Uncategorized | Too Old To Work, Too Young To Retire

Surprise, Surprise, Surprise

April 18, 2012 by tooldtowork 10 Comments

Study: Helicopter beats ambulance for trauma patients

BALTIMORE, Md. — If you are severely injured, a helicopter flight to a top-level trauma center will boost your chance of survival over ground transport. That’s the conclusion of a rigorous, national comparison of the effectiveness of helicopter versus ground emergency medical services, published in the April 18, 2012, issue of the Journal of the American Medical Association.

According to this study, if you are severely injured and get to a trauma center faster (by helicopter) as opposed to slower (by ambulance), you stand a better chance of survival. That makes sense, since in many cases quicker surgery results in better survival rates. We’ve known since the Civil War that getting patients into surgery earlier increases the chances of survival. Not exactly news.

Survival after trauma has increased in recent years with improvements in emergency medical services coupled with the rapid transportation of trauma patients to centers capable of providing the most advanced care. What has not been clear until this study, is the effectiveness of helicopter emergency medical services (HEMS), a limited and expensive resource, compared to its alternative, ground emergency medical services (GEMS).

Well, not exactly true, and this study isn’t going to answer the real question. Which, as has been raised for a number of years now, is this. Are we (as an industry) flying too many patients for whom time is not important and who will do as well by being driven as opposed to flown. In other words, where is the cutoff in acuity for flying versus driving?

“We looked at the sickest patients with the most severe injuries and applied sophisticated statistical analyses to the largest aggregation of trauma data in the world,” says the study’s principal investigator, Samuel M. Galvagno Jr., D.O., Ph.D., assistant professor, Department of Anesthesiology, Divisions of Trauma Anesthesiology and Critical Care Medicine, University of Maryland School of Medicine. “We were careful at every step to balance all the potential other factors that could explain any benefit of the helicopter. After all that, the survival advantage of helicopters remained,” says Galvagno.

Dr. Galvagno is on the staff of the R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center, where many of the life-saving practices in modern trauma medicine were pioneered. The Shock Trauma Center was the first fully integrated trauma center in the world, and remains the epicenter for trauma research and training both nationally and internationally today.

The principal investigator for this study works at the R. Adams Cowley Shock Trauma Center, which coincidentally is heavily invested in HEMS. How surprised should I be that a study run by a doctor at a trauma center that gets the vast majority of it’s patients by helicopter shows that patients who arrive by helicopter fare better than those that don’t?

“The use of helicopter emergency medical services in the United States has been a controversial subject over the last decade or so, centering on the costs and the potential for crashes, says Thomas M. Scalea, M.D., the Francis X. Kelly Professor of Trauma in the Department of Surgery; director of the Program in Trauma, University of Maryland School of Medicine; and physician-in-chief at the R Adams Cowley Shock Trauma Center. “Previous studies have found a survival benefit by using helicopters, but the studies were small and left some doubt. This study in JAMA is very robust,” says Dr. Scalea.

Dr. Scalea as you will note is the boss at the R. Adams Cowley Shock Trauma Center, so presumably he’s Dr. Galvagno’s boss. So, the guy who is the boss to the guy that says that helicopters are better is the guy who runs the center that is heavily invested in having patients coming in by helicopter. Another big surprise here.

“Dr. Galvagno’s research demonstrates how statistics and technology can be used to help researchers mine huge databases for useful information to help determine best care for patients and appropriate utilization of limited health care funds,” says E. Albert Reece, M.D., Ph.D., M.B.A., vice president for medical affairs, University of Maryland; the John Z. and Akiko K. Bowers Distinguished Professor; and dean, University of Maryland School of Medicine.

Were I the skeptical type, I’d says that Dr. Galvagno’s research shows how statistics and technology can be used to prove anything you want to prove. Good thing I’m the non skeptical, trusting sort.

The question that isn’t answered here, in fact it’s not even asked, is where is the cutoff for sending patients in by helicopter as opposed to sending them by ground ambulance? The second unasked question is, when do patients need a trauma center? The study looked at severely injured patients, those who unquestionably needed a trauma center. It looked at two different modes of transportation, one faster, one slower. It asked which would do better, those getting to definitive care sooner or those getting to definitive care later. Unsurprisingly the study found that severely injured patients did better when they get to trauma centers more quickly. You don’t need a Ph.D. to figure that one out, but surprisingly Dr. Galvagno used this research as part of his Doctorate in Public Health program.

This study was performed without any commercial funding or extramural sponsorship. Dr. Galvagno was funded, in part, by an institutional training grant when this study was initiated as part of his Ph.D. program at the Johns Hopkins Bloomberg School of Public Health.

Pretty neat, getting your homework published in the Journal of the American Medical Association. All I ever got was mine taped to the refrigerator.

Still, it seems like a PH.D. in Duh! to me. Getting acutely injured patients to definitive care faster means that more of them will survive. We’ve only known that since the 1860s, but now we have numbers to prove it. Even at that, the study showed that one life was saved for each 65 or 69 patients flown to a Level 1 or Level 2 trauma center. Now, we need to compare that in a meaningful way to the number of crashes and lives lost to see if the cost in lives outweighs the benefits lives or vice versa.

Again, what we don’t know is where is the cutoff for defining who goes by air and who goes by ground. Until we know that, which is what patients will have a good outcome or no change in outcome no matter which mode of transport is used, we can’t have a real debate over to what extent helicopters are really helpful in saving lives.

Theoretically, if we were able to use teleportation to instantly transport patients they’d do even better. Dr. McCoy said so, didn’t he? Then again, if our molecular pattern were stored in the transporter’s memory banks, what is to keep patients from being treated by being transported and using the molecular pattern to restore them to their pre injury state of health? I need a grant. Well, two. One to invent the transporter and one to see if patient’s do better when beamed to Shock Trauma as opposed to being flown in by archaic helicopters. But, I digress into Sheldon Cooper like fantasy.

The big question yet to be answered, and I’m repeating it for the sake of clarity, is where is the cut off for flying patients versus driving them? The related question is, where is the cut off for patients needing to be in a Level 1 or Level 2 trauma center and those that will do just as well in a community hospital?

Once we know the answers then we’ll have a much more realistic idea of when patients need to be flown and when they don’t.

Filed Under: Uncategorized

Random George Jones

April 4, 2012 by tooldtowork 2 Comments

For some reason I don’t have any George Jones MP3s. I don’t know why, but it’s not because I don’t like him. He’s a great singer with a long career. Enough said, here’s the music.

Filed Under: Uncategorized

It Followed Me Home, Can I Keep It?

March 18, 2012 by tooldtowork 6 Comments

Hanging around gun forums is dangerous. Dangerous to my bank account, that is. I should know better. A couple of weeks ago someone mentioned a gun shop that I didn’t even know existed. Well, I guess “exist” is subject to definition. In this case, it’s not a physical store, it’s an on line enterprise. Which I didn’t know when I was directed there and started looking. In the long run, it didn’t matter because I found a very nice Smith & Wesson Model 3904 9mm semi automatic.

The Third Generation S&W semi automatics in 9mm are like Lays potato chips to me. No one (well I) can’t have just one. It’s not a purely emotional thing, because they come in a wide variety of styles and essentially five sizes. Full size double stack, full size single stack, compact double stack, compact single stack, and sub compact single stack. No other caliber S&W semi autos come in such a wide variety. In addition to the different sizes, they come in steel, stainless steel, and a variety of alloys. Oh, did I mention traditional single/double action and double action only variants. There are people who try to collect at least one of each model. I’m not that bad, at least not so far as I’ve striven to keep my addiction in check. With limited success of course.

Anyway, I looked at the pictures on line, called the seller, made a deal contingent on an in person inspection and arranged to do the deal.

Today was the day and I drove out to his place to take a look and make my decision.

Of course my household appliances don’t like it when I spend money on things I actually enjoy, so the washer machine picked today to have it’s transmission go huckle, buckle, bean stock, and die a noisy, smelly death.

Sigh.

At the behest of Mrs. TOTWTYTR, I took a good look at the washing machine, determined that it was not something simple like a belt, or a switch, or anything else that I could repair economically. Or at all for that matter. A washing machine transmission doesn’t cost as much as an automobile transmission, but it’s not cheap. Especially not for a 12 year old machine. Which is about what a modern washing machine lasts, actually a bit more than the mean. They used to be good for 20 years, but that was 32 years ago when we bought our first washer.

I told the Mrs. that we’d go out washing machine shopping once I got back from firearm shopping. I’ll leave it to my reader to decide which one is more enjoyable. And not surprisingly, less expensive.

I went out and bought the pistol and came back home. I took one more look at the washer in the forlorn hope that maybe I’d missed the simple fix. Fat chance.

So, here’s a picture of the 3904. You’ll excuse me if I don’t show you a picture of the washing machine as we’ve ordered it but it’s not here yet.

After I got back home I placed the S&W into the gun safe and off we went to Sears. We like Sears for appliances because if you hit it right, you can get a good deal off of their regular prices. We hit it about right and found a nice full size machine for about twice what I paid for the pistol.

Although I’ll enjoy using the pistol more, the truth is that all the pistol can do to my laundry is put holes in it. Which presumably the washer won’t do. It should however clean my clothes, even after a day at the range.

On the other hand, I can hand the pistol down to my son or grandson. That’s not likely with the washer.

Well, we bought both, so it’s OK. Well, I bought the pistol and WE bought the washer. Mrs. TOTWTYTR has no interest in shooting, so I don’t have to share with her. I have no interest in doing laundry, but surprisingly she still expects me to share the laundry duties.

Oh well, such is married life. At least she didn’t insist I not buy the pistol, some wives would. I’m pretty lucky when you come right down to it.

Surprisingly she didn’t think it was funny when I handed her the receipt for the washer and said, “Happy Mothers Day, dear”.

Filed Under: Firearms, Uncategorized

All That Wheezes Is Not Asthma

March 7, 2012 by tooldtowork 11 Comments

Back when I was in paramedic school, the text we used was “Emergency Care In The Streets” by Nancy Caroline MD. It was a pretty good text book, although not written at the college level. In fact, the original paramedic program that Dr. Caroline ran was intended to provide inner city youths with a job that didn’t involve flipping hamburgers or selling drugs. As such, it was written at, I think, the Eigth Grade level. Some people scoffed at the level of writing used and in fact, we used a number of supplemental texts, but Emergency Care… was our main text book.

One of the things that Dr. Caroline wrote about was what she termed “Cardiac Asthma”. She also used the phrase that I used for this post title. Her point was that wheezing is a sign of airway restriction, not necessarily of bronchoconstriction. All too many people jumped (and sadly still do) to the conclusion that a wheeze must be caused by COPD or Asthma. They then immediately throw nebulized medications at the patient.

People used to laugh at the term “Cardiac Asthma” and in truth it’s not very accurate. Like “The Golden Hour”, it was a conceptual tool to help people get that it’s dangerous (to the patient) to assume that a wheeze can only be caused by Asthma or COPD. At various points in the evolution of a Congest Heart Failure exacerbation one can hear any number of breath sounds. Or one can ominously hear no breath sounds which can fool people into believing they are hearing clear breath sounds.

The point here is that it’s easy to be fooled if 1) You want to believe one particular thing, and 2) You don’t do a thorough exam.

All of which is preamble for rest of the post.

We were dispatched to a call for an elderly man having trouble breathing. No details in the call, not that they are always helpful. Nothing but his age, gender, and the fact that he was having breathing problems.

We arrived behind the fire department and the BLS ambulance, gathered our equipment, and proceeded into the house. Up to the second floor (what else?), and into a tiny, cramped bed room.

The BLS crew arrived a couple of minutes before we had, but had not released the fire company, which just made it more crowded. Turns out the BLS crew had an oops with their portable oxygen tank which left it empty. So, they used the fire department’s oxygen while one EMT ran down stairs to get a fresh tank. What his partner was doing in the mean time is a mystery, since it didn’t involve taking a pulse, blood pressure, asking any questions, or doing even one thing to help figure out what was going on with the patient. Harsh, I know, but for this particular EMT it’s the norm. She’s a wealth of information on a call, none of it useful.

Such is my lot in life.

My partner took a set of vital signs while I asked the patient a few questions.

His story was that he had got out of bed to use the bathroom and upon returning to his bed felt out of breath. This was not normal for him, which is what prompted him to ask his son to call 9-1-1. His son wasn’t particularly helpful, although he was pleasant and tried. He did tell us that his father had inhalors prescribed and had for years, but never used them. Not surprising since his Dad is a veteran and gets his care at a VA clinic. Nothing they do surprises me, although if they did something right, that would in fact surprise me.

While the EMT wrote down an incorrect list of medications, I listened to the patient’s lungs. Normal, except for a fairly localized area of wheezing on one side. Odd, but not concerning… yet. My partner gave me the vital signs which were pulse 120, BP, 200/100, RR 40. O2 saturation on a non rebreather was only 96%. Hmmm. ETCO2 was 45. The plot was thickening.

My early thought was Congestive Heart Failure. I’ll be honest. With most patients over the age of 50 or so, new onset dyspnea, with suddent onset, and no history to suggest otherwise, and after midnight, my early thought is always CHF. As a very wise doctor told me when I was a new paramedic, “People do not suddenly develop Asthma in the middle of the night, but they do suddenly develop CHF in the middle of the night.” I’ve followed that advice for almost 20 years and it’s always held me in good stead.

The 12 Lead, which I include because people like to look at them, was non informative. Which is to say that nothing jumped right out at us.

I suppose you could split hairs and say that V1 and V2 are “suggestive” of an MI, but I wasn’t and still am not convinced. At least not convinced enough that I’d insist on going to a PCI capable hospital. Wouldn’t do to have Rogue Medic accuse me of kidnapping a patient, would it?

I asked the patient’s son if his father seemed to be having trouble breathing or was working harder than normal to breath. He couldn’t really answer, but the grandson offered that the patient was in fact working to breath and looked pale. Hmmm.

The wave form was more instructive, at least I thought so. While I have often said that a O2 saturation of 100% is pretty meaningless, an O2 saturation of 96% on high flow O2 is informative, at least to me.

When looking at pulse oximeter readings, it’s important to make sure that the pulse wave form is good as that affects the accuracy of the readings. This is a good wave form, so I had no reason to doubt the accuracy of the reading. The ETCO2 waveform was similarly informative, showing me that there was no hint of CO2 retention or a “shark fin” wave form. The clinical picture was becoming more clear, but as is usually the case, the numbers were more confirmatory than diagnostic.

You’ll notice that the time on this is later than on the 12 Lead. We had the monitoring probes on much earlier than the print out, but you have to print about six seconds of waveform out for the readings to be set into the Code Summary. Which I constantly have to remind my technophobic partner. Well, oddly technophobic when it comes to some things like a monitor that we’ve been using since about 1998.

Sigh.

My gut feeling was that this was very early Congestive Heart Failure, but I really had nothing to pin that to. The patient wanted to go to the hospital that was the furthest away from us (of course). I wasn’t particularly comfortable with that non only because of the distance, but because care in that ER is marginal on a good day. We had a little bit of discussion and agreed to transport that patient to a closer hospital. Not my first choice, but my role in determining destination is limited in most cases.

The next task was to get the patient into the chair for the carry down stairs. This is actually a good diagnostic test, although that might seem odd. It might even seem a bit cruel, but it often helps to confirm clinical suspicion. If the patient can stand and pivot 90 degrees without difficulty, it’s a positive sign. If he can’t, it’s not so good. Maybe that sound cruel, or like I’m lazy, but it often helps clarify a murky case such as this. Being a paramedic often means being a detective.

Think about that for a minute. If a person who normally can stand and walk without assistance or difficulty suddenly gets short of breath standing, there is a clinical clue for the alert practitioner.

The patient stood (with me holding his arms) pivoted and sat down. And was short of breath. The diagnosis was clinched in my mind.

We carried him down the long wooden stairs and out to the ambulance.

The rest of the call was pretty routine. In the ambulance we listened to his breath sounds again, which were without change. We started an IV and gave some Nitroglycerin. The Nitroglycerin worked as it should, lowering his blood pressure, reducing his preload, and helping his breathing. We stabilized him enough so that the hospital could continue his care and he’d be fine.

Well they could once I convinced them that the wheezing was not due to his non existent COPD or Asthma. The nurse persisted in asking me if he used his nebulizer at home before calling us. This, despite the medication list print out from his clinic which I brought with us and which showed NO, I repeat NO, medications of any sort for Asthma or COPD. At which point the doctor told the nurse that the wheezing was probably cardiac wheezing, not Asthma. Which, as I had pointed out repeatedly, the patient did not have.

At least the doctor had paid attention to my report. Or maybe she had been a paramedic in a previous life. Either way, she ordered CPAP, not a nebulizer and she didn’t even wait for the Chest Xray to come back. She did what we did, only probably better. She used good clinical judgement to determine what was going on with the patient.

Filed Under: Paramedicine/The Job, Uncategorized

Modern Sounds in Country and Western Music

February 8, 2012 by tooldtowork 6 Comments

While cruising along the other day and listening to Willie’s Roadhouse on XM I heard the following song.

Yes, Ray Charles singing Country music. Or at least his interpretation of a country classic originally sung by Buck Owens.

What’s up with that?

A little research was in order on my part.

Turns out that in 1962 Ray Charles produced an album in which he sang a number of country music classics which had been rearranged to suit his style of music. Which was not very different to what is now known as The Nashville Sound.

Modern Sounds in Country and Western Music included the following songs,

(from Wikipedia)
Side one

“Bye Bye Love” (Boudleaux Bryant, Felice Bryant) – 2:09
“You Don’t Know Me” (Eddy Arnold, Cindy Walker) – 3:14
“Half as Much” (Curley Williams) – 3:24
“I Love You So Much It Hurts” (Floyd Tillman) – 3:33
“Just a Little Lovin’ (Will Go a Long Way)” (Eddy Arnold, Zeke Clements) – 3:26
“Born to Lose” (Frankie Brown, pseudonym of Ted Daffan) – 3:15

Side two

“Worried Mind” (Ted Daffan, Jimmie Davis) – 2:54
“It Makes No Difference Now” (Floyd Tillman, Jimmie Davis) – 3:30
“You Win Again” (Hank Williams) – 3:29
“Careless Love” (Traditional, Arranged by Ray Charles) – 3:56
“I Can’t Stop Loving You” (Don Gibson) – 4:13
“Hey, Good Lookin’” (Hank Williams) – 2:

That’s some pretty impressive country music right there, folks. All done in Charles’s R&B and Jazz style.

So, how country was Ray Charles?

Buck Owens, Ray Charles, a Steel Guitar. The only way it could be more country is if they were on a show like Hee Haw.

Oh, they were.

One last Country song from Ray Charles.

Country, Pop, Blues, it’s all in the arrangement folks.

Filed Under: Uncategorized

Sort Of A Meme

February 5, 2012 by tooldtowork 5 Comments

Rob over at Sharp as a Marble started this, although probably unintentionally by asking,

What 5 firearms would I purchase, should price nor practicality be an issue?

These are don’t need, but want, money and practicality are not considerations, just plain old gun lust want guns.

Always in search for post ideas and despite my general dislike for memes, I decided to play. I’m not going to tag anyone since this isn’t officially a meme.

Anyway, here are five guns I’d buy if money were no object. Some are practical and I might even get them someday. Others are just pure fantasy.

1) Colt Gattling Gun – Current Production.

I posted about this before. It goes for $50,000.00 so I’m not likely to get one. If you have to ask how much ammunition costs, you can’t afford the gun. Still, it would be wicked cool to drive up to the range with one of these on a trailer. It’s not a machine gun (at least I don’t think so) because you have to crank it manually. 800 rounds a minute of 45-70 Government goodness going down range. The ultimate fantasy gun.

2) Smith and Wesson Model 547.

A 9mm revolver originally intended for use by the Israeli Defense Force, well actually for Palestinian Police working under the IDF. S&W designed a unique extractor mechanism to handle the rimless cartridges, but in most other respects this is a K frame revolver with a heavy barrel. Two versions were offered, a 3 inch Heavy Barrel with Round Butt, and a 4 inch Heavy Barrel with Square Butt. The IDF took delivery of a small number of these, but cancelled the contract in favor of a locally made copy. As a result, most of these were released for domestic sale. A commercial failure then, they are collectible now due to their rarity and accuracy. I’d love a 3 inch version if I could find one that I could afford. They seem to go for at least $1,000.00 these days.

3) M1 Carbine.

Not particularly rare, but even beat up WW II production versions seem to command a premium. Something like 6,000,000 were made during WW II, but many were exported to other nations during WW II, the Korean War, and afterwards. Democrat controlled administrations have banned their reimportation, although there have been some imported over the years. Right now there are a bunch sitting in Korea waiting for a change in administrations or attitudes. Probably the most likely to be bought gun on my list.

4) Browning Hi Power.

The first high capacity 9mm handgun, designed in part by John M. Browning, the design was completed after his death. Widely used, it is still in use by military and police units around the world.

5) S&W Model 13, 3 inch Heavy Barrel, Round Butt.

A .357 Magnum K frame revolver. The variation I want was made for and issued by the FBI shortly before they changed over to semi automatic pistols. A Model 10-6 would be a fine alternative, but is probably more rare and more expensive.

There you have it, my wish list. I know people who have all of these except of course the Gatling Gun. They are out there and can be found, for the right price of course.

Filed Under: Firearms, Uncategorized

The Name Game

January 23, 2012 by tooldtowork 1 Comment

Rebranding is defined by Wikipedia as,

Rebranding is the creation of a new name, term, symbol, design, or a combination of them for an established brand with the intention of developing a differentiated (new) position in the mind of stakeholders and competitors.[1][2]

Far from just a change of visual identity, rebranding should be part of an overall brand strategy for a product or service.[3]

This may involve radical changes to the brand’s logo, brand name, image, marketing strategy, and advertising themes. These changes are typically aimed at the repositioning of the brand/company, sometimes in an attempt to distance itself from certain negative connotations of the previous branding, or to move the brand upmarket. However, the main reason for a re-brand is to communicate a new message for a company, something that has evolved, or the new board of directors wish to communicate.

Rebranding can be applied to new products, mature products, or even products still in development. The process can occur intentionally through a deliberate change in strategy or occur unintentionally from unplanned, emergent situations, such as a “Chapter 11 corporate restructuring,” “union busting,” or “bankruptcy.”

Apparently, DC Fire EMS (DC-FEMS) Chief Kenneth Ellerbe has decided to rebrand DCFD into DC-FEMS. Not exactly news since he issued the order some time back. Predictably, the fire suppresssion side of the agency isn’t happy with this and would like to stay with the moniker DCFD with an EMS division and a fire suppression division.

On the surface Ellerbe seems to be sending a message that DCFDEMSEIEIO is one big happy family. From news reports over the past few years, I’d think it’s one big dysfunctional family, but what do I know?

The crux of the latest crisis is that the agency has banned perfectly good outer wear that has the old, no longer permitted, lettering and logo.

DC Firefighters Taking Stand Against Latest Uniform Change

“I know it looks like a Home Shopping Network display here, but this is what
we have gone through,” said Lieutenant Robert Alvarado with Truck 13,
showing FOX 5 on a table all of the winter weather gear he has purchased
that is now no longer compliant with the uniform policy. “We started out at
the end of the year with this t-shirt here and this sweatshirt here and both
were an acceptable uniform item. As of January 1st, these items are done,
can’t wear them. This jacket as well because it has DCFD on the back, and
this is a winter jacket purchased with my own money which makes me clearly
identifiable as a member of the department. That’s no longer good.”

What is infuriating to Lt. Alvarado and others on the department is the fact
these changes don’t come cheap.

The fire department does not pay for winter outerwear and the only option
for firefighters to remain compliant and not be disciplined is to buy
additional outerwear with the proper identification or wear their turnout
gear around the clock.

Since fire suppression personnel have to, for some reason that I can’t fathom, buy their own outer wear, this is gotten fire suppression noses out of joint. Even worse, the agency has bought new outer wear for EMS only and command personnel. Again, that’s inexplicable to me, but it must make sense to El Jefe.

The bigger issue, again at least to me, is that this just might be image building to create the perception that Chief Ellerbe is changing the culture while doing nothing to correct the structural problems which make EMS delivery in the nation’s Capitol a sad, but dangerous joke.

Rather than superficial, exterior changes, the Chief’s efforts would be better directed to improving hiring standards, working on response times, some QA to catch problems before the demand letters and lawsuits arrive, and maybe even buy some more ambulances.

All of that takes committment and of course money. Both of which seem to be in short supply at DCFD, DC-FEMS, or Comedy Central, whatever the agency is calling itself this week.

As the saying goes, perception is reality. If the perception is that your EMS service delivers slow, sub optimal medical care, the reality is that rebranding won’t fix the problems.

Filed Under: Paramedicine/The Job, Uncategorized

Another Fire Department With EMS Problems

January 19, 2012 by tooldtowork 3 Comments

Report: Tensions rile Fire Dept.

PHILADELPHIA — A scathing report released yesterday rebuked the Philadelphia Fire Department’s culture, which it said caused paramedics to quickly hit a career ceiling and feel unappreciated and firefighters to undervalue calls for medical emergencies compared with fire calls.

A fire department run EMS system where the medics are treated like second class citizens? I’m shocked, shocked, I say. How can this be?

More here, Study on Philadelphia Fire Department urges bold action to meet goals

“We’re wasting a half-million-dollar truck and four guys because of a bellyache,” said Bill Gault, president of Local 22 of the firefighters union. “In a perfect world, every firefighter would be a paramedic, and that would alleviate everything.”

More clueless comments from a fire union official. In fact, systems where “every fire fighter is a paramedic” have significant problems with quality assurance and skill retention. The probable truth is more ambulances are needed, whether they are staffed by paramedics, EMTs, or some combination. Also, it sounds like some sort of phone triage system to prioritize responses is needed. What’s probably not needed, except to keep fire fighters busy, is fire apparatus first response for most calls.

You can view the entire report here.

Most of the recommendations are standard consultant fare. Somehow I don’t think that much will come of this. As I said, like Captain Renault, I’m shocked, shocked I say.

Filed Under: Paramedicine, Paramedicine/The Job, Uncategorized

How Much Can You Spend On A Ruger 10/22?

January 1, 2012 by tooldtowork 13 Comments

Note: I almost deleted this post because I thought it was kind of lame. Let me know what you think.

I’m going to try to make Sunday posts, or at least one of them firearms related. This is the first in what will hopefully become a regular feature.

The Ruger 10/22 has been around since it was introduced in 1964. It’s still in production by Sturm, Ruger & Company and comes in a wide variety of models. It’s even available in calibers other than .22 Long Rifle. There are also a dizzying assortment of after market parts available for it. Many people have bought new rifles just for the receiver and have replaced every other part with upgraded components. Along with the 1911 pistol and AR15 rifle, it is probably the most modified and customized firearm out there.

Which started me thinking. How much could one spend on a customized 10/22? I’m not including the price of a new rifle because it’s notw possible to buy a receiver alone and build a rifle from scratch. So, I went to MidwayUSA (you can do the same thing with Brownells) “built” a rifle from scratch. I used retail, not dealer prices, because not everyone has access to dealer pricing. I didn’t choose the most expensive pieces in all cases, instead I picked the ones I liked the most. Who knows, I might actually do this some day, although that’s not likely.

Note that the receiver is the “firearm” part of a firearm. That is to say that this part is what the BATFE considers the firearm and must be purchased from a Federal Firearms Licensed Dealer (FFL). Every other part can be bought by anyone with a credit card and computer access. For this exercise, I’m assuming that I could find a FFL to do the transfer for me.

Receiver. Tactical Solutions X Ring Receiver and Bolt. This is a bargain, since it includes the bolt as well as the receiver. Plus it’s tacticool with an integral Picatinny rail. $399.99

Barrel. Tactical Solutions Barrel Ruger 10/22 22 Long Rifle Keeping with the tactical theme, I picked the lightweight black tactical barrel for $234.99

Next, the parts for the action. Trigger, trigger guard, disconnector, springs, shims, and so on. Volquartsen Trigger Guard Assembly 2000 Ruger 10/22 Magnum Black has all the parts you need to build the action for $214.99

Stocks. Not from Midway, but I like the looks of the E. A. Brown M1 Tribute stock for the 10/22. $109 plus $19 dollars for the matching sling.

Sights, we have to have sights. For me, with my aged eyes and that the barrel is not cut for a front sight, a scope it is. I’ll limit myself to one designed for rim fire rifles only. Leupold FX-I Rimfire Rifle Scope 4x 28mm Fine Duplex Reticle Gloss for $219.99 will do nicely thank you. Must have the matching Leupold 1″ Mark 4 Picatinny-Style Rings Matte Medium for $140.99

Small parts, Volquartsen Hex Head Takedown Screw Ruger 10/22, 10/22 Magnum Steel $3.99, Shooters Ridge Magazine Ruger 10/22 22 Long Rifle 30-Round Polymer Smoke $21.99 times as many as you want. Also, a muzzle compensator is required Tactical Solutions Compensator .920″ Outside Diameter Ruger 10/22 Aluminum Matte Black for $34.99.

The total, minus shipping is $1399.92, which is actually pretty inexpensive considering the options out there. Then again, you can buy a brand new similarly built 10/22 for a retail price of $316.00 minus a scope. The street price is likely to be somewhat less, but you get the idea.

I’m sure that some of my readers will have their own ideas of how they would build their own 10/22 rifle. That’s the neat thing about this rifle, there is virtually no end to the options and variations you can build.

And of course that is nothing compared to what one can pay for a build it yourself AR 15 or 1911.

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The Christmas Post

December 25, 2011 by tooldtowork 11 Comments

Now that I’ve had some sleep and can write semi-coherently, I’ll tell you about my morning.

I worked a double shift Christmas Eve/Morning. The first part was to let one of my co-workers have the night off with his young kids. That shift was pretty quiet all things considered. Of course the devils in dispatch did send up to the other end of Sort Big City the second I paid for a meal. Fortunately, the call was silly in it’s entirety, someone who didn’t want to go to the hospital, didn’t ask anyone to call 9-1-1, had no reason to go to the hospital, and just wanted to go home. So, we let her and I went back to fetch my dinner.

Then, I smoked a really nice cigar because it was that quiet. Outside the station of course because we have rules about that.
The rest of the shift passed without incident and I drove over to my regular assignment for my regular shift.

We drove around a bit, got coffee, drove around a bit more, then went back to the station because we were bored and no one was out. Which is as it should be on Christmas morning. People want to be with their families, so they aren’t out and about. The college kids are mostly home, so we don’t have a lot of calls for them, most bars and restaurants are closed. Nothing much going on.

We lounged around the station for a bit and I thought about closing my eyes for a short nap. No such luck.

We were sent to one of our regular addresses for one of our regular patients. We see him every couple of months for some ailment or another. Don’t get me wrong, he has a lot of legitimate medical problems. Much of that is because he doesn’t take good care of himself, signs out of the hospital a lot, doesn’t seem to follow up, and so on. So, we see him a lot. I was resigned to having to deal with him yet again for one of his non specific ailments that make it frustrating to try to figure out what to do for him. Usually, we just drive him to the hospital and monitor him because there’s nothing else to do.

Today was no different. He had sharp-dull chest pain that did or didn’t radiate, might have had some shortness of breath, the pain had gone then it came back. Got that? The 12 lead ECG was interesting only in that it looked like a paced rhythm only our monitor didn’t pick up the pacer spikes like it should. Which might mean that he has a demand pacemaker and his rate was above the settings. Or it might mean that there was a problem with our monitor. Or it might mean that there was a problem with the pacemaker itself. Nothing to be done but treat his vague chest pain and go to the hospital. So we did what we do for vague chest pain and went to the hospital.

It’s telling when the triage nurse knows the patient by name and brings his chart up before you’re all the way into the triage area. He was duly assigned a bed and we moved him over. Then I finished my report and we once again went back to the station.

I was channel surfing desperately for something to watch when we were dispatched for a report of a person shot. Off we went listening to the police radio on the way. The first units arrived and found no one outside. Then the BLS arrived and stood around while the police looked for a victim or any indication that any shooting had been going on. There was a crowd of people standing in front of the address, all playing Mickey the Dunce. Or whatever that is in Creole. One of the eagle eyed police officers noted some blood, actually a good amount of blood, on the ground and front porch of the house. This caused the police to go into the house and all the way up to the top floor. Where they found more people with blank stares, including the man with the gun shot wounds in his leg and foot.

Yeah, he had been shot and then run a block or so and up three flights of stairs just to make the call more challenging for us. We gave him a quick exam, did some vital signs and went down to the ambulance. Where we took off the rest of his clothes, did a more thorough exam, found three wounds, and went off to the hospital. One bullet had gone through his wallet and grazed his ass, another was in his thigh and the third was in his foot. Seems that when the shooting started he wisely ran away, just a bit too slow. He wasn’t hurt so badly that he couldn’t make several phone calls on the way to the hospital. Normally I take the phone from the patients since it interferes with my conversation with them, but this time I didn’t bother.

Off to the trauma center we went. They weren’t too excited since they already had a bunch of patients and this particular one wasn’t that severely injured. Oh well, they had a nice Christmas buffet set out and invited us to partake. Which was nice of them.

While my partner was finishing his report another call came in, this time for another chest pain. Off we went to one of the city’s more convoluted housing projects to play find the address because some genius thought using black lettering on red brick would be just fine at night. Really, I think you have to be a moron to work for the public housing agency.

We finally found the patient sitting on his couch. Dull pain in the middle of his chest, which radiated up to his left jaw and arm. Oh-oh. He also mentioned that he was out “for a walk” when this happened and that he had almost fainted because he got so dizzy. Oh, that. Fall of of that, he was an incredibly stoic patient, the exact opposite of our first patient. He had already taken aspirin, so that was good.

We started him on some Oxygen and attached the cardiac monitor.

As we looked at the screen we noticed that Lead III had some elevation in ST segments. “That will probably disappear when we do the 12 lead.”, said my partner optimistically.

“Nooo, I think it will be worse when we do the 12 lead.”, said I pessimistically.

Sometimes I hate being right.

Our stoic gentleman was having a pretty decent Myocardial Infarction, with ST elevation in Leads II, III, and AVF, as well as reciprocal changes in leads I and AVL. Now, every good paramedic knows to look at Leads II and III and see if there is more elevation in III than II. If there is, the patient is likely having a right Ventricular MI as well as the more prevalent left Ventricular MI.

Guess what our patient had? So, we did a quick V4R which looked fine and meant that he likely wasn’t having a right Ventricular infarct, which was at least something positive.

12 Lead with V4R.

While my partner and the BLS guys got the patient into a stair chair, I went out to the hospital to give them a head’s up. Same hospital we had just left because it was the closest one with a cardiac cath lab. The staff of which had to be called in because no one staffs their cath lab 24 hours a day and on nights we try to give early notification so they can wake people up and get them in to activate the lab. I called on the radio and a bored sounding nurse answered. She handed the radio off to the bored sounding charge nurse. Who is really only bored because he’s been doing this as long as I have and nothing much phases him.

My radio call went something like this,

“Good morning ED, we have a STEMI alert for you this morning, yada, yada, yada, blah, blah, blah.” I omitted everything after STEMI alert because that was what they needed to hear. The bored sounding charge nurse didn’t sound so bored when he acknowledged my traffic.

Back to the patient. He still had chest pain, so as my partner started the IV I again asked the patient if he had any previous medical problems, took any medication, or had any allergies. Negative to all of the above he assured me.

Time for another 12 Lead. Not that it was going to change anything we did, but it would be nice to see if there were any more changes.

Pretty much the same, but his heart rate did have this disconcerting habit of slowing down to about 50, which almost had me putting on pacer pads just in case. But, I held off and his rate stayed where it should be.

Since he was clearly having an MI and his blood pressure was a bit low, we decided to skip Nitroglycerine and just give him Morphine. Which we did while we were driving him to the hospital. We got a grand reception at the hospital and a couple of minutes after we arrived the cath lab team started to show up. Pretty impressive since less than 30 minutes before they likely had been all snug in their beds with visions of sugar-plums dancing in their heads. Or something.

Oh, remember that Nitroglycerin we didn’t give? Good thing, because apparently our stoic little gentleman had plans when he went out for his “walk”. Which plans involved taking some Viagra, which he hadn’t wanted to mention in front of his wife. Not that I blame him. So, I don’t know if the pain actually came on while he was walking or doing something else. Not that it matters, but it might have been bad if we had given the Nitroglycerin.

That’s enough good calls for a week, let alone a single shift, but we weren’t done yet because we were only a bit more than halfway through our shift.

We finished the paperwork, restocked, went back to the station. Once again, we were sitting around being bored when I heard the police call for an ambulance in a hurry for a man “shot or stabbed in the neck bleeding very heavily.” That got our attention and since it would take a couple of minutes for the message to get from their dispatcher to ours we called in and told the dispatcher we were responding. Which, being a nitwit dispatcher, torqued her off, but well, to put it bluntly, screw her. We have a scan function in our radios for just this sort of situation and it’s reduced our response time often in the past.

We were just about a mile from the location so it took us no time to get there. Or it seemed that way the way my partner was driving. We arrived along with a BLS crew to find the police waving frantically and pointing to car which had the patient in it.

Whichever cop said he had a bad neck wound was right. At first I wasn’t sure the patient was alive, but he was. And covered with blood. With a nasty wound to the left side of his neck from the lower jaw down almost to the back of his neck. Nice anatomy lesson since we could see the base of his tongue, his external carotid (intact), lots of muscle, and lots and lots of blood. We got him into the ambulance and stuffed a multi-trauma dressing into the wound and I held pressure while my partner called the other trauma center and told them we were coming in. Then he took over pressure while I started an IV. Not that an IV would do all that much in the field, but at least they could give blood through it.

We stopped, or at least slowed down, the bleeding enough to keep the guy alive until we got to the hospital. The trauma surgeon took one look at the wound and took the guy right up to the OR. He’ll probably live, but he’ll have a story to tell. At least I think he’ll live, but that was one nasty wound.

While there I did a bit of follow up on the first patient. They admitted him to rule out unstable Angina, which was odd. Not the diagnosis, but the fact that he allowed them to admit him. Usually he signs out against medical advice and goes home with a new prescription.

We cleaned up, did our report, re stocked and went back to the station to wait out the remaining two hours of our shift. Which mercifully passed without incident or another call.

For those of you looking to get into EMS, this is not a typical shift. It’s actually more like a month of shifts all rolled into one. No wonder I was so tired when I got home.

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