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A Cat

If you own a cat or a dog you know going in that they don’t have very long life spans compared to humans. Dogs generally live between 10-14 years depending on the breed, what they are fed, and other factors. Cats can live up to 18 years, but 14-16 years seems to be the normal range.

In the case of cats, it’s very often kidney failure that causes their demise, although heart disease and Feline Leukemia are not uncommon.

We had dogs when I was young, because my father liked dogs and my mother didn’t like cats for some reason that was never made clear to me.

When I was grown, married, and had children we didn’t have any pets because I just didn’t have the time needed to properly care for one. At that point I was still a “dog person” although I always liked cats and cats seemed to like me. More than once I’d go to a friend’s house and their cat would cozy up to me. I’d hear from those various friends that their cats never liked strangers, but apparently I was an exception.

When my son was in his senior year at college he lived in an off campus apartment. He met a girl and she liked cats. In fact her mother lived on a small farm and they had several cats. At some point, my son decided he wanted a cat around the apartment. I’m pretty sure that this decision had something to do with the girlfriend as a lot of his decisions at that point in his life involved something to do with his girlfriend.

The girlfriend departed, but the cat stayed. Cute little orange Tabby guy and at some point my son had to go out of town for several days for job interviews. He asked us if the cat could stay with us while he was out of town.

Mrs. EMS Artifact, never an animal lover, agreed but Lenny had to stay downstairs in one part of the house. She didn’t want him roaming around the house, so I set up his litter box, food, water, and some toys in the room that was my office.

That lasted about two days and then Lenny had the freedom of the house and would sit with Mrs. EMS Artifact while she was upstairs in the Living Room. I’ve heard in the past that cats would gravitate to people who didn’t like them and this certainly seemed to be the case with Lenny.

In due course my son returned from his trip and and retrieved Lenny. I missed him and thought that I’d like to have a cat around the house, but was pretty sure that Mrs. EMS Artifact would object.

As is so often the case, I was wrong about that. A couple of days later Mrs. EMS Artifact mentioned that it would be nice to have a cat around. You think you know somebody.

I was given the task of finding a suitable candidate and so I turned to the internet and in due course found a shelter that had four kittens from one litter available for adoption. One of them was named Moe and being a die hard Three Stooges fan, I was immediately attracted to the cute little fellow.

We went to meet the cats and be interviewed. Not by the cat, but by the people at the shelter. We passed muster and Moe was going to be ours in a few days.

While driving home Mrs. EMS Artifact mentioned that Moe would be lonely without another cat to keep him company while she and I were at work. I looked at my wife and wondered if she had been abducted by aliens and replaced with someone who like cats.

Thus, a cat lady was born. I agreed that we could handle two cats and we called the shelter to arrange to adopt a second cat. Her name was Minnie, and she and her brother looked like twins, because they were.

An interesting thing about cats is that females can mate with more than one male and have a litter with more than one father.

So, we became a two cat family. Initially, my wife wanted to have the same rules about staying downstairs as we had with Lenny, but that didn’t last long and the soon had the run of the house.

It’s amazing how quickly you can bond with an pet.

That was in early 2005 and the cats quickly became part of the family. Minnie was the alpha cat and Moe spent a lot of time hiding in various places. He was good at it, but still affectionate when he wanted to be. Which was often at about 03:00 when he’d jump up on our bed and want to be petted. Somehow, we never minded.

All was well until early this year when Moe’s behavior changed. He was still affectionate, but didn’t have much of an appetite and didn’t want to be petted. After a few days of that I took him to the vet. The doctor couldn’t fine anything wrong with him other than the early stages of kidney disease. He prescribed a change of diet and advised us to make sure he drank a lot of water.

In a couple of weeks Moe was back to being Moe.

What lasted until the end of April, when he again lost his appetite, became morose, and his fur started to look ragged.

Early on the morning of May 1 I took him to the emergency 24 hour vet and they took him in. At the time, and actually for a couple more weeks humans weren’t allowed in with their pets. It’s a silly rule that was put in place because of Covid. I don’t understand it and frankly think it’s stupid.

A little while later the doctor called and told me that Moe wasn’t doing well and that his kidney disease had progressed rapidly. We discussed options and agree that they should attempt aggressive resuscitation and see if he got better.

He didn’t. The vet called again and said that he hadn’t responded at all and in fact was worse. I had to make a very hard decision, but I put his best interests ahead of my desire to try and prolong his life.

In due course we received his cremated remains in a very nice wooden urn.

We also learned that cats mourn. I never thought of it, but Minnie knew that he was gone, although not why. Here we are a month later and she’s started accept that he’s not coming back, but she’s still confused.

For that matter, so am I.

I don’t know how much longer we’ll have her, but we’re going to cherish the time that’s left. After that, I don’t know that we’ll adopt again. As Mrs. EMS Artifact pointed out, we’re not kids ourselves and there is a decent chance that any cats we adopt will outlive one or both of us.

Anyway, that’s the story of a cat. Here is a picture of Moe on his bear rug, which was his favorite napping spot.



Memorial Day


“Think not about their passing, remember the glory of their spirit.”

The Court Takes A Case

The Supreme Court in today’s order list granted certiorari to a Second Amendment case. This is the first time that certiorari has been granted for a Second Amendment case in ten years.

The case 20-843 NEW YORK STATE RIFLE, ET AL. V. CORLETT, KEITH M., ET AL. concerns the requirement in New York State the a person show a need to carry a firearm for self defense. The state is the sole judge of whether or not a permit to carry a concealed weapon will be granted.

On paper at least a person denied a permit can appeal to a court to over rule that decision, but it virtually never happens.

There are about seven other states that have similar restrictions. They are known as “may issue” states and the requirements vary widely. New York and New Jersey are more like “never issue unless you’re politically connected” states. Massachusetts may or may not issue a permit depending on what the local police chief feels like doing.

The other “may issue” states are California, Connecticut, Delaware, Hawaii, Maryland, and Rhode Island. Rhode Island is actually a “shall issue” state if the permit is issued by the local town, and may issue if the permit application is filed with the Attorney General. In real effect, it’s a probably won’t issue state as some local departments refuse to even process an application. That has lead to a lot of litigation, but I’m not going to go into that now.

The grant of certiorari states the following,

The petition for a writ of certiorari is granted limited to the following question: Whether the State’s denial of petitioners’ applications for concealed-carry licenses for
self-defense violated the Second Amendment.

It’s not unusual for the Court to take a very narrow approach to cases brought before it. In this case, a favorable decision will likely require the seven may issue states to issue some sort of permit. The problem may be what restrictions the place on the permits. Which will likely lead to yet more litigation as none of those states are likely to change their laws voluntarily.

The fact that the Court granted certiorari is significant in and of itself. They have refused to take up several Second Amendment cases over the past several years, including a previous one from New York City. The city successfully convinced the Court that the case was moot as the city had changed the laws that had been challenged.

There was also a case out of Illinois that might have resulted in a similar decision as is being requested here. That was back in 2012 as I recall. Illinois was a “no issue” state at the time and the Seventh Circuit Court of Appeals ruled that the state must enact a law to allow for concealed carry or the court would decree that no permit was required for concealed carry.

Illinois was going to appeal that decision to the Supreme Court, but it appears that several other states pressured the Attorney General of the state not to do so. The fear was that “shall issue” would become the rule of law and states would lose the discretionary power.

Since certiorari was granted just today, I’d expect that the case won’t be heard until the fall session of the Supreme Court and a decision won’t be issued until about this time next year.

Hold on to you hats folks, the ride is likely to get bumpy.

Thoughts From On The Road

Mrs. EMS Artifact and I took a longish road trip starting the first week of March. We were headed for north South Carolina to spend some time with the grand kids while their parents took a vacation break.

I have enough airline points to fly around the world, or at least part way. My most used credit card is tied to a major airline so I get points whenever I use it. Since the last time either of us boarded a plane was in late 2019, there are a lot of points sitting around waiting to be used.

Given the additional PITA that flying now is, we opted to drive. I planned out a two day drive with an overnight stay in northern Virginia along Interstate 81.

Driving at this time of year can be dicey as the weather is still unsettled. It’s March, but early March can have some wild weather as anyone living north of about Florida can attest.

Fortunately, weather was a non factor for the most part.

We started out and followed a route that was mostly interstate highways. We got on I-84 along the MA/CT border and headed west. Gas prices were higher than a few weeks before, but not horrible. Well, not yet.

If you’re taking a route through CT, NY, or PA try to fuel up before hand. Ironically, NJ has pretty good prices, even though you’re not allowed to pump your own gas. Well, on paper because we stopped on Matamoras, NJ and I forgot that quirk of NJ law. I pumped my own gas in New Jersey! I’m a criminal. Well, not really as the attendant must be used to that because he gave me a thumbs up and walked away.

We took I-84 across New York to Pennsylvania. The New York State Police are very active with traffic enforcement. Waze is pretty good about safety alerts, but the troopers like to sit on the median waiting for a scoundrel to come along.

Crossing into PA, we found the PA State Police to be using pretty much the same tactics, but there are fewer of them. We didn’t notice any local agencies in either state doing traffic enforcement.

PA is cold in early March. We had some light snow.

Restaurants are open, but many will only do delivery or take out. People were walking around on the streets wearing masks even though they were alone. The Mrs. and I have eschewed wearing masks unless there is no other choice, so we notice what people are doing.

We continued on south towards Virginia and noticed that the further south we went, the more tractor trailers we noticed. At one point the Mrs. counted 25 trucks traveling in the opposite direction during a one minute period.

EVERYTHING travels by truck at some point. Diesel prices are up almost a dollar a gallon since the first of January. That’s going to effect us all at some point since everything we buy, including gas, travels by diesel truck at some point.

Be sure to thank President Biden for that and the increased price of gas for you car or truck. Prices on everything are going to rise.

Crossing into VA I set the cruise control to exactly 5MPH over the speed limit. They’ll give you that, but if you go faster you run substantial risk of meeting a VA State Trooper. Or a Sheriff’s Deputy since local agencies do traffic enforcement as well.

I think it’s 10MPH over the speed limit where they can arrest you and require you to go before a magistrate. Or so I’ve been told, but fortunately have never had the experience.

We also found that restaurants are, uh, different in VA. Some are open, but with limited seating, some only do take out or delivery. The websites aren’t all accurate, so we found out (the hard way) that a phone call is prudent before pulling up to the door.

We found an open Waffle House for breakfast. A typical WH has 2-3 cooks, 4-5 waitresses, and at least one person busing tables. These are not normal times. The one we found was empty at 08:30 except for two employees. They were taking orders, cooking, serving, running the cash register, and busing tables. Two people.

Which was okay because one other couple came in while we were dining. Mrs. EMS Artifact asked if this was normal and our waitress said that’s how it’s been for a year.

I suggested that their governor was a moron, and despite the fact that she probably wasn’t supposed to, she laughed. We felt bad and were more generous than usual with the tip.

We passed through VA into North Carolina without incident. Traffic enforcement wasn’t as vigorous there as it was in VA, so I just went with the flow of traffic. Based on a previous experience last summer, we opted not to stop in NC and drove on through to our destination.

South Carolina has far fewer restrictions than any other state we went through. Masks are only required in larger stores, restaurants operate pretty much as normal, most people don’t seem to care if you wear a mask or not.

Oddly enough, people were not keeling over in the streets from the virus. Covidiocy was really at a minimum.

After a week visiting, it was time to head back. The return trip was much the same, only with much more expensive gas prices. They had gone up about $0.50 per gallon over the week we were there. South Carolina still had the cheapest prices, but they weren’t cheap.

Thanks, President Biden.

On the return trip, we noticed even more big trucks on the road. There were very few tractors without trailers, “deadheading” as it’s known in the trade. Oh, all of the big companies had signs on their trucks looking for drivers. Which either means that they are very busy or people are leaving faster than they can replace them. One is good, one isn’t.

We’re planning another trip and unless things change dramatically in terms of what you have to do to fly, we’re likely going to do this drive again.

Here’s a hint if you ever plan to travel with firearms. AVOID the New York City area and all of New Jersey. Swing inland a bit and drive worry free as normal states don’t care if you are transiting with legally owned firearms.

Things I Read Part 3

In Part 1, I groused about over use of Blood Glucose Level (BGL) checks in patients that don’t need them. Of course shortly after that I came across a case where the patient absolutely should have had his BGL checked.

Briefly this was a male in his mid 30s who had a seizure. When EMS made contact, the patient was no longer actively seizing. He was post ictal, which is a generic description of the mental state of a patient after the seizure has ended.

The range of post ictal states can range from unresponsive, to sleepy, to slightly irritable, to wildly violent.

This patient was sleepy until the medics decided to pick him up and move him to the stretcher. At which point he became wildly violent. He fought with the medics, the firefighters, and the police on scene.

Once on the stretcher, he calmed down and became sleepy. So, the medics decided to continue their assessment. At which point, he started fighting again. The medic who wrote the report documented that they were unable to start an IV (understandable), and unable to place EKG electrodes for cardiac monitoring (also understandable). They administered 6mg of Versed which made the patient barely manageable. That’s well within their protocols.

The report documents that the patient continued to buck the restraints and try to get off the stretcher. That’s a bid odd, but not inordinately so, when Versed is used. Ativan is actually a better drug, but is not authorized in the state where the medics work.

Up to this point, they were doing things within the protocols and care was appropriate.

Here is where they went off track.

They didn’t perform a BGL. The medic didn’t explain why he didn’t do one, but he didn’t. That’s a major deviation of the protocols and one that absolutely needs explanation.

The only thought that I had was that they just didn’t think of it. Most medics will do a BGL when the start an IV. Technically, they are supposed to do a separate finger stick with a lancet and get the reading that way.

Medics can debate for hours whether there is a real difference between a finger stick (capillary) or IV (venous) Blood Glucose Level and whether the difference is significant. This is much like theologians debating how many angels may dance on the head of a pin.

In truth, it’s going to be pretty close no matter which method you use. The important part is to actually get a reading.

While obtaining a BGL on every patient may drive me nuts, there’s no rule against it. I just think it’s an indicator of a lazy provider who doesn’t or can’t think the situation through.

On the other hand, not getting a BGL when it’s indicated by good clinical judgement or the protocols is going to get a call flagged for further review. Many EMS and a few law enforcement careers have been ended by the “It’s just a drunk” syndrome when encountering a patient with an Altered Mental Status.

My last observation, or if you prefer gripe, in this series is overuse of IV fluids.

There are several indications for administering boluses of IV fluids. Generally so called Normal Saline is the fluid of choice, but there are others that are used in some systems. Normal Saline is good for several things, although it’s use has been curtailed for trauma patients in many situations over the past few years.

It’s good for Septic patients. In fact, in the EMS setting it’s the best treatment we have for Sepsis and it’s also the one that’s used first in the hospital.

Briefly, in Sepsis the underlying problem is dehydration. The treatment for dehydration is… hydration. That is IV fluid. That is not dependent on blood pressure, as there are several markers for Sepsis other than that.

Hyperglycemia is another good indication for Normal Saline.

Shock, to a limited extent depending on the underlying cause is another good use for saline.

All of which I see on a regular basis when I’m reading ambulance reports.

The problem lies with the other things I see. While it has many uses, there are sometimes when Normal Saline can be dangerous to the patient.

Think of Normal Saline as a medication. All medications have indications, doses, contraindications, and adverse effects. There are no “harmless” medications.

In the case of Normal Saline, the things that should give a provider pause before administering doses of Normal Saline are patients with a history of Congestive Heart Failure, Hypertension, cardiac arrhythmias, any  sort of cardiac pump disease, among others.

Given large doses of Normal Saline to patients with medical histories like those can have serious adverse effects.

The one that always comes first in my mind is pushing fluid into the lungs. Lungs are designed to hold air and fluid overload will displace air and make it much harder for the patient to breath. This isn’t a huge risk in most younger patients, but may elderly patients have minimal cardiac and/or respiratory reserves so an amount of fluid that someone in their 20s, 30s, or even 40s will tolerate with no adverse effects could well kill a person in their 60s, 70s, or older.

Like every other medication, it’s important to know not only it’s benefits, but the draw backs to using it.

Which will bring me to my last complaint, at least for now.

When I was a young medic and even before that when I was a younger EMT a wise older (like his late 30s) medic told me that medications have specific indications and if I understood a medication list, then I’d have a pretty good idea of what the patient’s medical history was. That would be true even if the patient or other people on the scene couldn’t give me any information.

It was not, and is still not, unusual for patients no to know what a a particular medication was for. If you asked why the patient took a medication, the answer often would be “Because my doctor told me.” This doesn’t mean that the doctor didn’t tell the patient why they were prescribing a medication. It very likely meant that the patient forgot, or didn’t understand and was afraid to ask questions, or maybe didn’t listen in the first place.

The best current example of that is a newer drug called Eliquis. Depending on your TV viewing habits you may have seen a commercial for that medication. It’s prescribed for one thing and one thing only. Atrial Fibrillation not caused by a heart valve problem. That’s what the advertising says.

So, if I were working in the field and saw that on the medication list, I’d be looking for an irregularly irregular pulse and if the patient complaint indicated an EKG, I’d be looking for Atrial Fibrillation.

If the patient list included Metoprolol, I’d be looking for Atrial Fibrillation or Hypertension, maybe both as part of the Past Medical History.

There are a lot of medications out there. Even in the years since I retired several newer medications have come on the market. No one is going to be able to remember them all. That’s where a Smart Phone comes in handy. Even in the last few years of my active field career, I’d turn to my phone and type in an unfamiliar medication name to see what it was for.

Not only would it tell me what it was for, but I could find out if any of the medications I might plant to administer would result in an adverse or allergic reaction.

It’s better to avoid an adverse reaction than have to treat the patient for one on top of whatever there original complaint was. At a minimum it means some risk to the patient and more work and documentation for the provider. At maximum, it can cause the patient significant harm and a loot more documentation, possible remediation, possible career ending actions by an employer or regulatory body.

EMS can be a hard field to work in, but it’s a lot harder if you don’t pay attention and don’t use your brain while you’re doing it.

Things I read Part 2

I meant to get this out earlier in the week, but work responsibilities and a couple of other things delayed it until today.

So, I mentioned a couple of things that I see in case reviews that I irk me. Well, the part about moving hypotensive patients inappropriately more than irks me. It’s a practice that clearly has the potential to harm a patient. The BGL check is more irksome than anything else, but it makes me wonder what some paramedics are thinking. Or even if.

So, on to part 2 of things I read.

I read a lot of reports where the patient had either a limb lead EKG or a 12 lead EKG and I can’t figure out what the clinical indication was. I first have to explain that when I was trained and educated there was no such thing as a 12 lead EKG in the field. Paramedics just didn’t to them.

At the time a lot of physicians felt, and some still do that a paramedic can’t interpret a 12 lead EKG. Most can, some can’t. I also have to editorialize about the accuracy of the computer based interpretation of 12 leads. It’s not good. I’m not alone in that opinion as a physician I know who runs a one day intense 12 lead class shares the same opinion.

His advice is to look at the computer interpretation, but over read that with your own assessment. Given the choice, I wouldn’t turn on the computer interpretation, but I think that from a risk management perspective that train has left the station.

Even after we started doing 12 lead EKGs in the field, very often I would only do limb leads first and then if the patient clinical impression indicated that a 12 lead was indicated, I’d perform one. I wouldn’t do one just because I happened to have a patient of a certain age.

Some complaints require a 12 lead EKG. The older the patient, the more inclined I’d be to do a 12 lead. An older patient, let’s say 50 older, who presented with syncope, chest pain, or dyspnea would automatically get a 12 lead. We had a lot of education regarding “Anginal Equivalency” and how often a patient having a cardiac event didn’t present with the traditional mid sternal chest pain.

On the other hand, an 18 year old male who is having an anxiety reaction and feels “nervous” very likely isn’t going to be a cardiac patient.

Nor is the person who was just shot in the chest. Yet, I’ve read reports where the medic delayed getting a patient to a trauma center to do a 12 lead EKG. I’d always ask them what they were looking for. “Because the hospital wants one.” is not an acceptable answer.

My practice, and the practice of just about every medic I worked with was to reserve EKG monitoring for trauma patients to the ones that I expected to intubate during transport. Not once did a doctor say anything to me because I brought a patient into a trauma room without an EKG strip.

Today’s cardiac monitors do far more than monitor EKG rhythms, perform 12 leads, pace, and defibrillate. In addition to Oxygen saturation, they can read Carbon Monoxide (it’s an option), and Carbon Dioxide and of course provide often inaccurate blood pressures. One of my former co workers sometimes derisively referred to our cardiac machine as the “Symptom Checker.” He was a bit on the sarcastic side, if you didn’t guess.

Still, he had a point. Which brings me to my point. Some paramedics over rely on the readings from these very expensive machines and don’t perform their own clinical evaluation.

A few years ago I did a presentation for BLS providers on using ALS assessment skills at the BLS level. Everything I told them could be done without a cardiac monitor. In fact, the only pieces of equipment that they would  need were a stethoscope, BP cuff, and glucometer.

What that assessment required was looking at, touching, listening to, and on occasion smelling the odors emanating from the patient. If you do that as a provider at any level you’ll discover that the “Symptom Checker” is an aid, but not  replacement for examining your patient.

Henry J.L. Marriott MD in the Eighth Edition of Practical Electrocardiography wrote,

“The  electrocardiogram should be considered confirmatory clinical impression, and should not supersede it. If the patient is suspected clinically of having sustained a myocardia infarction, he should be treated accordingly even if his tracing is completely normal.”

The Eight Edition was published in 1988 and has been superseded by the Thirteenth Edition. I should probably pick up a copy, but it’s not an inexpensive book. It is a good teaching tool, though. I also don’t know of anything that would negate his statement. EKGs are still essentially the same although the technology for acquiring them has improved.

Put another way “Treat the patient not the monitor.” Yes, that’s an EMS cliche, although I think of it an axiom. If a patient looks sick, they are sick and should be treated as such.

A good paramedic can walk into a room, look at a patient, and know that they are sick. He or she may not know what is wrong, but they know that something is wrong. The History of Present Illness (HPI) and Physical Exam (PE) will likely help determine what treatments need to be done immediately and which hospital to go to.

The bottom line is that there is no guarantee that the cardiac monitor/symptom checker is going to magically diagnose the patient for you. It’s poor form to over rely on technology instead of knowing what you are doing.

If a patient has symptoms consistent with Acute Coronary Syndrome, then treat them as if they have Acute Coronary Syndrome.

The last thing I’ll mention today is Intravenous skills. I first will note that the patient population that EMS is seeing seems to have aged considerably over the last eight years. Then again, so have I.

Older people often have fragile veins do to a combination of underlying medical problems, the changes to both skin and vascular structure as we age, and often medications that patient are taking.

It’s no great sin to “miss” an IV. I certainly missed more than my share over my years in the field. Just don’t make excuses. About 90% of the reports I read where a medic misses an IV blames it on “poor vasculature.” This is alien to me as I never felt the need to justify a missed IV.

To a down stream reader, be it a doctor, nurse, QI reviewer, or anyone else, it looks like the provider is making an excuse for missing an IV. It also looks like the provider is blaming the patients veins for being fragile.

I laugh, but not in mirth, more in the line of derisive laughter when I see that. Our guidelines don’t allow us to make editorial comments on writing style, so I can’t put a comment in the auditing notes.

Speaking of which, we don’t audit for spelling, syntax, or grammar. If we did, it would take an hour to do each audit.

That said, in the context of professionalizing EMS by improving education if it were up to me I’d require entry level English and Math classes before would be paramedics to go on to the Anatomy and Physiology portion of school.

That’s Part 2 of this. I think I will do a Part 3 just on respiratory assessment. It’s a key skill that should be fundamental, but is lacking at both the ALS and BLS levels from what I read.


Things I Read

It’s been a bit over eight years since I last worked on an ambulance. Since then the only times I’ve been in one was when I was talking to a paramedic from one of my client agencies.

Mostly what I do is read ambulance reports. Between auditing, doing case reviews with providers, and doing quality improvement for our own auditors, that can be 75 or more a week. Have mercy on my poor eyes.

Sometimes the things I see on a report make me scratch my head. Other times, they make me want to bang my head on the desk. Once in a while I’ll read a report and think “WTF were you thinking!”

It’s not all doom and gloom because truth is that most of the reports indicate that the medic or EMT knew what he was doing and did it properly. Despite what some of the providers at our client agencies may think, we do not get paid more we  write up an infraction.

As a friend of mine who is a retired police officer used to say when he was accused of writing a ticket to meet a quota, “We don’t have quotas, we have all the business we can handle as is.”

Anyway, here are a few of the recurring themes I see when I read reports. I mention these as pointers and tips for medics to keep in mind. Sometimes, in the heat of a call, it’s easy to forget something basic that needs to be done.

That’s why it’s good to rehearse in your mind what you are going to do when you contact your patient. Keep in mind that all of the various Emergency Medical Dispatch systems are imperfect. They will tell you that they are, but nothing involving humans talking over a telephone is perfect.

So, here the the things big and small that I see and which give me an “Ice Cream Headache.”

Universal Blood Glucose Checks. My state’s protocols are quite clear on when those should be done on patients. 1) Altered Mental Status. 2) Suspected Stroke.

Those both make a lot of sense. AMS covers a lot of territory, so there is some degree of latitude. For example a person who is suspected of being drunk could be a diabetic with hypoglycemia. You don’t want to be the medic or EMT who sent a person off to a jail cell because he was “Just a drunk.” only to find out that he died from hypoglycemia. That is, as we say, a career limiting move.

The Stroke protocol is also clear. Very similar to the “Just a drunk.” scenario is thinking that someone is having a Stroke, calling a Stroke Alert and then finding out at the hospital that they were hypoglycemic. That’s not as bad as the first scenario, but you are going to get a talking to from someone.

With that having been said, some EMTs and medics seem to think that the only needed indications are that the patient has finger and the provider has a lancet. I can’t for the life of my understand why a 20 year old man who twisted his ankle and needs a trip to the hospital should have his Blood Glucose Level checked. Even if he is a diabetic, if he is sitting up talking to you, makes sense, and has no indication that he is in need of Glucose, there is no reason to stick a needle in his finger so that you can get a number to put in your report.

A more serious issue is treatment of hypotensive patients. When I read a report that says that a patient, especially an older one, has a very low blood pressure and the next sentence says that the crew picked the patient up and sat him in a chair, I know what to expect the next line to say.

It will often, but not always, say that the patient became dizzy or passed out. The medic always seems to be mystified that this happened. In a recent case a crew did that and the patient not only passed out, but he went into cardiac arrest. Where he stayed despite their best efforts.

I am not saying that sitting that poor man with a blood pressure of 78/50 up is the proximate cause of his demise, but I won’t be surprised if a personal injury lawyer does. Fortunately, I have never been called to court to testify about a call I audited. At least not yet.

Now, the city I worked in had and still has some older housing stock. Some of that goes back to the years before World War 2. Well before. Buildings with three stories and no elevator are the norm. Buildings with four or five stories and no elevator are not at all unusual. As a result I know what a pain (literally) it can be to carry someone down narrow stairs that have a lot of twists and turns. Believe me, I feel the effects of over more than 30 years of doing that every morning when I get out of bed.

Still and all, there is a proper way to move a hypotensive patient and a wrong way. The proper way involves a lot more work, but it’s better for the patient. Which is what we are supposed to be here for.

There is a section of the basic EMT course that covers “Loads, Lifts, and Carries.” It’s fairly early in the program and it’s rather important. EMT students learn the proper way to move patients, restrain (for safety) patients, carry patients, and get them in and out of the ambulance. It’s not mentally difficult, although it can be physically.

As a result, every EMT and paramedic knows the proper way. So, they can’t claim bad training. They can claim bad education if no one every taught them the physiology of shock, but that’s covered in EMT programs as well.

So, my default position is that they are lazy. Pure and simple. Of course, I can’t write that in a review. I have to keep the language pretty dry.

“Patient was found at contact to have a BP of 78/50. Medics sat the patient up and placed him in a stair chair. Patient became unconscious.” Pretty dry, but all but the dumbest person can understand what that means.

Okay. I’m a bit over 1,000 words so I’ll post part 2 tomorrow or the next day.




2020 was a pretty bad year. I can’t say it was the worse year I ever had, but it was annoying and infuriating. Or rather, many of the people were annoying and/or infuriating.

The response of the much of the government AND a lot of private organizations was inadequate and aimed at the wrong targets. Not to mention that some of those government and private entities used it to advance political agendas.

We were lied to early on and lied to more later on. I won’t go into all of the fudging of numbers done by people upon whom we should have been able to depend, but it’s there.

Politics were nasty and will get nastier. The election was stolen from the rightful winner. If you’re racing to your keyboard to tell me that it was all on the level, don’t bother. I can read, and I can count a bit too. Math doesn’t lie.

Back to the pandemic. Since I’m retired and only work a bit on the side to keep from being overwhelmed by boredom, my income didn’t go down by much. On the other hand, there are a lot of small businesses that are gone and will never come back. Their former owners will likely never recover financially. Or emotionally in many cases.

Depression, suicides, and drug overdoses hit record numbers. Speaking of record numbers, murders hit record numbers in cities where the police were “defunded.”

Neither George Floyd nor Breona Taylor should be considered heroes. I’ll leave it at that. I’m sure I’ll get a lot of hate comments, but I frankly don’t care.

So, even though 2020 is over calendars are just the way humans mark time. It’s arbitrary and this being the first day of 2021 doesn’t mean that the misery is over. In fact, there are those who are actively trying to extend the misery. If you break down the virus totals by state, you’ll find that the states with the harshest restrictions are also the states with the highest rates of infections, hospitalizations, and deaths.

Is that a coincidence?

On one hand, we are told that hospitals and their staff are overwhelmed. Staff is depressed and exhausted. On the other, we are treated to hospital staff performing elaborate dance routines. I’ve been overworked and exhausted in the past, and the last thing I felt like doing was dancing. I felt like taking a shower and getting some sleep.

I know, I sound overly cranky, but what I’m seeing and what I’m hearing from people working doesn’t match what I’m being told by the media and government officials.

Back to time and 2021. Just because we flipped over pages in a calendar doesn’t mean that all of our woes are over. There is some likelihood that the problems of 2020 are just going to keep on.

Think about that.

Ripples of Battle


In 2003 author, historian, and former professor of the classics Victor Davis Hanson published “Ripples of Battle.”

In that book he picked three historic battles spanning a couple thousand years and explained how those battles continued to ripple through history.

As was trying to figure out what to write on the 79th anniversary of the Japanese attack on military and civilian facilities on the island of Hawaii, I came across this article.

Remains Of Four Pearl Harbor Sailors ID’d as Nation Marks 79th Anniversary of Attacks

Seventy Nine years after the attack, the work of identifying those killed continues. There aren’t that many survivors of the attack still with us. In fact, even the children of relatives of those killed are becoming more rare as the “Boomer” generation starts to pass from the scene.

Still, the military works to identify and honor those who died a Sunday morning long ago.

Three of those who were identified had served on the USS Oklahoma. Two of those were brothers. The fourth served on the USS West Virginia.

The Oklahoma was salvaged, but was too badly damaged to be returned to service. The West. Virginia was salvaged, repaired, and returned to service in late 1944. Which was in time to participate in several Pacific campaigns leading to the defeat of Japan.

There are of course many memorials to those who died on December 7, 1941. Perhaps the most famous is the USS Arizona memorial. The ship still rests on Battleship Row where she sank during the attack.

Inside the memorial, there is a large wall with the names of those who died, but whose bodies could not be recovered.

Long after everyone who was alive at the time and even those who were born shortly after the end of the war are gone, these memorials will still be there for new generations to visit and honor those who died to preserve a nation.


Thing That Goes Bang


A few, well maybe more than a few, years ago I bought a used Marlin 336. It was in very nice condition and I had long wanted a lever action gun for range use and at some point, maybe hunting. The only modification I made to the rifle was replacing the original lever with a “wide loop” style that is a bit easier on my hand. I have no John Wayne pretensions and besides, he used Winchesters. It’s just a more comfortable way to get my hand in the loop to manipulate the action that way.

I shot it a few times and a friend gave me a low end scope to put on it. As I recall it was a BSA Deerslayer 9×40 scope. Now, I know that real rifle shooters will kind of laugh at that because cheap scopes are like cheap antennas on expensive radios.

About 10 years back I had an opportunity to shoot a Barrett 50 Caliber rifle. I think the owner told me that it cost about $10,000.00, but I’m not 100% sure. I do remember that he told me that he had a $3,000.00 Leopold scope on it. He said that wasn’t even a top end scope, but it was sufficient for his shooting. His shooting was at 600 yard ranges on his farm in Iowa.

I wasn’t even close to good enough to shoot that far out, but he did let us shoot at about 100 yards. It was amazing how accurate that rifle and scope were. We were shooting 12 gauge shotgun hulls and easily picking them off. It was also impressive what a .50 caliber bullet will do to a red brick at 100 yards. Pink dust was all that was left.

But, I digress as I so often do.

Back to my rifle. After a few trips to the range I was able to hit targets at about 100 yards, but then the scope fell apart and I had to stop shooting it. It wasn’t a defect, just the age of the scope. Apparently something dried out and the lenses fell apart.

I replaced that with another Deerslayer a couple of years ago, but never got around to taking it to the range and sighting it in.

I know that basics of sighting in a rifle from the Appleseed course I took some years ago. I’m not an expert, but have sighted in a couple of other rifles.

The first step I use is to go to our indoor range and use a laser bore sight to get the scope “on the paper.” My light is not all that expensive, but it’s worked well enough. The reason I use the indoor range is because it’s dark compared to the outdoor ranges. So, I did all of that got, the cross hairs lined up with the dot from the laser. Cool.

Outside I took a target and back up paper out to the 100 yard range and stapled them up. The back up paper was from a stack of architectural drawings someone donated to the club. It’s a nice white piece of paper that will show me where my rounds are actually landing. As I said, the bore sight is just supposed to get me on the paper and then I can dial in from there.

Supposed to.

I set up my spotting scope and lined it up with the target. I set my rest down, set the rifle down, and took out a box of .30-30 rounds.

Understand that someone who really know what he is doing can get a rifle sited in with three rounds. I’ve seen it done.

I am not that person.

I fired my first shot, got up and looked through the spotting scope. I saw a nice white piece of paper and my target. Neither had any holes in them. I had missed the three foot by three foot target entirely.


I tried a couple of more shots with the same results. Finally, I noticed that I was hitting the berm over the top of the target. What?

So, I started experimenting by aiming at the bottom of the target frame. Ahhhh, now I was on the paper, but way, way, low. Interestingly, I was not off horizontally, just vertically.

So, I dialed in some vertical correction until I was near where I should be. Once I had that done, I hit the orange dot in the middle of the five dot pattern.

Not being one to make my life too easy, the only targets I had were NRA small bore rifle targets. Those are supposed to be used at 50 yards. At 100 yards, they look like little dots.

Once I had everything dialed in where it should be, I started working on the basics. Lock my off hand into the sling. Keep my off hand lightly on the fore end, not too tight. Use that to pull the stock into my shooting side shoulder. Concentrate on the target. Exhale and hold my breath. That’s actually pretty hard, by the way. Feet flat on the floor. Then squeeze the trigger and don’t drag my trigger finger across the bottom of the stock.

Oh, and keep the sights on the target after the shoot.


Well the concept is easy, but the execution is far less.

It was a fun, frustrating, and informative 90 minutes.

It’s a skill like any other and I have to remember to practice as often as I can. That’s if I can find ammunition. This is hunting season and although my state restricts deer hunting to shotguns, a lot of people who live here go to other states.

I’ll have to keep my eyes open for rifle ammunition when ammunition starts to show up again. IF ammunition starts to show up again, but that’s a topic for another time.

Shooting is fun, but hitting what you shoot at is a lot more fun.

The picture with this post is not of my rifle, but it is identical to it.