Uncategorized | Too Old To Work, Too Young To Retire

Speaking Of Response Times

October 13, 2011 by tooldtowork 2 Comments

Follow Up to 2007 Audit of Philadelphia Fire Department EMS

If you want a shorter version read,

Butkovitz finds EMS responses still badly inadequate

I’m going to include this quote because it underlines what happens when non medical people try to help improve EMS systems.

Butkovitz called on the department to cross-train paramedics as firefighters. Unlike ambulances, fire engines usually arrive at emergency calls within three minutes of calls. But they are not staffed with paramedics

If the problem is not enough available ambulances to meet demand, wouldn’t the answer be to add more ambulances. Sending fire fighters, whether trained as paramedics or not, is a band aid approach to the problem.

Speaking of the problem I am compelled to add a second quote.

Butkovitz echoed the sentiment, saying the department needed to bring its financial resources in line with its need: EMS incidents account for 82 percent of the department’s workloads, but EMS receives only 17 percent of the department’s budget.

Soooo, Mr. Butkovitz correctly identified a need to resource mismatch, but then goes on to recommend a fix that isn’t a fix.

Other cities have had success with paramedics on engines, Butkovitz said.

Define success, Mr. Butkovitz. I’ll be it has something to do with response times, but little to do with outcomes. Has anyone ever done a study to see if there is an advantage to having paramedics on fire trucks. I mean a peer reviewed, blinded, study, not a “White Paper” issued by the hacks at the IAFF.

If there is one, please point me to it. For that matter how many fire based EMS systems publish their cardiac arrest survival rates? But I digress.

Last quote,

Even though more than half of the calls flooding in are for non-emergencies, the department does not have a priority dispatch system, Butkovitz said. Rather, it operates “robotically” on “first come, first served.” And the city’s 311 system has not eased the load on 911, he said.

Even though I very recently pointed out that priority dispatch type systems aren’t always very accurate, they are better than a system that amounts to little more than pulling a number out of a hat.

My thought would be not to get sick or hurt in the City Of ~~Brotherly Love~~ EMS Chaos.

Filed Under: Uncategorized

From The Journal Of Iatrogenic Medicine

September 1, 2011 by tooldtowork 1 Comment

Of course there is no such thing as the Journal of Iatrogenic Medicine, but sometimes I wonder if there should be.

For the record Iatrogenic is death, illness, or injury caused by a medical practitioner. Wikipedia has a pretty good article on the subject. Iatrogenia is a frank violation of the real first rule of medicine Primum non nocere, which is Latin for first do no harm. Which, despite it’s inclusion in the Hippocratic Oath apparently only dates to the 19th century. Still the principle is sound and often requires medical folks to do nothing because the cause of the problem is totally opaque. I’ve often told co workers that they shouldn’t just do something, but stand there until they know what to do. I think that’s a more sound course of action than trying a treatment because of the compulsion to “do something”. Every treatment, procedure, or medication has some degree of risk of harming the patient. The more we learn, the more it seems that things that we were taught might help, but couldn’t hurt, actually can hurt. Oxygen therapy and spinal immobilization come to mind in the case of EMS. As more studies are done on both topics, we learn that either can cause more harm than good when done under the wrong circumstances.

Every once in a while I’ll encounter a patient who is extremely ill or even dying and I’ll have no idea what is causing this. It’s a helpless feeling to see a sick person and not know exactly what to do to help them. At times like this I practice minimalist medicine. Which is to say that I stick with the ABCs, Airway, Breathing, and Circulation and use a large bolus of diesel fuel to get to the hospital as quickly as possible. In those cases it’s a relief to go back a few hours later and have the physician tell you that he couldn’t figure it either and turfed it to a specialist. It doesn’t make me feel smarter, just less dumb.

Herewith are three cases of Iatrogenic medicine. Fortunately none of them were committed by EMS practitioners.

DOCTOR CUT OUT THE HEALTHY PART OF MY HUSBAND’S BRAIN

A FORMER paramedic had the wrong part of his brain removed by a bungling NHS surgeon during an operation he didn’t even need.

Not only did they remove the wrong part of his brain, he didn’t need the operation in the first place. Speaking as a paramedic myself, I know that I don’t have enough brain that I can spare any in a needless operation.

Richard Kennedy, chief medical officer, said: “I very much regret the tragic outcome for Mr Tunney and his family and on behalf of the trust would like to apologise.

“Since 2008, this case has been thoroughly reviewed through our governance process and I am confident that measures have been put in place to prevent this type of incident reoccurring.

“For example, we now collaborate with expert clinicians at other trusts in these kinds of cases.”

So, they need to consult experts at other hospitals before they open up a patient’s skull and start hacking out parts of their brains. I wonder what the expert clinicians tell them other than to hack out the right part of the brain and to make sure that said part needs hacking out before commencing. Obviously the folks at University Hospitals Coventry and Warwickshire NHS Trust are no brain surgeons. I’m not making light of this because Mr. Tunney is now permanently and severely disabled. Iatrongenic medicine at it’s finest.

Hospital Admits Mistake After Teen Left Paralyzed

A British teenager was left permanently paralyzed from the waist down after an epidural anesthetic was left in her spine for too long after a routine operation to remove a hospital has admitted.

Sophie Tyler, 17, from Newport, South Wales, was 14 when staff at Birmingham Children’s Hospital left the painkiller in her back for two days, Sky News reported Wednesday.

You’d think that they’d notice that, especially after she started to have signs and symptoms and while just maybe it was early enough to do something to stop the damage. But no, they didn’t. Maybe they didn’t want to interrupt their afternoon tea or something. Rank incompetence.

Both of these cases are from Once Great Britain and it’s tempting to blame their national health care system, but the truth is it happens here too.

Parents get $7m in death of infant

A Suffolk County Superior Court jury awarded a South Hamilton couple a judgment of $7 million yesterday in the 2004 death of their newborn daughter at Beth Israel Deaconess Medical Center, according to their attorney.

Jurors found Dr. Janet Lloyd and nurse practitioner Michele Ambrosino negligent in the care of Katherine Bellerose, who was born about two months early at the hospital on June 13, 2004, and developed a condition that caused her intestinal tissue to die.

Once again a preventable death if only someone had paid a bit closer attention to the patient and the family’s concern.

And they tell me that guns are dangerous.

Filed Under: Medicine, Paramedicine/The Job, Uncategorized

It’s Electric

August 30, 2011 by tooldtowork 5 Comments

Actually, it’s not. While we are fortunate that we did not suffer injuries or damage to our property, we have no electricity. Which means no Internet, cable, or phone. I’m banging this out on my Blackberry, so I apologize if it looks like a ransom note.

Once I get back on line I’ll have some posts to write. One will be about Irene, one about an interesting cardiac case (maybe two), and one about interesting multi media resources for EMS folks.

Hoping to rejoin the 21st century later today.

Filed Under: Everything Else, Uncategorized

The Top 100 Science Fiction And Fantasy Novels

August 27, 2011 by tooldtowork 3 Comments

At least according to a poll by NPR.

Like other bloggers I’m publishing the list with the books I’ve read highlighted in bold. Comments at the bottom of the list.

1. The Lord Of The Rings Trilogy, by J.R.R. Tolkien
2. The Hitchhiker’s Guide To The Galaxy, by Douglas Adams
3. Ender’s Game, by Orson Scott Card
4. The Dune Chronicles, by Frank Herbert
5. A Song Of Ice And Fire Series, by George R. R. Martin
6. 1984, by George Orwell
7. Fahrenheit 451, by Ray Bradbury
8. The Foundation Trilogy, by Isaac Asimov
9. Brave New World, by Aldous Huxley
10. American Gods, by Neil Gaiman
11. The Princess Bride, by William Goldman
12. The Wheel Of Time Series, by Robert Jordan
13. Animal Farm, by George Orwell
14. Neuromancer, by William Gibson
15. Watchmen, by Alan Moore
16. I, Robot, by Isaac Asimov
17. Stranger In A Strange Land, by Robert Heinlein
18. The Kingkiller Chronicles, by Patrick Rothfuss
19. Slaughterhouse-Five, by Kurt Vonnegut
20. Frankenstein, by Mary Shelley
21. Do Androids Dream Of Electric Sheep?, by Philip K. Dick
22. The Handmaid’s Tale, by Margaret Atwood
23. The Dark Tower Series, by Stephen King
24. 2001: A Space Odyssey, by Arthur C. Clarke
25. The Stand, by Stephen King
26. Snow Crash, by Neal Stephenson
27. The Martian Chronicles, by Ray Bradbury
28. Cat’s Cradle, by Kurt Vonnegut
29. The Sandman Series, by Neil Gaiman
30. A Clockwork Orange, by Anthony Burgess
31. Starship Troopers, by Robert Heinlein
32. Watership Down, by Richard Adams
33. Dragonflight, by Anne McCaffrey
34. The Moon Is A Harsh Mistress, by Robert Heinlein
35. A Canticle For Leibowitz, by Walter M. Miller
36. The Time Machine, by H.G. Wells
37. 20,000 Leagues Under The Sea, by Jules Verne
38. Flowers For Algernon, by Daniel Keys
39. The War Of The Worlds, by H.G. Wells
40. The Chronicles Of Amber, by Roger Zelazny
41. The Belgariad, by David Eddings
42. The Mists Of Avalon, by Marion Zimmer Bradley
43. The Mistborn Series, by Brandon Sanderson
44. Ringworld, by Larry Niven
45. The Left Hand Of Darkness, by Ursula K. LeGuin
46. The Silmarillion, by J.R.R. Tolkien
47. The Once And Future King, by T.H. White
48. Neverwhere, by Neil Gaiman
49. Childhood’s End, by Arthur C. Clarke
50. Contact, by Carl Sagan
51. The Hyperion Cantos, by Dan Simmons
52. Stardust, by Neil Gaiman
53. Cryptonomicon, by Neal Stephenson
54. World War Z, by Max Brooks
55. The Last Unicorn, by Peter S. Beagle
56. The Forever War, by Joe Haldeman
57. Small Gods, by Terry Pratchett
58. The Chronicles Of Thomas Covenant, The Unbeliever, by Stephen R. Donaldson
59. The Vorkosigan Saga, by Lois McMaster Bujold
60. Going Postal, by Terry Pratchett
61. The Mote In God’s Eye, by Larry Niven & Jerry Pournelle
62. The Sword Of Truth, by Terry Goodkind
63. The Road, by Cormac McCarthy
64. Jonathan Strange & Mr Norrell, by Susanna Clarke
65. I Am Legend, by Richard Matheson
66. The Riftwar Saga, by Raymond E. Feist
67. The Shannara Trilogy, by Terry Brooks
68. The Conan The Barbarian Series, by R.E. Howard
69. The Farseer Trilogy, by Robin Hobb
70. The Time Traveler’s Wife, by Audrey Niffenegger
71. The Way Of Kings, by Brandon Sanderson
72. A Journey To The Center Of The Earth, by Jules Verne
73. The Legend Of Drizzt Series, by R.A. Salvatore
74. Old Man’s War, by John Scalzi
75. The Diamond Age, by Neil Stephenson
76. Rendezvous With Rama, by Arthur C. Clarke
77. The Kushiel’s Legacy Series, by Jacqueline Carey
78. The Dispossessed, by Ursula K. LeGuin
79. Something Wicked This Way Comes, by Ray Bradbury
80. Wicked, by Gregory Maguire
81. The Malazan Book Of The Fallen Series, by Steven Erikson
82. The Eyre Affair, by Jasper Fforde
83. The Culture Series, by Iain M. Banks
84. The Crystal Cave, by Mary Stewart
85. Anathem, by Neal Stephenson
86. The Codex Alera Series, by Jim Butcher
87. The Book Of The New Sun, by Gene Wolfe
88. The Thrawn Trilogy, by Timothy Zahn
89. The Outlander Series, by Diana Gabaldan
90. The Elric Saga, by Michael Moorcock
91. The Illustrated Man, by Ray Bradbury
92. Sunshine, by Robin McKinley
93. A Fire Upon The Deep, by Vernor Vinge
94. The Caves Of Steel, by Isaac Asimov
95. The Mars Trilogy, by Kim Stanley Robinson
96. Lucifer’s Hammer, by Larry Niven & Jerry Pournelle
97. Doomsday Book, by Connie Willis
98. Perdido Street Station, by China Mieville
99. The Xanth Series, by Piers Anthony
100. The Space Trilogy, by C.S. Lewis

Looking at the list, I’ve read a good part of the list, which signifies nothing. Well, other than I’m a bit of a geek, which you should know by now. I remember the first science fiction book I read, which is not on the list, and the circumstances under which it came to my attention. Blame my mother for starting that.

I think lists like this are pretty meaningless, even if put together by a survey or poll. I don’t think that the Lord of the Rings trilogy is the best science fiction or fantasy novel ever written. Not by a large margin. Eight to be exact, since off the top of my head Asimov’s Foundation Trilogy is the best novel (although it’s three book) ever written, but others won’t agree. Actually, other than the fact that book sellers put them on the same shelves, I don’t even think of science fiction and fantasy as the same genre, even though I’ve read some of both. Is Harry Potter fantasy or science fiction? Or a kid’s book for that matter. They should be separate lists since some people only read one, but never the other. As you can see, I’ve read some of each, but much more science fiction than fantasy.

Heinlein does no better than 17th? And that’s with Stranger in a Strange Land, which he wrote when he was broke and needed the money. He mentioned a couple of times over the years in various publications that he hated that book. Unlike everything else that he wrote, I’ve read it once and haven’t owned a copy in 25 years or more. Most of his so called juvenile series books are better written than Stranger, but because they were written primarily for young boys I don’t know that they’d be considered serious literature.

Do you notice a name missing from the list? I do, and it’s glaring to me although he was much better known for his short stories than novels. Theodore Sturgeon.

I don’t think that Stephen King writes either Science Fiction or Fantasy, but then again I’m not a King fan so I don’t think he belongs on a top ten list at all.

All in all, this is just another top 100 list that is essentially meaningless, but will give people something to debate endlessly without changing anyone’s mind.

Filed Under: Everything Else, Uncategorized

Train Wreck, The Follow Up

August 18, 2011 by tooldtowork Leave a Comment

The patient survived and is doing, well, I guess OK. He had another infarction, which we knew, had another stent placed, and is conscious. His heart suffered major damage, for the medical folks his Ejection Fraction is 25%. For the non medical folks, the normal EF is anywhere from 50-70% or so depending on whose study you want to adhere to.

Not the best quality images, but I did them with my cell phone not a scanner. If you click on them they enlarge and become easier to see.

This is what we saw when we attached the ECG leads and turned the monitor on.

After six defibrillations we finally got a perfusing rhythm with a blood pressure. By this point the patient was sedated and intubated.

The 12 Lead ECG tells the story. If you’re not one of my medical readers I’ll just say that this is NOT the ECG you want to have. The patient has a long road to go for recovery.

Filed Under: Uncategorized

Is Jon Stewart A Racist?

June 29, 2011 by tooldtowork 15 Comments

Decide for yourself.

I’m not sure about you, but if I did that sort of thing at work I’d be fired. Jon Stewart purports to be a comedian, but you can’t be a comedian if you’re not funny.

Oh, remember what happened to Micheal Richards when he made some racist comments in response some hecklers.

Filed Under: Civil Rights, Politics, Uncategorized

No Weiner Jokes, Please

June 28, 2011 by tooldtowork 8 Comments

This is actually fairly serious stuff, since it involves preventing a potential injury to human sex organs.

A Release Valve for Cyclists’ Unrelenting Pressure

It’s the area of soft tissue called the perineum, and it’s not just a male problem — female cyclists have also reported soreness and numbness in this genital region. But neither sex seems interested in these saddles, and I’m as baffled as Mr. Brown is by their apathy.

I do a fair amount of bike riding too, between 10-15 miles per day, depending on a number of variables. I have more than one bike, but the one I ride the most has a noseless saddle on it. When I first started riding, about seven years ago I noticed the symptoms that were described. It was very uncomfortable and cut into my enthusiasm for riding. I did some research on noseless bike saddles and came across the Moonsaddle. While it looks funny and takes a bit of getting used to, it works well and now I feel strange trying to ride without it. I haven’t put one on my secondary bike (a mountain bike) yet, but I have tilted the traditional style saddle down at an angle to reduce pressure on my perineum and make riding a bit more comfortable. Of course mountain bike saddles are built a bit differently than road saddles, especially in terms of padding.

“There’s as much penis inside the body as outside,” Dr. Schrader told me. “When you sit on a regular bike saddle, you’re sitting on your penis.”

Well there’s a medical fun fact you won’t find on the NREMT exam. But, it’s an important point.

It’s an important enough an issue that the National Institute of Occupational Safety and Health (NIOSH) has issued a recommendation that police officers and other people who spend a long part of their work day on bicycles switch to noseless saddles.

But, of course there are some people, in this case it seems a majority, of people who don’t agree,

“I suppose there’s a small niche of people for whom a noseless saddle might be a solution,” Mr. Flax said. “But a saddle without a nose has real problems in terms of function. A cyclist can make turns using the weight in the hips against the nose. I just don’t think a noseless saddle is safe in a race.”

Well, Mr. Flax here are couple of points for you to ponder. First, this is based on science, not tradition. Also, most bike riders are NOT racers. In fact, I’d say that most people who ride bikes ride for fun and exercise, with a smattering riding to save the environment or even gas money. I don’t know if I’m atypical as a bike rider, but I have no pretensions of being Lance Armstrong and winning the Tour de France. I ride because it increases my aerobic capacity and helps me decrease my weight. I think there are a lot more riders like me than elite racers out there. If more of them knew about the variety of noseless saddles available, I suspect more of them would use them.

The BiSaddle, which is mentioned in the article seems a bit spendy to me, but there are other options. The Times article does not mention the Moonsaddle, but does mention several other brands of saddle sans nose.

Let’s hear some more wisdom from Mr. Flax,

“Serious bike riders would be totally embarrassed to show up at a race in a noseless saddle,” Mr. Flax said.

Well, they’ll be seriously embarrassed if one day Mr. Happy doesn’t stand at attention when their significant other is expecting something after the race. If you get my drift.

Well, there’s a certain logic to that retail strategy, at least for the short term. But if you’re in it for the long term, if you’d like your customers to keep cycling — and creating new customers — then it pays to protect the perineum.

The perineum and the delicate structures that run through it. It would seem to make business sense to inform customers and potential customers about a potentially serious problem and some ways to avoid it.

Filed Under: Medicine, Uncategorized

Surprise!

June 8, 2011 by tooldtowork 6 Comments

Visits to ER rise despite health law

Emergency room visits have been on the rise in Massachusetts since the passage of the 2006 health care law, much to the chagrin of supporters who projected that the opposite would happen as more people had insurance and were connected with primary care providers.

Only of course payments to primary care physicians are being cut and an increasing number of primary care physicians are not taking new patients. Maybe the geniuses that came up with Romneycare should pass a law to force physicians to take new patients whether they want them or not. After all, politicians and social scientists know what’s best for us.

A new study published online shows that the issue may be a bit more nuanced.

I love nuance. Nuance means never having to say you’re wrong. It’s sort of the educational elite of “Who are you going to believe, me or your lying eyes?”

Smulowitz said the 2006 law has done what it was designed to do, expand health insurance, but its success has been unfairly measured by emergency room usage.

The idea that the law has failed if it has not reduced those visits is “nonsensical,’’ he said.

Nonsensical or not, the law was touted as reducing costs because uninsured people would now be insured and not have to go to the emergency department for non emergency care. In fact, costs have risen and more not fewer people are going to EDs for their non emergency care. Dr. Smulowitz can spin this any way he wants, but the truth is the law did not do what it was advertised to do.

CNN looked at Massachusetts health care reform last year in this article, 5 painful health-care lessons from Massachusetts

In explosive emails released last week, Robert Dynan, chief of the financial analysis unit at the Division of Insurance, told Commissioner Joseph Murphy that the price caps would cause a “potential train wreck” and threatened “catastrophic consequences for the non-profit industry.” Dynan warned that the non-profits, unlike national giants such as WellPoint operate on such slim margins that the controls could drive them into bankruptcy. Even now, four of the biggest insurers are threatening to stop taking new patients at rates so low they lose money on each new enrollee.

If the private insurers go out of business, then the government becomes the insurer. Which will allow the government to control costs, mostly by determining who gets what type of care, from whom, and when. Which sounds like rationing to me.

All of this because the then Democrat controlled Congress refused to look at the real causes of out of control costs and do anything serious about it.

Lovely.

Filed Under: Uncategorized

Happy Mother’s Day

May 8, 2011 by tooldtowork Leave a Comment

Happy Mother’s Day to all of my readers who are Moms. Or Moms to be for that matter.

Enjoy the day.

Make your husband do something.

Filed Under: Uncategorized

RMS Titanic

April 15, 2011 by tooldtowork 2 Comments

About 0220 on the morning of April 15, 1912 the unsinkable luxury liner RMS Titanic sank beneath the North Atlantic after having struck an iceberg about two and on half hours before.

1,517 passengers and crew died as a result of panic, over loading of the ship, insufficient numbers of life boat and rafts. That more, possibly all, of the crew and passengers didn’t perish can be credited in part to the use of the newfangled “wireless” radio which sent out a distress call that was picked up by the Cunard liner RMS Carpathia. Which ship raced to the site where Titanic had already sunk and picked up the 706 survivors.

The inquiries and litigation resulted in major changes to ship design, maritime regulation, and prompted the creation of the International Ice Patrol.

Filed Under: History, Uncategorized

Stay Up To Date

Speaking Of Response Times

Follow Up to 2007 Audit of Philadelphia Fire Department EMS

Butkovitz finds EMS responses still badly inadequate

From The Journal Of Iatrogenic Medicine

DOCTOR CUT OUT THE HEALTHY PART OF MY HUSBAND’S BRAIN

Hospital Admits Mistake After Teen Left Paralyzed

Parents get $7m in death of infant

It’s Electric

The Top 100 Science Fiction And Fantasy Novels

Train Wreck, The Follow Up

Is Jon Stewart A Racist?

No Weiner Jokes, Please

A Release Valve for Cyclists’ Unrelenting Pressure

Surprise!

Visits to ER rise despite health law

Happy Mother’s Day

RMS Titanic

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