes with the services field staff we spend a lot of time going over documentation. In general, EMS education on documentation is pretty poor. Paramedic students might get a couple of hours of classroom, EMTs get almost none. I don’t know of any programs that have their students write reports as part of the classroom experience.

We have found that the 4-5 hours we spend on documentation issues have a positive effect on documentation. In turn, that has a positive effect on patient care because the EMTs and medics put more thought into their documentation and thus more thought into what they are doing. We don’t want them to turn into “protocol monkeys” but knowing what’s in the protocols and why it’s there is part of the job.

One thing we don’t do is comment or score on spelling, punctuation, sentence structure, etc… We do suggest that the providers use SOAPIE or CHART formats as it gives a well defined structure to the reports.

I do mention that while we don’t score on those factors, we sometimes laugh at what we see.

Once the providers realize that those formats work well, reports improve and scores for both the individuals and the services improve.

Sometimes when doing a review (everyone that works for the company does reviews), I have to bite my figurative tongue at some of the things I read.

Then, there is this,

m1 dispatched to above location for a m pt with daphretic. u.o.a pt was alert x 3. pt was having a hard time walking around. nursing staff called ems. pt has a history of crones and anxiety. pt is not taking any meds for it. pt had this since he was 16. pt as no primary dr. pt was placed on our stretcher via Stand and pivot. pt was placed on the monitor and showed nsr. pt was soaked from head toe from sweat. pt has abd pain and he has not eating anything for a few days. pt bg was 132 mg/dl. iv was attempted but not started. 12 lead was unreadable pt was shaking. pt was transported to XXX. en route pt vitals were taken and noted. pt lungs were clear and heent was normal. u.o.a pt was taken to room 25 where verbal and written report was given to the nursing staff

This is supposed to be a medical report. I had to read it three times before I could figure out what was going on. Actually, that’s not true. I read it three times and STILL couldn’t figure out what was going on.

My comments started out “Spelling aside…” and went on to point out that this was a very confusing narrative. I also noted that the care appeared to be appropriate, but that it was very incomplete. Keep in mind that treatments and procedures are documented in a different section of the report, so that part was okay.

That being said, the narrative is the most important part of the report. The drop down lists can’t tell the whole story. The narrative has vital details and must be written clearly. This was a report fail. A total report fail.

I winced at the thought of a doctor, nurse, or billing coder reading this.

Many people in EMS pride themselves in the profession of EMS. That includes me, because I worked in one of few systems that has been determined by an independent arbiter to be staffed by professionals. I won’t go into the details as they aren’t germane to today’s subject, but the elements of EMS as practiced in my former agency met the legal definition of “profession”. As opposed to trade. Which EMS for the most part isn’t either.

For the most part, EMS is a skill set. Some people do EMS full time and it’s their agency’s sole function. Others are fire departments or police departments that also do EMS. Or something else that also does EMS.

If you consider EMS a profession and yourself a professional, then you want to look and act the part. Clear, accurate documentation is part of that. The narrative above does not present the author as a professional. I don’t know what it does present the author as, but I can’t think of it as anything other than a person who writes a sloppy report. By extension, a sloppy report represents sloppy care.

I remember a police case from some years back. The officer who wrote that report also did a sloppy job. When it went to trial, defense counsel tore the report and by extension the work of the officer, apart. The result was an acquittal of a person who was otherwise caught red handed. By the time the lawyer got done tearing the report apart, the officer looked like a clown. Why that report wasn’t reviewed by a supervisor and corrected, I never found out.

I would not want to be the paramedic or his employer if the report I audited was ever called into question by a regulatory agency, court, or even a physician.

Quite bluntly, my eight year old grandson could write a better report.

The moral of the story, if there is one, is this. What your write in your report is a reflection of your abilities as an EMS provider. I am not the best speller in the world, but I use one tool that very few people in EMS seem to use. That is spell check. Even if the PCR system has a poor spell check, and many of them do, most providers I know have a smart phone. Which is a great tool for checking the spelling of not only medical terms, but common words as well.

The struggle to have EMS recognized as a medical profession started before I was in EMS, continued throughout my career, and is still going on as I type this.

Illiterate reports like this don’t help at all.

This all sounds very preachy, I know. Still, writing a decent report is not that hard. It’s not even EMS specific. Writing is something that is taught from Kindergarten on and an adult who is out in the working world should not be writing a document like this.

With that, I’ll step off my soapbox and await your comments.

The Forgotten War Starts

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On Sunday, June 20, 1950 soldiers of the Democratic People’s Republic of Korea (DPRK) supported by heavy artillery fire crossed the 38th Parallel and attacked the Republic of Korea (ROK).

The DPRK troops were battle hardened from fighting the Japanese in World War II and were better trained than the ROK soldiers. The Communists had artillery and tanks, while the ROK troops had none.

The United States had token presence in South Korea, but they were ill equipped and unprepared for combat. After all, World War II was over and the military was in piece time mode. As always seems to be the case, the military was cut to the bone after the war.

By the end of June, Seoul had fallen, the ROK Army had been reduced by almost 2/3, the US troops were in full retreat.

On June 27, the United Nations passed a resolution urging member nations to provide military support and assistance to the ROK. By the signing of the Armistice in 1953 14 member nations of the UN would be fighting along side the US and ROK. The Chinese would come in on the side of the DPRK, and Russia would supply logistics support.

The war was on.

On July 5, a small detachment of the US Army 24th Division “Task Force Smith” attacked a superior force of DPRK troops. Without tank or artillery support the attack was beaten back with heavy casualties. The DPRK troops then pushed south and a several days later defeated the main body of the 24th Division inflicting heavy casualties.

The advance continued throughout August into September. Aircraft of the US Navy and Air Force provided air support and attacked DPRK forces and logistic assets. This had the effect of stretching the supply line to the breaking point. Which in turn allowed the ROK and US forces to hold at Pusan. Most of South Korea was in Communist hands, but that was soon to change.

On September 15, a combined US Army, USMC, and ROK force landed at Inchon. That force drove the DPRK forces back, and eventually recaptured Seoul. By mid October, ROK forces had captured Pyongyang, the North Korean capital.

At which point, China decided to enter the war.

The war went back and forth into the next year.

There is, of course, a lot more to the Korean War than I can cover in a blog post. One very good book is “This Kind of War” by T.R. Fehrenbach. The book covers the first year of so of the war in detail. It’s a must read for anyone who is interested in the history of the war that was known as a “police action.”

 

 

Day of Days

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Unlike Google or almost all of the Fake Stream Media, I can’t let this day go by without comment.

Operation Overlord was the second largest amphibious landing in history. More troops landed at Okinawa, but the impact of the Normandy landings was arguably more widespread. Both had significant impact on the outcomes of their parts of the war.

Today, however is about Normandy and the liberation of France and the eventual defeat of Germany.

There are plenty of books and movies about the landings and the battle to secure the beachhead. Or maybe “landings” since there were five beaches, airborne, and Army Ranger landings as well.

The story is well told in the move “The Longest Day”, a movie of the type that Hollywood used to make. Almost without exception, every movie star that there was wanted to be in on this movie. Richard Burton and Roddy McDowell flew in from Rome where they were  filming “Cleopatra” to do play their roles. For free.

Eddie Albert, of “Green Acres” fame, served in the US Navy during World War II. He landed in a real battle, at Tarawa in 1943. He was awarded a Silver Star for his actions in that battle.

The movie was based on the book of the same name, by Cornelius Ryan. Who also wrote “A Bridge Too Far” which was also turned into a book. Both books and both movies are worth your attention.

I’ll forgo the boring numbers, but the operation was huge in terms of equipment, cost, and most importantly, lives. It was also necessary as the Germans had to be defeated and Europe liberated.

I’ll close with a short clip from the movie portraying the landing on Omaha beach.

4 June, 1940, 1942, 1944

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Three different events on 4 June during World War II mark the progress of the Allies in defeating Germany, Italy, and Japan.

First, on 4 June, 1940 the British Army evacuation of Durnkirk France was completed. “Operation Dynamo” as it was known the was the heroic effort by mostly civilian boat owners to evacuate the British Army from the beach and thus avert a war ending disaster. The British lost most of their equipment and many of their soldiers. Many, but not all and not a majority. Along with much smaller numbers of French and Polish soldiers, they were evacuated back to England.

Britain was at it’s nadir in the war. Germany now controlled most of Europe, withe the exception of the neutral countries. Still ahead were the German air blitz, the submarine war, the Western Desert Campaign. Still ahead was the planned invasion by sea of Britain by German troops.

The United States was still neutral and negotiating to stay that way with it’s main potential ally (at the time) of Japan. Britain and the Commonwealth stood alone and it looked very bleak indeed.

On this date Prime Minister Winston Churchill gave his “We Shall Never Surrender” speech to rally the beleaguered nation.

Here is an excerpt,

I have, myself, full confidence that if all do their duty, if nothing is neglected, and if the best arrangements are made, as they are being made, we shall prove ourselves once more able to defend our island home, to ride out the storm of war, and to outlive the menace of tyranny, if necessary for years, if necessary alone. At any rate, that is what we are going to try to do. That is the resolve of His Majesty’s Government – every man of them. That is the will of Parliament and the nation. The British Empire and the French Republic, linked together in their cause and in their need, will defend to the death their native soil, aiding each other like good comrades to the utmost of their strength.

Even though large tracts of Europe and many old and famous States have fallen or may fall into the grip of the Gestapo and all the odious apparatus of Nazi rule, we shall not flag or fail. We shall go on to the end. We shall fight in France, we shall fight on the seas and oceans, we shall fight with growing confidence and growing strength in the air, we shall defend our island, whatever the cost may be. We shall fight on the beaches, we shall fight on the landing grounds, we shall fight in the fields and in the streets, we shall fight in the hills; we shall never surrender, and if, which I do not for a moment believe, this island or a large part of it were subjugated and starving, then our Empire beyond the seas, armed and guarded by the British Fleet, would carry on the struggle, until, in God’s good time, the New World, with all its power and might, steps forth to the rescue and the liberation of the old.

There was still almost five years of horribly difficult war ahead, but this was the point at which the British stood resolute. The invasion of Britain never happened because the Royal Air Force stood fast and defeated the Luftwaffe in the air. That was aided by some stupidity by the German General Staff and Adolph Hitler, but the resolve of the British people was the key element.

Here is the entire speech, which includes a most pessimistic assessment of the situation. Of note is not so much the defeat, but that but for the perfidy of King Leopold of Belgium, the Germans might have been held at bay outside of France. More evidence, if we needed it, that weakness emboldens your enemies.

Two years later, 4 June 1942 came one of the greatest victories in the history of the United States Navy. A thousand miles northwest of the Hawaiian Islands near the pre war refueling stop called Midway, the US Navy sprung a trap on the heretofore unstoppable Imperial Japanese Navy. While there is still debate over the Battle of the Coral Sea, there is no debate over who won at Midway.

The loss of four of the six aircraft carries that had carried out the attack on Pearl Harbor a mere six months prior, along with experienced air crews, and planes was a blow from which Japan was never able to recover. Add to that the losses of crews and planes at Coral Sea, and for at least the short term, the IJN wasn’t able to carry out air offenses.

There was still more than three years of incredibly difficult fighting ahead. There would be the brutal invasion of Guadalcanal, the devastating losses at the Battle of Savo Island, and a succession of island invasions that would cost thousands of American lives before the war won.

The tide was turning, but the issue was still in doubt.

Two years later, on the other side of the world the big news on 4 June, 1944 was the Liberation of Rome. American soldiers under the command of General Mark Clark marched into the city to the cheers of the Italian people. The battle in Italy was far from over and would go on until the end of the war. The Germans fought a series of defensive actions and the fighting was incredibly vicious.

German resistance, along with the mountains and weather made the capture of all of Italy all but impossible. To complicate the problem, the Allies pulled many experienced units out of Italy for the invasion of Southern France. That happened after the invasion of France two days after Rome fell.

The Normandy Invasion became the big news in June as the Allies opened the “second front” in Europe. Not that liberating Africa, Sicily, then most of Italy, didn’t qualify as a second front. It just didn’t satisfy Josef Stalin’s demands for action that would relieve his troops on the Eastern Front. Which is a different story.

So, the Liberation of Rome became a footnote in history instead of the big story of the week of 4 June, 1944.

From bitter defeat to victory encapsulated in three dates four years apart. In a war that could have been prevented almost a decade earlier. What a waste of lives.

It’s all summed up here,

What indeed where they thinking?

 

Failure Is An Option

3

After the 1999 Columbine school attack, standard operating procedures (SOP) changed for police. Or were supposed to. The days of setting up a perimeter and waiting the the cavalry in the form of the SWAT team to come and deal with the threat were supposed to be over.

Until Columbine changed the paradigm, these were primarily hostage situations and primarily didn’t take place in schools. Just as the September 11, 2001 plane attacks changed how we viewed “hijackings” and how everyone responded to them.

The new paradigm for dealing with “Active Shooters” was for the first arriving police officers to move into the building, make contact, and engage the shooters. This wasn’t limited to schools, but any venue where there was someone shooting unarmed (for the most part) people.

Following the neutralization of the threat, EMS was supposed to be brought in to the “warm” zone. EMS was supposed to be escorted by police and advance into the building immediately behind the “hot” zone. Conceptually, EMS would advance to where the victims were. At which point they’d stop being victims and start being patients.

Those that were dead, were going to stay dead. Those that were seriously injured, but had survivable wounds would be stabilized (read the bleeding would be stopped) and then evacuated. Those with minor wounds would be brought out and placed in a treatment area.

Sounds great in theory, doesn’t it?

Only it doesn’t always seem to happen. As I’ve mentioned before, at the Los Angeles International Airport shooting back a few years ago, the LA Police Department stopped the LA City and County paramedics from entering the building even though the shooter was in custody. As a result, as at Columbine someone with serious, but survivable wounds bled to death before he could be treated and transported.

Two years ago, at the Pulse nightclub terrorist attack, police initially confronted the shooter, but were told to hold the perimeter for SWAT. There was a serious amount of confusion in this case, and that may have been the correct action. It’s also possible if the police had pressed home their initial attack, fewer people might have died.

You would think that by now, every major police department and even most smaller ones would have a good idea of what to do when someone starts shooting up a building full of innocent victims. Even more so for attacks at schools.

Apparently, you’d be wrong.

Paramedics wanted to enter Parkland school where kids were dying. BSO said no.

Michael McNally, deputy chief for Coral Springs fire-rescue, asked six times for permission to send in specialized teams of police officers and paramedics, according to an incident report he filed after the Feb. 14 Marjory Stoneman Douglas High School shooting that left 17 people dead.

But every time McNally asked to deploy the two Rescue Task Force teams — each made up of three paramedics and three to four law enforcement officers — the Broward Sheriff’s Office captain in charge of the scene, Jan Jordan, said no.

Initially, you may say that the Broward’s Sheriff Captain was being overly cautious because the situation wasn’t clear. Okay, that’s possible. Then I read this.
“The [BSO] incident commander advised me, ‘She would have to check,’ ” McNally wrote in the report released Thursday by Coral Springs. “After several minutes, I requested once again the need to deploy RTF elements into the scene to … initiate treatment as soon as possible. Once again, the incident commander expressed that she ‘would have to check before approving this request.’ “
Check with whom, exactly? I attended to many drills over the years and more than a couple of actual incidents during my carreer. At all of them the Incident Commander made the final decisions. He or she didn’t “have to check” before making a command decision. If the incident grew very large, then someone else might come in to assume the position of Incident Commander. Then that person made the decision.
I don’t recall any set of circumstances where the IC had to “check” with anyone before giving an order. That’s why the person was the IC.

Even after the shooter had been arrested, the answer remained the same.

It’s not known whether paramedics, who arrived at Stoneman Douglas within minutes of the shooting, could have saved lives. Thirty-four people had been shot inside the school’s freshman building. Gunshot wound victims can bleed out quickly, meaning fast action is necessary. The special RTF teams allow paramedics to treat victims under the protection of police officers in situations where a shooter has been pinned down or fled but has not necessarily been captured.

SWAT medics went in instead, although it’s not clear exactly how many or when.

What this article doesn’t mention is that generally “SWAT Medics” are there for the SWAT officers, not the victims. Depending on the team configuration, the SWAT Medics might go in with the stack. They might be sworn officers or they might not. No matter what the configuration, the SWAT medics were expected to stay with the officers and not break off to treat the victims.

In his report, McNally acknowledged that RTF teams may not have helped in the end — but he said Jordan couldn’t have realized that when she repeatedly denied his requests.

“Later, it was determined that the RTF element may not have aided in any additional care to patients,” McNally wrote. “However, this information was not known at the time of the requests.”

You can’t know if you can help until you get inside to evaluate the situation. There certainly wasn’t a shortage of police officers on the scene. Or paramedics for that matter. There were certainly enough resources on scene.
Medical considerations aside, it seems that Captain Jordan didn’t have a good grasp of the situation. It seems that lack of planning and execution might be an issue for the Broward Sheriff’s Department,
“The command post was inundated with too many people and made it impossible to establish and function,” McNally wrote, echoing criticisms of the disorganization and lack of a unified command structure that plagued BSO’s response to a deadly shooting at the Fort-Lauderdale-Hollywood International Airport last year.
One of the main considerations at a command post is controlling who is there. Each person is supposed to have an identified area of responsibility and place to be inside the area. Milling around aimlessly is not permitted.

Broward County Sheriff No Stranger To Criticism For Past Handling Of A Mass Shooting

A 99-page report of the 2017 Fort Lauderdale Airport shooting, drafted by officials in the department, said that their own agency made mistakes from the start by not taking command of the shooting area at the baggage claim, where the perpetrator killed five people and injured six others.

“During the events, the absence of a clearly defined [incident command] created unnecessary entanglements and unclear responsibilities,” the report revealed.

Keep in mind that these changes take time, especially when new equipment is required. I have to wonder if the agency has even started on the process of replacing their radio system. Which is mentioned in both incidents as adding to the confusion. The training and doctrine issues should take far less time to implement, but it doesn’t seem like that happened either.

Before the 2017 report came out, Israel described his agency’s response to The Sentinel in an interview in April 2017, saying, “Everything was done excellently,” and adding that the situation was more like  “controlled chaos.” The response is similar to Israel’s defense of his own present performance following the Parkland shooting, stating he has given “amazing leadership.”

You can’t fix an issue unless you recognize and admit that you have an issue. Two SNAFU incidents in ten months and the answer is the same each time. Denial is one of the most powerful forces in the universe.

Hopefully, there won’t be a next time for Broward County, but if there is, the response should be more organized and just plain better.

Should be.

Memorial Day

0

For some reason, many people conflate Veterans Day with Memorial Day. Veterans Day is a day to thank all military veterans for their service. Memorial Day is a day to remember those who gave their lives in the defense of their country.

While doing research for this post, I came across the following on You Tube. “The Blue and The Gray” was written in 1867 by Francis Miles Finch. The recording gives the history of what inspired Finch to write it, followed by a recitation of the poem. This is from 1912, so it’s a bit scratchy, but it’s clear nonetheless.

There are other poems, music, and even videos in tribute to soldiers who have died, but this one is specific to the holiday and America’s deadliest war.

I have nothing to add.

 

EMS Artifact Versus The Forsythia, Part Deux

2

That was a fast month. When last we left our gripping tale, I had dug out most of the Forsythia, cut back some other stuff and had fire pit day one.

Fire pit day two went better as I had the hang of getting the fire going. That involved going to Walmart and buying a couple of fire starter “bricks”. That, along with some cardboard and small twigs and brush, got the fire going well. Once that was started, I commenced to dragging out the larger brush and some saplings I’d cut down.

I was careful not to let the fire get too high, lest I become “that guy” who set the woods on fire and caused the fire department to come out and extinguish the fire. And tear up my permit.

I also decided to dig out that one root ball that was left. Which turned into about half a dozen or so root balls of various sizes. Each of which seemed to have a boulder attached. Lot’s of quality time with a pick axe and shovel as I dug around the boulders and pried the root balls out of the ground. I would swear that these things were growing as I dug them out, although that doesn’t seem likely.

Speaking of root balls, I burned the ones that I had dug out the previous days. I tossed them on the fire and watched gleefully as they burned. At least those wouldn’t start sprouting leaves again. I hope.

I carted some of the larger rocks and still wet root balls out into the woods behind my neighbor’s yard. Which he was okay with as long as I carted them way out into the woods.

I also now had a friend’s electric chain saw. He bought it as a yard sale, realized he had no practical use for it and gave it to me. It worked okay except it really needed a new chain. Which I only found out after I had bludgeoned a few small trees to death. Still, it was better than cutting them down by hand. Slightly.

Periodically, I’d stop to throw more brush, root balls, branches, or whatever on the fire. Periodically, I’d also stop to let my heart rate drop below 100 beats per minute. This was starting to be too much like work.

After about four hours of work, I had most of the debris burned, most of the big rocks out in the woods, most of the smaller rocks thrown out into the woods, and had discovered and disposed of a dozen or so baseballs, a similar number of tennis balls, a couple of whiffle balls, and several toy cars. All of which had resided for several years out in the Forsythia wilds.

Oh, and I also picked up a nice contact dermatitis. Which didn’t actually manifest itself for a few days, just about the time I landed in Dallas. Since I had the same thing last year when I attacked this mess, I knew to get some Hydrocortisone and use it liberally. Here we are a month later and most of it is gone. Most of it, but there are still a few stubborn areas that insist on periodically causing me to be slightly itchy.

Next time I do this, if there is a next time, I have to remember to wear one of my Louisiana fishing shirts with the long sleeves. They breath, so it doesn’t get too hot and they block the sun. And, hopefully whatever gave me the dermatitis.

Did I mention the thorns? Mixed in with the Forsythia were some thorn bushes, more like thorn trees. The stems or whatever they are called were the diameter of a shovel handle. The thorns themselves were about the size of a Ka Bar blade. Man, those things hurt like hell and left ugly cuts.

I also bought several bags of top soil at a big box store and got several five gallon buckets of prime top soil from a friend’s compost pile. All of which are spread on top of the sandy soil in the back yard to fill in holes and make seeding easier.

Seeding will take place in the fall, along with applying fertilizer. One the advice of a garden specialist (really) I will defer using my handy dandy roto tiller? Why, you may ask. Because it will dig up some deeply buried you know what and it will just start growing again.

Here is what the area looks like, so far.

As you can see, it’s a pretty large area. All of which I used to have to mow, but which became overgrown over the years. Some of the green in the dirt patch grew up literally overnight. Which means that the dirt I got from my friends compost pile is very fertile. It also means I’ll have to do more weed control during the summer.

I’ll spare you part three of this story, unless of course it turns out really well in the spring. Or really poorly.

 

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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