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EMS Artifact
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Social Media Assisted Career Suicide Syndrome is a phrase created by Dave Statter of Statter911. That term goes under the “I wish I thought of it first” file. At least I wish I put it on line first, because I came up with a similar “Social Media Assisted Career Syndrome” term sometime in the past, but still probably not before Dave.

By the way, if you’re interested in fire stuff, or EMS stuff related to fire stuff, Dave’s blog is a good place to go.

As any of you who have read my blog for a while know, whenever there is some sort of bad thing in EMS, I always want to find out what the real story is before making judgement. From a long career in EMS, I know that initial reports and media stories are often inaccurate. At the least inaccurate, sometimes deliberately slanted.

Having seen EMS management take a cynical attitude of “We’ll fire them first and then do an investigation after.” approach I am at the least skeptical.

I could regal you with stories of people I worked with who were disciplined first and then had their salary and status restored later because of sloppy work by management.

Which brings me to today’s blog post.

Paramedic hurt patient on purpose, then bragged about it on Facebook, state says

Two years ago an East Tennessee paramedic bragged on Facebook that he intentionally drilled into a patient’s bone without anesthesia, then allegedly told other first responders this was a “teachable moment” on how to deal with troublesome patients.

The paramedic also instructed another first responder to insert a plastic breathing tube deep into the same patient’s nose but told her to coat the tube with alcohol-based hand sanitizer instead of lubricant.

“If you should ever find yourself drunk in my ambulance, do not become belligerent,” the paramedic wrote on Facebook during the incident. “I have a drill and I ain’t scared for a second to use it.”

The State of Tennessee has already had a hearing and revoked his paramedic certification, so there has been an extensive hearing on the matter.

Just in these three paragraphs, Stokes indicts himself for being a Certified EMS Dumbass.

First Stokes used a Intraosseous (IO) drill to administer Narcan. I have never, ever, heard of that being done that way. Which doesn’t mean that it hasn’t or can’t be done. It’s just a stupid thing to do.

Here is an EMS “Top Tip”. Narcan can be administered in several ways, including IO, but in my experience the least invasive way is the best. Nasal administration is the least invasive, but it’s onset of action is a bit slow. IV or IO is the most invasive. The problem with that, from a patient management standpoint is that patients wake up fast and they wake up mad. That’s when they want to fight because you, the life saving paramedic, have ruined their high. Forget that you also probably saved their life, you now have a made patient with an IV in their arm.

Things can, as the saying goes, go sideways in a hurray. In cases like that, paramedics and patients can get hurt.

If you do an IO insertion, the very first thing that you do is then inject Lidocaine through it. Why you may ask? Because while the actual insertion doesn’t hurt more than an IV, once the paramedic starts to push fluid or medications through the IO, the pain is excruciating. When we first started using IO for treating patients, we didn’t have a protocol for Lidocaine. One day we had a patient who was unconscious and had no IV access. So, my partner whipped out our IO “gun” and drilled into the patient’s leg. No reaction. We then hooked up an IV bag full of “normal saline” and started to run some in. THAT woke the patient up and he was not very happy.

After that, we got a new protocol which included Lidocaine for all patients getting IO insertions, unless they were in cardiac arrest.

So, right there we have two strikes on Mr. Stokes. Okay, a strike and a half because per protocol IO Narcan is an appropriate route of administration. It’s just not too smart.

Then we have this,

After the bone injection, Stokes told the other AEMT to insert the breathing tube, known as a nasopharyngeal airway, which extends into a person’s nose and reaches into the back of their throat.

The AEMT initially questioned this decision, insisting that the patient “had a good airway,” but Stokes told her “that he would explain later,” according to state records. The AEMT then began to put lubricant on the nasal tube, but Stokes “stopped her and instructed her to use hand sanitizer” instead.

Once the tube had been coated in hand sanitizer and inserted into the patient’s nose, Stokes removed it — revealing it was not necessary — and told the AEMT this had been a “teachable moment on how to deal with belligerent patients,” according to state records.

I find myself in the uncomfortable position of defending one part of this, but only one part. I don’t think it was unreasonable to insert a nasopharyngeal airway (NPA) into this patient. It’s a non invasive airway, used by EMS providers at all levels. I’ve used one, although it wasn’t my preferred BLS level airway device. Perfectly acceptable.

The part that isn’t acceptable is using hand sanitizer instead of the proper lubricant. Which is more slippery than hand sanitizer and doesn’t have alcohol.

Stokes’ excuse is that he was taught that by an “army surgeon” while he was working in Afghanistan. I’ve been fortunate to sit in on some military medical training. It’s far different in some case than what we do (and can do) in civilian medicine. I can, sort of, see where someone might have to use a “field expedient” lubricant under combat circumstances.

Such is, however, not the case in the back of an ambulance in Chattanooga, TN, even with that city’s problem with gang violence.

At best, I *might* tell someone about that sort of thing after the call was over. I certainly wouldn’t advocate doing that sort of thing.

Then there is this,

State records say Stokes then began to conduct a “drill,” quizzing the AEMTs on what could be wrong with the patient. The AEMTs responded by saying he was suffering from an “obvious overdose” and that there was no time to “conduct class” when they needed to hurry to the hospital.

I hate when I read or hear a media report that “paramedics rushed the victim to the hospital.” The inference of course is that is all that was done for the patient. Toss in the back of the ambulance and then drive like The Three Stooges to a hospital.

Opioid overdoses are pretty routine to treat. So much so that some families of addicts have Narcan kits in case their family member should overdose.

That being said, the time to do some “drilling” of students is before or after a call, not during. After the call, while at the hospital or elsewhere, you go over the case, ask questions, solicit answers and do your teaching. Not during the call.

Finally there is this,

State officials interpreted the letter as Stokes encouraging a full revocation of his license, but Stokes now argues a “null and void” finding is a lesser discipline than a revocation, which he says will prevent him from pursuing a career as a nurse.

A nurse? I rather doubt that the nursing profession wants or needs Mr. Stokes. He exhibited poor judgment in the first place by doing the things of which he was accused. He compounded his error by posting about it on Facebook. Then, he didn’t attend his hearing. I don’t know if he had an attorney or not, but if I had to guess, I’d say no.

Almost as dumb as the foregoing, he then gave an interview to the media. That didn’t help, not one bit.

As always, if Mr. Stokes or anyone comes forward to show me that the course of action he took that day was correct and appropriate, I’ll delete this post and put up another one announcing his vindication.

Side By Side Comparison

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EMS Artifact
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A couple of months ago, I posted about a new gun that I bought. It’s a very nice Springfield Armory XDE in 9mm.

Anyone who reads my column on a regular basis knows of my fondness for Smith&Wesson Third Generation semi automatic pistols. I have a small collection and a pre rail 3913TSW is my go to carry gun most days.

The XDE is for times when I’m out of state traveling and don’t want to bring the hard to replace 3913TSW with me. If something happened to it, it would be almost impossible to find a replacement as they weren’t made in large quantities.

I decided to do a side by side comparison of the XDE and the 3913TSW. I brought three boxes of ammunition, the guns, and some targets to the gun club.

The targets were B29 reduced size silhouette.

The ammunition was as follows,

UMC 115gr FMJ, Blazer Brass 124gr FMJ, and American Eagle 147gr FMJ. I put 25 rounds of each through both guns and compared accuracy.

First up was the XDE filled with the UMC 115gr. On my prior trip to the range, I used up a random box of 115gr UMC in the XDE. I was pleasantly surprised by the accuracy of what I consider a very light round. In contrast, my 3913TSW never performed all that well with this ammunition. Impact was always well below point of aim.

Recently I learned that I was using the wrong point of aim for the type of sights installed on my gun. The correct one is counter-intuitive, but it is in fact the correct one.

I should note that I do have a tendency to pull to the right side of the target. When I slow down and concentrate on the fundamentals, it improves greatly. It is evident here in some of the targets.

To my surprise the ammunition did not perform as well as my previous test. Not horrible, but more spread than I’d previously seen.

Not bad, but the pull is obvious. I’d call this acceptable for self defense shooting at close range. The grouping is okay, at least I think so.

The 3913TSW was up next. To my surprise aiming with the top of the site a bit higher up corrected the low hit situation I’d seen before. There was a bit more spread of the shots, but more of them hit the center ring. Not that I expect to go back to 115 gr for this gun, but I don’t have to be scared of it either.

On to the XDE with 124gr ammunition.

A couple of down and out fliers in the first magazine, for reasons unknown. Again, once I bore down a bit and spent time on the fundamentals accuracy improved.

Still a bit of pull to the right, but not bad. The grouping is pretty reasonable. Certainly, this is an acceptable bullet weight for personal defense carry. A 124gr JHP will be a fine choice.

Next, back to the 3913TSW with 124gr ammunition. I was a bit disappointed with the results when compared to previous outings with 124gr ammunition.

Interestingly, at least to me, the 3913TSW didn’t do quite as well as the XDE. At least in terms of consistency. A few more X ring hits than with the XDE, but more spread of hits. Again, acceptable, but I can do better with more practice and attention on fundamentals. (That seems to be a theme)

Now for the XDE with 147gr ammunition.

Some spread, but more hits on center than with the other ammunition. Overall, pretty good, or at least pretty average. Certainly acceptable, but not as good as the 124gr ammunition. I think that the XDE will, at least for now, be carried with 124gr ammunition. Maybe that will change after more experience with it.

Last up, the 3913TSW with 147gr ammunition.

I think this is the best grouping of all of the tests. I take no credit for this, I just think that the gun was designed around this weight of bullet. It certainly seems to be most accurate with 147gr ammunition. Which was the standard law enforcement 9mm round back when the Third Generation guns were being designed.

Reasonably good accuracy overall. A very good choice for personal defense carry.

A couple of final thoughts.

The XDE is a very nice handgun, but it’s not a Third Gen. One of my excuses for some of the shot placement is that it’s considerably lighter than the 3913TSW. Not that that gun is heavy, but the alloy frame does add some weight and at least for me that improves balance.

I’m sure that when I get the XDE to the range more often, I’ll get used to the balance. Recoil is very manageable, so the lighter weight doesn’t hurt in that regard.

Of course, I’ve shot the 3913TSW and other Third Generation guns a lot more than the XDE.

More range time is needed in general, but particularly with the XDE.

The controls on both guns are similar. The XDE has a thinner profile, which some people don’t like. I like it because it aids with concealability. I’ve had some thinning done on the TSW, and it’s much better than as it came out of the factory.

I prefer the TSW, but won’t be embarrassed to carry the XDE when I’m on the road.

 

The Dying Continues

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

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

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

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

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

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

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

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

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

D

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

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

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

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

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

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

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

He now has Sacoidosis and is waiting and hoping.

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

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

Prostate Cancer Awareness Month (PCAM)

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

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

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

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

Take it like a man.

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

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

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

Yesterday In History

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EMS Artifact
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2

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

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

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

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

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

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

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

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

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

 

A New Firearm And A New Blog Link

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

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

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

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

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

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

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

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

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

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

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

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

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

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

All of which brings me to today’s subject.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A New Blog Link

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

Duly added.

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

 

Comeuppance

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

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

Tonight, I saw this story.

Politican who protested Dallas NRA show pleads guilty to corruption charges

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

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

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

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

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

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

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

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

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

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

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

Another Great Idea Fails To Prove Its Worth

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

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

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

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

 

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

 

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

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

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

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

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

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

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

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

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

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

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

The science, it seems, is never settled.

Well, That Is Stupid

By
EMS Artifact
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1

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

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

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

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

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

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

Here’s hoping that they succeed.

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

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

She Should Know Better

By
EMS Artifact
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2

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

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

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

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

One would be wrong, I guess.

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

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

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

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

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

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

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

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

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

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

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

Article V (Article 5 – Mode of Amendment)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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All About Me

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

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

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

Thanks for visiting.

Latest Posts

About Me

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

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

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

Thanks for visiting.

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