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Yesterday In History

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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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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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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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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.

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

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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

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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.

Bougie All Night

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The Bougie, has been around for a number of years now. Actually, bougie is a generic name for a number of devices that are shaped like an Algerian candle. Don’t ask.

The one I am talking about today is more formally known as the tracheal tube introducer. Originally developed as an easy way to change ET Tubes in ICU and other units. At some point, about 15 years or so ago the device made it’s way to EMS. Anyone who practiced in the days before any sort of video laryngoscopes were around knows that it can be tough, sometimes impossible to intubate some patients in the field.

As a rule, paramedics are pretty good at intubating under less than ideal circumstances. When we learned to intubate actual patients in the hospital we generally did so in the Operating Room. Conditions in the operating room are ideal for intubation. At least most of the time when the surgery is pre scheduled and the patient has been fully prepped.

The patient has been evaluated prior to going into the OR, so you have a good idea of what difficulties you might face. The light is great, and adjustable. The height of the patient and the person intubating can be adjusted. The patient has been medicated. The patient’s head has been put on a cute little pillow to put the patient’s head at the right angle. It’s nice and clean in there, well sterile actually. Oh, you have trained help standing literally at your shoulder to do anything you need. Did I mention that the patient hasn’t eaten in the 6-8 hours before the surgery is scheduled.

Mostly you don’t have those advantages in the field. I won’t go into stories of intubating patients trapped in an upside down burning car, that is floating down a river towards a waterfall or BS like that. I think I intubated one patient sitting up right in a car in my career. Or maybe it was my partner, I really don’t remember. I did intubate a patient inside a building that was on fire. The Sorta Big City FD had dragged her out of a smoke filled room, down a flight of stairs, and dropped her in the hallway for us to treat. I’m not sure why I elected to intubate her there, but since the fire was two floors above us, the risk wasn’t all that high.

Anyway my point, to the extent I have one, is that field intubations are much different than in hospital intubations. More challenging for the most part. Which is why paramedics who work in busy systems generally have very good airway management skills.

Back to the Bougie. When my former system first adopted them, a lot of us were skeptical to say the least. Since individually each paramedic usually had more than one intubation a month, we were pretty proficient. Since we were one of the very few systems in the state allowed to use drugs to facilitate intubation, every intubation attempt was reviewed by our medical director. That was every one of them, whether medications were used or not.

What’s a good word for scrutiny?

Scrutiny.

While we were beating our chests about how great we were at intubation and airway control, something happened. Well, a couple of things. First we had some promotions, resignations, and retirements among paramedics. Some of the more senior people were no longer treating patients, so they weren’t intubating. The people promoted to replace them weren’t as experienced or proficient.

So, our success rate dropped.

Then, one of the other great innovations in EMS, CPAP was finally approved by the clerks and secretaries who seem to determine medical policy in my state. We were just about the last state in the union to allow paramedics to use CPAP. Even though in about half of the other states, it was considered a BLS level skill, our clerks and secretaries wanted more studies because as you know, human anatomy and physiology differ once you cross state lines.

Once the administrivia was out of the way, we started using CPAP. We liked it, the patient’s liked it, the hospitals liked it. The insurance companies loved it because CPAP resulted in fewer hospital days and complications than intubation. Winners all around.

The only problem was that we were intubating fewer patients, especially fewer living patients. While good for the patients, it was bad for intubation proficiency.

Which brings us back to the Bougie. We started to use it and our success rate went up. Some people, including yours truly, initially only used it on difficult patients. Which meant that we were making a second attempt since we had failed on the first.

After a little bit of time passed, more medics started using the Bougie on the first attempt for every patient. That really improved our first attempt success rate. In addition to being a number, intubating on the first pass is likely to be better for the patient.

Eventually, most of us started using the Bougie and stopped using stylets. Which I generally didn’t use, but stopped using completely once I mastered the not that difficult task of using the Bougie.

Which brings me to this link,

Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial.

Among 757 patients who were randomized (mean age, 46 years; women, 230 [30%]), 757 patients (100%) completed the trial. Among the 380 patients with at least 1 difficult airway characteristic, first-attempt intubation success was higher in the bougie group (96%) than in the endotracheal tube + stylet group (82%) (absolute between-group difference, 14% [95% CI, 8% to 20%]). Among all patients, first-attempt intubation success in the bougie group (98%) was higher than the endotracheal tube + stylet group (87%) (absolute difference, 11% [95% CI, 7% to 14%]). The median duration of the first intubation attempt (38 seconds vs 36 seconds) and the incidence of hypoxemia (13% vs 14%) did not differ significantly between the bougie and endotracheal tube + stylet groups.

This was an Emergency Department study, not an EMS study. EDs intubations are somewhere between OR and field intubations in terms of conditions and difficulty. Will these results transfer into the field?

I’m not sure it matters. The Bougie is a great airway management tool. It helps in the pre hospital setting, even now when video laryngoscopes are readily available and not insanely expensive.

It’s a simple and inexpensive device, yet it can have a huge impact on patients and makes providers lives far easier.

There are far more expensive devices in EMS that do far less for patients. They might be cool and sexy, but they really don’t improve patient outcomes.

Which, in medicine is the measure of the true value of a device.

 

Sorry For The Outage

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I didn’t quit in a huff. Or a minute and a huff as Groucho Marx once said.

I just forgot to renew the domain. That’s all fixed now, as you can see.

I’ll try to find time for an EMS related post tomorrow. Time might be tight as I’ll be going on vacation soon.

How does a guy that’s retired go on vacation? I know, it’s silly.

Kevin Bacon assures us that all is well,

 

 

The Declaration of Independence

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

For quartering large bodies of armed troops among us:

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

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

For imposing Taxes on us without our Consent:

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

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

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

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

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

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

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

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

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

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

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

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

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

New Hampshire:
Josiah Bartlett, William Whipple, Matthew Thornton

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

Rhode Island:
Stephen Hopkins, William Ellery

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

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

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

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

Delaware:
Caesar Rodney, George Read, Thomas McKean

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

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

North Carolina:
William Hooper, Joseph Hewes, John Penn

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

Georgia:
Button Gwinnett, Lyman Hall, George Walton

 

(Il)literacy In EMS

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

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

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

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

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

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

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

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

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

Then, there is this,

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

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

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

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

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

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

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

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

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

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

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

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

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

Illiterate reports like this don’t help at all.

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

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

All About Me

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

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

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

Thanks for visiting.

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