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Of Bullets And Penetration

I was in my, ahem, reading room perusing the January copy of Shooting Illustrated when I came across an article titled,

The Terminal-Performance Triangle: Measuring Ammo Effectiveness  by Ricchard Mann.

I don’t know Mr. Mann, but I have to believe he knows what he’s talking about or he wouldn’t be writing for Shooting Illustrated. Maybe I’ll get to meet him at the NRA Annual Meetings in April. I’ve read some of his other articles and he certainly appears knowledgeable.

So, who am I to question an article by him? Well, nobody, at least not in the world of guns and shooting. I have, however, treated a good number of people who were shot over my years in EMS.

Because of that, in part I agree with Mr. Mann when he comments about the effectiveness of bullets in personal defense. Unlike on TV and in the movies, people who are shot do not generally fall down dead, let alone fly across the room as in this shoot out from “Last Man Standing.”

Look starting at about 0.41 to see what I mean,

The law of physics just don’t allow for that sort of thing, although it does look cool on the big screen.

Newton’s Third Law of Motion tells us,

For every action, there is an equal and opposite reaction.

All of which is to say that if people went flying when they were shot, the shooter would go flying in the other direction. Especially if the firearm that they are using is not an auto loader.

Back to the article,

Established on good intentions, and because of the infamous 1986 Miami shootout, the work of the FBI has driven the design and manufacture of defensive-handgun ammunition ever since. All because a single and lethal hit from a 115-grain Silvertip (oh, the irony) fired from a 9 mm did not incapacitate a bad guy fast enough. The bullet stopped in the lung, just short of the heart.

The 1986 Miami shootout was infamous because two FBI agents were killed, five others were wounded, and while the two suspects were killed, they weren’t killed or even stopped very quickly. Additionally one of the suspects had a rifle and the other had a shootgun. It took 12 shots to kill one suspect and six to kill the other.

The investigation after the shooting named inadequate stopping power as one of the reasons that it took so many shots to stop the suspects. There was also serious criticism of the tactics and lack of preparation, but I’m not going to go into that here.

As a result of the investigation and subsequent tests, the FBI decided to adopt a 10mm round and new semi automatic handguns by Smith & Wesson. The round and the guns themselves proved to be problematic and the FBI returned the guns to S&W. Meanwhile, S&W developed the .40 S&W round, which used the same bullet as the 10mm, but with a shorter case and less powder. That round was eventually adopted by the FBI for most Special Agents.

Following the lead of the FBI, many law enforcement agencies adopted the .40S S&W round and a variety of handguns to shoot it out of.

Meanwhile, back at the ammunition manufacturers, development on new bullets and powders was proceeding apace. 9mm ammunition became far more potent than it had been heretofore, as did other rounds. One of the biggest developments was in the shape, deformability, and expansion of the bullets.

When I was young, revolver ammunition was mostly .38 Special with bullets made of lead and weighing in at 158gr. That was the standard law enforcement round and the one that I learned to shoot on. As did a lot of other people. 9mm wasn’t considered a serious self defense round because it had a reputation for over penetration. The standard 9mm round had a 147gr full metal jacket bullet that came out of the barrel at high velocity. The worry was that a round that hit a person would continue through and hit anyone who happened to be behind the the intended target.

Hitting unintended targets is bad. Well, it’s worse than bad as even if the intended target is a bad guy and the shooter is defending his or her life, bad things are going to happen to the shooter if he hits an innocent person.

Which brings me to the point of Mr. Mann’s article,

It’s true, it will neither deform nor expand, and the wound cavities will be narrow. But, it’s very likely that, had the bad guy in Miami in 1986 been shot with hardball ammo from a 9 mm or .45 ACP, the round would have made it to his heart, and all this silver/magic-bullet development during the last 30 years might have never occurred. At the most-basic level, the terminal-performance triangle is made up of penetration, expansion and velocity. Hardball may not be sexy, but lack of penetration—the most-important side of that triangle—should not be a concern. And those made of silver should work just fine on werewolves.

Lack of penetration is, as he points out, bad. That being said, over penetration could well be much worse. If I’m in a self defense situation there are a few things I want to happen.

First, I want to hit the intended target.

Second, I want the round or rounds I have to fire to stop the person who is attacking me. Not necessarily to kill them, but to stop them from killing me.

Third, I don’t want the rounds to go through the intended target and off into the wild blue yonder.

Looking at the triangle, penetration is a function of velocity and bullet shape. Sufficient penetration is important, avoiding over penetration is even more so. A round with a good balance of penetration and expansion will cause enough injury to make the attacker stop.

Interestingly, Mr. Mann wrote this article for Shooting Illustrated in July of last year.

Personal-Defense Ammo: Top Picks from the Experts

Finally, you’d expect these loads—selected based on years of experience—to have something in common? I’ve tested them all, and other than their ability to penetrate at least 12 inches, they don’t. Penetration ranges from 12 to 20 inches and expansion from 1.2 to 2.2 times bullet diameter. Then there is velocity and energy variances, which range from 940 to a high of 1,240 fps, and from294 to 423 ft.-lbs., respectively.

Does this mean some of our contributors are wrong? No, just that their experiences have created differences of opinion. As Shooting Illustrated’s Ammo editor, my opinions differ, as well. You’ll find either 135-grain Hornady Critical Duty or 124-grain Remington Black Belt +Ps in my 9 mms, and DoubleTap’s 160-grain TAC-XP Mann load in my .45s.

In that article, he asks nine associates from Shooting Illustrated what they carry for self defense ammunition. All of them have good resumes` and certainly know more about shooting than do I. Each of them carries a hollow point round of some variety. Mr. Mann mentions at the end of the article that he carries one of three different rounds. All of them use hollow point rounds. One of them is a round that I use on one of my 9mm guns for a number of reasons. Again, I won’t go into that here.

As do some of the other people cited in the July article, I try to match the round to the particular gun. Some guns “like” a particular ammunition more than others. It’s important to practice with any firearm you think you might use for self defense and find the ammunition that works best for you and the firearm.

I think any expert will tell you the same.

As I’ve Long Suspected

The TSA Is in the Business of ‘Security Theater,’ Not Security

A tell-all from a former Transportation Security Agency worker confirms pretty much every awful thing you’ve suspected of the ineffective and invasive airport pat downs. That’s okay, though: the TSA’s main purpose isn’t security so much as “Security Theater.”


Harrington readily notes that these reactionary policies, as they stand, are ineffective at actually stopping terrorism, as potential attackers can simply change tactics. But this is in many ways an effective way to combat the perception of American insecurity. Terrorism is, by definition, an act that seeks to create fear in its target. By battling those specific fears of shoe and underwear bombs, the TSA can claim some success on the security stage. However, now that Harrington has blown the lid on that theater, don’t expect anyone at the TSA to take a bow.

Wrong. Everyone I know who travels by commercial airline anywhere considers TSA security to be a sick, perverted, useless joke. Mrs. EMS Artifact frequently comments that the terrorists must be laughing their asses off when they see airport security in action.

Note that to date, the TSA has not stopped one terrorist. Not. One.

Abusing the traveling public doesn’t do a thing to make people feel more secure. A couple of years ago, before she got Pre Check, Mrs. EMS Artifact was selected for “additional screening.” Her crime? She beeped when she went through the scanner.

Just like the airport security scene from High Anxiety . They detained her for 20 minutes trying to figure this out, including asking her three times is she was SURE that she’d never had a knee replaced. Like that’s something you’d forget.

I do think that Harrington is full of fertilizer when he says people from the Middle East were profiled for extra security. From my observations, it was always white people, particularly elderly ones, who were selected for sexual abuse. Well, them an nubile young females. Wouldn’t seem to me to be two demographics high on the list of potential terrorists, but I didn’t go through the intense four week TSA training course, so what do I know?

Creating the TSA was a knee jerk reaction to the September 11, 2001 terrorist attacks. Originally “officers” were supposed to be non union and non civil service, so that it would be easier to terminate bad employees.

That didn’t last long at all.

There is really no reason that the TSA can’t be dissolved and the functions contracted out to private contractors, selected locally by airport authorities.

Maybe then we’d have real airport security, or at least some accountability if we don’t.


Hygeine In EMS

This story appeared on line the other day,

Many paramedics ignore hand hygiene rules, study finds

Paramedics have a “remarkably low” rate of compliance with hand hygiene standards, which could put patients at risk for deadly infections, according to a new report.

For the study, researchers observed 77 paramedics in Finland, Sweden, Denmark and Australia as they dealt with 87 patients. The paramedics’ compliance with basic hygiene was high: short, clean nails at 83 percent; hair short or tied back at 99 percent and no jewelry worn at 62 percent.

But many ignored World Health Organization guidelines in five situations when cleansing with soap and water or an antiseptic rub is needed. Too many relied instead on gloves, suggesting they care more about protecting themselves than patients, the study authors said.

77 paramedics, 87 patients, and from that they draw general conclusions.

Unfortunately, there is no link to the original study and no information as to what organization conducted it.

There seems, at least from my reading, to be a lot of false assumptions and bad information in the article. There is also nothing to suggest that this is the same in the US as it is in the systems studied.

We wear gloves for two reasons. The primary one is to protect ourselves from becoming infected by the patients. The second, and lesser, is to prevent contaminating our equipment and thus possibly infecting the current or a future patient.

If anything, in the US we wear gloves too often, don’t remove them promptly, and don’t reglove when we should. I worked with people who “double gloved, but I always felt it was pointless from a protection standpoint and made it harder to perform some tasks.

I, and a lot of the people I worked with would go through a couple of pairs of gloves on a call. If they got bloody, or torn, or contaminated with “yuck”, off they’d go and on would go another pair.

One thing that drove me crazy is when the EMT that was driving us to the hospital kept his gloves on while driving. Which meant that we had to decontaminate the cab of the ambulance. Or, sometimes they’d take the gloves off and drop them on the cab floor. More than once I retrieved a pair of used gloves and dropped them on the front seat of the BLS ambulance that assisted us. Crude, maybe a bit childish, but it got the message across.

I’m not making it up when I say I had a partner that put on gloves to answer the radio when we were dispatched. She was a bit odd in many ways, so I just laughed at her.

One thing that I do agree with in the article is that we often put gloves on when they are not needed. On some calls, because I was running the call and not going to touch the patient (the luxury of having an adequate number of personnel on a call), I wouldn’t put gloves on.

On a note from the article, if you’re putting your gloves on after touching bodily fluids, you’re not putting the patient at risk, you’ve already put yourself at risk.

One thing that is not clear from the article is that the researchers actually understand that the risk of contamination FROM the patient is much higher than the risk of contamination TO the patient.

As to the risk of cross contamination, the only times I’ve seen providers touch more than one patient without changing gloves was at a Mass Casualty Incident. Especially if it’s something such as the Boston Marathon Bombing for example, patients are going to be moved quickly and there wouldn’t be time to change gloves. In that case, anyone with an open injury is going to get antibiotics at the hospital, so the point is moot.

One area that many providers can improve is in cleaning equipment after calls. I was a bit of nut about that. After every ALS contact, the EKG and all other cables got cleaned, my stethoscope got cleaned, the stretcher got cleaned, and any areas that the patient might have touched got cleaned. Sheets and blankets were changed after every call.

I don’t know that everyone I worked with was that thorough, but most of them were.

In sum, I think that this article is over blown and if there was an actual study, it was poorly structured.

Pretty typical of the Main Stream Media reporting on medical issues. Flashy, scary headlines without much substance.


Something Is Wrong With This Story

I read this story a few days ago.

Police: St. Louis officer killed by colleague in accidental shooting

ST. LOUIS — A St. Louis police officer “mishandled” a gun and accidentally shot and killed a colleague early Thursday, authorities said.

The shooting happened around 1 a.m. at an officer’s home, police Chief John Hayden told reporters during a news conference shortly after the shooting. Two on-duty male officers were at one of their apartments when Katlyn Alix, who was off duty, stopped by, according to police.

A police incident report said the three officers were seated in the apartment living room when one of the male officers “mishandled a firearm and shot (Alix) in the chest.” The male officers, both 29, drove Alix, 24, to a hospital, where she died.

This was a tragedy for the officer and her husband. It’s going to be an ongoing tragedy for the officer who shot her. It’s not going to be too pleasant for the officer’s partner, either.

The officer who did the shooting (allegedly) has already been arrested and charged with Involuntary Manslaughter.

All of that being said, this story seems incomplete. There are a lot more questions than answers in the news reporting so far.

Why were two on duty police officers at an apartment that was outside of their patrol district?

Why was an off duty officer at that apartment in the middle of the night?

What on Earth would induce to responsible adults to play “Russian Roulette”?

The parents of the deceased officer have already retained a lawyer, so we can expect litigation to follow. During discovery, the truth will likely come out and I’m not sure that the family of the deceased is going to like what they are told.

All of which is besides the point. No matter what happens there are two things we know for sure.

Katlyn Alix is dead because at least two people, both police officers, were irresponsible with a firearm.

Firearms are not toys and anyone who owns or uses them does so at their own peril and to the peril of those around them.

Sad and ultimately so unnecessary.


Where Is EMS Going?


And how do we get there?

Recently there has been debate about an education requirement for paramedics beyond just having a paramedic certification. Some, maybe many, people want to require at least a bachelors degree in “Emergency Medical Services” for someone to work as a paramedic.

There are different opinions as to exactly what courses should be required. More biology, more anatomy and physiology, more chemistry, all seem to be popular ideas.

Many people see nursing as the model to which EMS should aspire. After all, they ask, isn’t better education how nurses became recognized as a profession and how pay for nurses improved?

Yes, but that has nothing to do with how EMS is going to advance, if EMS is going to advance.

There are many differences between nursing and EMS. First, the work venue and opportunities. If you work in EMS, in most areas that means you work in an ambulance. Or maybe you’re a supervisor or lower level manager. Sure, there are some systems where there are Community Paramedics, but that’s not wide spread and isn’t likely to become widespread unless and until there is a funding mechanism. Right now, most of the Community Paramedic programs are funded by grants of one sort or another.

Once that funding runs out, if it’s not replaced by another source, we’re likely to see Community Paramedicine disappear once more.

Nursing, on the other hand has a lot of different work venues available. Even within a hospital there are different types of nursing. Some of those don’t even involve direct patient care. There are nurses who do research or work with doctors who do research. There are nurse managers, who do management and administration.

I have a cousin who has a PhD is nursing. She does research into Stroke care and a very small amount of direct patient contact. She works at a major teaching hospital and is well paid. I don’t see that sort of thing happening in EMS. Not that it can’t, just that it won’t.

By the way, there are two different types of Doctorates available for nursing.  This post isn’t about that topic, interested readers can read the short article at the link.

In addition to working in hospitals, there are all sorts of nursing jobs outside of hospitals. Again, many of them don’t involve patient care.

In contrast, being a paramedic mostly involves working in an ambulance doing direct patient care. That’s not likely to change.

Also, in contrast to EMS, nursing in many areas is unionized. I won’t get into that debate here, but it should be noted that EMS systems that are uniionized generally have better pay, benefits, and working conditions.

Nursing also has far more control over who is a nurse than EMS has over who is a paramedic. Which is a problem for EMS. A lot of people who are paramedics identify primarily as something “and” a paramedic. It’s even more prevalent with EMTs. There are a lot of people who have gone through EMT courses and taken the test to get certified. Many of them have no intent or interest in working in EMS, but wanted or needed the certification for some reason.

Even people who are paramedics look at that certification as a means to an end and not as a career itself. Many of them are good paramedics, but they don’t see being a paramedic as their primary career.

I’m up to almost 600 words and still haven’t gotten to the biggest problem with a college degree requirement for paramedics.

Cost. More specifically cost and return on investment.

A Bachelors degree is not inexpensive no matter where you go. A person is going to have to lay out X amount of dollars to get that degree , if indeed one does exist.

Does anyone expect that ambulance services, especially privately owned for profit services, are going grant wage increases just because a person has a degree?

“Ahh,” you say, “When every paramedic has a degree, services are going to have to raise wages.”

Would you like to bet on that? Since paramedics have limited job opportunities, there is no incentive to give raises to them.

If I were to be asked by a young paramedic what type of college degree he should get, my advice would be to either get a Bachelors of Science in something like biology or chemistry OR a degree in business administration. Both are far more portable than a specific degree in EMS. Both give a paramedic a route on to professions outside of EMS. There is far more likelihood of a good return on investment with those degrees.

This is not to say that better education is needed in EMS, at both the BLS and ALS levels. That’s not going to happen at the BLS level for reasons I won’t go into. It should and might happen at the ALS level.

As long time readers will know, post retirement I make money in the Quality Improvement end of EMS. A big part of that job involves reading Patient Care Reports. My company rules don’t allow us to score the quality of writing other than as it relates directly to patient care. That is, we can’t correct spelling, grammar, syntax, or anything related to them.

If we were allowed to, I’d be far busier than I already am.

Which is to say that many of the reports are horrendous when it comes to how they are written. I wince at some of what I read in those reports, even if the clinical care is fine. I can only only imagine what the doctors and nurses who read those reports think about EMS providers. Not to mention what the lawyers think when they are reviewing reports for possible litigation.

If I were building a paramedic program, or rather if I were responsible for setting the requirements, remedial English and Mathematics would be added as well as better Chemistry, A&P, and Biology classes. That would be the first part of the program, before we even got to the medicine part. I’d probably add a basic business course as well, so the students could understand the economics of EMS.

That’s the biggest need in paramedic education right now. Produce paramedics that know what they are doing and why, can write a coherent sentence in a report, and understand why EMS operates as it does, then you can talk about making EMS a profession.

As it stands now, EMS on it’s best days is a trade, but spends most of it’s time as a skill set that can be used in a variety of other trades and even a couple of professions.

Starting The New Year With A Bang


We had unseasonably warm weather in the northeast on New Years Day. Since I had nothing else to do, I decided to head over to my gun club and do some shooting.

I loaded up the range bag with a couple of guns, targets, and other stuff and headed out. I wasn’t sure that I was going to get to shoot, because I expected that other people would have the same idea.

I guess they were all doing something else, or maybe just hungover because there was just one other person there when I arrived. He was packing up and left pretty much as I walked into the range building and started to set up.

One of the things that I like about my club is that there is no requirement for a Range Officer to be present when members want to shoot. There are some pretty reasonable rules and some actual video surveillance, but we are treated like responsible adults.

I set a target on the handgun range and loaded up.

First up was a recently acquired Smith & Wesson CS9. Back in the late 1990s, S&W applied the “Chiefs Special” name to very compact Third Generation semi automatic pistol line. These were, in today’s parlance “sub compact” pistols with a three inch barrel, less capacious magazine, and overall smaller size than the full size or even compact versions of the same guns. I don’t think that they were specifically marketed to police chiefs, but maybe they were.

The firearms were also “Value Line” versions of the Third Generation guns. That meant that they weren’t as smoothly machined as the regular lines, used some plastic parts in none critical parts (if there is such a thing), and didn’t have the quality bluing of the larger guns.

There were other “Value Line” guns, which were intended to compete with the highly successful and less expensive to produce Glock pistols. Functionally, the Value Line guns were Third Generation pistols, they just weren’t as finely finished.

This particular gun was sold to a law enforcement officer, so it was a bit different than the regular production guns. The two major differences were that it was shipped with Novak low profile sights with Trijicon night sight inserts. The other was that it was shipped with an ambidextrous safety.

Since my new acquisition was built in September of 2001, the lamps have long since burned out. Easy enough to fix and I’ll be shipping the gun out Trijicon for relamping.

I’m not a big fan of the ambi safety levers and so I swapped a left side only safety that I had sitting in the parts bin into the gun. The big reason for this trip, other than it’s fun, was to make sure I hadn’t bunged that operation up.

That safety will be coming out and shipped to a gentleman down south for some reworking. He will shave a couple of steps off the lever and then dehorn the edges to make it easier to carry without digging holes in pants and shirts.

Once all of that work is done and the gun is back together, this will become my pocket carry pistol.

The actual shooting was a bit anti climactic. As expected the gun, is very accurate for a 3″ barrel firearm. I’ve tested various bullet weights and it seems to shoot best with 124gr bullet weight. I plan to use Federal HST 124gr Jacketed Hollow Point ammunition.

Once I was done with that pistol, I put up a fresh target and took the next pistol out of the case.

This is a Springfield Armory XDE, also in 9mm. I’m not a big fan of polymer frame guns, but this one is a bit different. I also bought it as a travel gun for occasions when I go out of state. I did that because unlike my no longer produced Third Generation semi autos, the XDE is easy to replace in the event it is lost, stolen, or for some reason taken by the police during an investigation.

I got a really good deal on this gun over the summer from a dealer I’ve done a fair amount of business with. All I needed was an additional magazine and well made Kydex holster to complete the package.

One of the reasons I selected this specific model is that it’s functionally very similar to the Third Generation S&W firearms. First shot is double action, follow up shots are single action. The manual of arms is similar, with two differences. First, the safety and decocker functions are different. The XDE safety lever is pretty much in the same location, but it moves down for decock and then up for safety. It can, at least in theory, be carried with the hammer cocked, but safety engaged. Well, it can be carried with the hammer cocked and safety NOT engaged, but that’s not something I would do.

Of course it can be carried with the hammer down and the safety not engaged, which is how I generally carry my Third Generation firearms. It can be carried with the hammer down and safety engaged, which again I don’t recommend.

Carrying with the chamber empty, as advocated by some people, is right out. Feel free to convince me I’m wrong in the comments.

This gun is very easy and comfortable to shoot. It’s also very accurate. The only modification I’ve made or will make is to put some Talon Grips grip tape on. It makes the grips a bit more “grippy” and covers up the rather silly “Grip Zone” logo molded into the factory grips.

The XDE doesn’t seem to care one bit about bullet weight. I’ve fired 115, 124, and 147gr range ammo through it without a hitch.

I’ll probably use 147gr JHP for personal defense, since the firearm is accurate with it and has a long enough barrel for good expansion.

Pictures to follow when I have a few minutes.

That was my New Years Day, how was yours?


Day of Infamy


As the attack on Pearl Harbor on this day in 1941 fades into history and the people who were there leave us, a theme has grown up that the American response to the attack by the Empire of Japan was somehow racist.

Sure, there was a lot of propaganda after the start of the war that was very harsh on the Japanese. Americans of Japanese descent were interned under the guise of what we now call “national security.” At the time, it no doubt seemed a reasonable step.

We had been attacked without formal declaration of war by the Japanese. Understand that such was not their intent, but they were inept in how they decoded, typed, and delivered the message. The effect was of an unprovoked “sneak attack.” The Japanese had a history of simultaneously declaring war and attacking, which is what they were planning for Pearl Harbor.

It’s odd, but the people crying “racism” either don’t know or don’t care that there was plenty of “racism” on the part of the Japanese.

Their treatment of prisoners of war was despicable. Japan, not being a signatory of the Geneva Convention of 1929 were not bound by its terms. Which does not excuse the starvation of,  the summary executions, or casual torture of prisoners of war.

Even worse was the treatment of civilians in areas captured by the Japanese military. Look up the Rape of Nanking, the Japanese Domination of Korea, or the Treatment of Civilians by the Japanese.

The Japanese were the provocateurs of the war in the Pacific, not the victims.

The war that followed in the Pacific and Asia was brutal. It was almost four years before the Japanese surrendered. At that, it took the destruction of two Japanese cities by Atomic Bombs before they finally, and in many cases reluctantly, surrendered.

It all started Seventy Seven years ago today.

Well Meaning, Not All That Well Informed

I came across a report from the Citizen’s Budget Committee of New York. This is not a city agency, but is comprised of concerned citizens who want to help the cities and state of New York operate more efficiently.

Founded in 1932 the Citizens Budget Commission (CBC) is a nonprofit, nonpartisan civic organization devoted to influencing constructive change in the finances and services of New York State and New York City governments. A major activity of CBC is conducting research on the financial and  management practices of the State and the City and their authorities.

The report that drew my attention is,

Reviving EMS
Restructuring Emergency Medical Services in
New York City

If you’re at all interested in EMS, you should read the report. If you’re interested in EMS in the City of New York, you really should read it.

The report is well structured and has some good suggestions. None of which will be adopted by the fire fighters who run EMS in New York City.

It also lacks any sense of history of how EMS in New York City operated in the past or operates now.

For those who don’t remember, until March of 1997, EMS in New York City was operated by the Health and Hospitals Corporation. That corporation also ran, and still does, the city owned hospitals.

Rudy Guilliani, then Mayor of New York City, decided to “merge” EMS with the fire department. There is a lot of speculation about the reasons he decided to do this, but no matter because he did it.

Allegedly, this was going to result in a unified fire department that would deliver EMS more efficiently than the existing EMS system that was run by people with medical backgrounds.

It was a merger with one willing partner and one unwilling partner. Much as the Borg used to merge with the Federation in Star Trek, The Next Generation. In fact there was a website that used that as a theme for the merger. Kind of funny, but kind of sad.

Once the agencies were merged fire department management decided to change everything about EMS. Well, everything but the things that mattered. They changed the uniforms, changed the color scheme and lettering on the ambulances and other vehicles, decided to change the radio call sign structure, and how ambulances responded. They also started to implement “Paramedic Response Units”, which were non ambulances staffed with paramedics. These are called “fly cars” in some parts of the country.

That lasted about a year or so, maybe a bit less. I forget exactly why, but after that the PRUs disappeared, the old call sign structure and deployment plan reappeared.

Neither response times nor cardiac arrest survival rates improved.

The problems that existed at the time of the merger were too many calls and too little resources, money was spent lavishly of fire suppression but niggardly on EMS, there were “frequent fliers” who took up a lot of resources, but didn’t really need ambulances.

In other words, what goes on in much of the United States when it comes to EMS.

So, what did the Committee find in it’s investigation,

Avoidable use—ambulance use for chronic conditions like diabetes, asthma, or addiction—is  partculiarly pervasive and costly, and for many of these patents, the ER is not the ideal treatment site.33 In addition there is evidence that a subset of patents with chronic conditions, called “frequent fliers,” are prone to recurrent EMS use, relying on ambulances and ERs for routine care.34 One study of urban EMS systems examined repeat  Utlization for three chronic conditions: acute alcohol intoxication, seizure disorder, and respiratory illness. Among these diagnoses researchers found
4.3 percent of patents accounted for 28.4 percent of transports.
35 The publicly available EMS data do not allow for tracking of  Frequent fliers; while the hospital intake and ambulance billing data would allow for such an analysis, the FDNY does not track the data in that manner.

There is nothing new in this paragraph. Nothing that EMS systems large and small don’t deal with on a daily basis. Also, patients with chronic conditions often deteriorate and have acute episodes. Missing one of those will get EMS on the front page of the newspapers, and not in a good way.

Here is what the committee recommends,

Many cites have begun to implement programs to reduce unnecessary  EMS use. Some programs, such as one in Reno, Nevada, use nurses to take 9-1-1 calls to assess whether the patent requires emergency care, and to link callers with non-ER resources when appropriate.52 The City of Houston has implemented a telehealth program in which arriving EMS staff assesses whether a situation is a genuine emergency and can consult an emergency physician via video. If the physician confirms there is no emergency, EMS staff works with the patient to connect to appropriate sources of care.53 In Dallas, the EMS department makes proactive community health visits to frequent fliers and has seen an 82 percent reduction in enrolled patents’ use of EMS.

What the committee doesn’t seem to consider is that an ambulance still has to go to the call. Doing the consultation can take longer than transporting the patient. Oh, and there is currently no revenue stream for non transports.

Oh, someone should tell the committee that “frequent fliers” is a pejorative term. I always advise clients to use “Valued Repeat Customer.”

The committee also recommends staffing ambulances with one paramedic and one EMT. Called “P/B” staffing, this is used in many areas. What no one knows is if one staffing pattern is better than another.

It’s incredibly difficult to compare different EMS systems because there are something like 50 different models of EMS delivery in the United States. I won’t go into even a few because I could write ten blog posts and not even scratch the surface of the topic.

Here is another committee recommendation,

Reducing the role of fire engines in medical incidents will not create savings without scaling back the number of engine companies. The City should conduct a thorough assessment of the location, coverage, and workload of fire companies; while nonmedical, nonfire emergencies have been on the rise, the precipitous decline in  fires and dramatic changes in building density and demographics since many fire houses were built have reduced workloads of several fire companies. Such an 15 assessment should identify where companies could safely close without jeopardizing response times to any type of emergency.63 For every fIre engine company closed, the city would save $7.2 million annually, enough to fund 10 additional ambulance tours each day.64

Good luck with that. The fire fighters union, which I believe is still separate from the EMS employees union, will fight that until the death. I know of only one city, Baltimore, that did that sort of thing. I think they did it by attrition, not layoffs. Nor can FDNY move firefighters without EMS certification to ambulance duty.

Back to the PRUs. FDNY reimplemented them on trial basis in 2016 in the Bronx. Which resulted in fewer ALS ambulances being available. So, more BLS units were fielded to make up for that shortage. The paramedic on the PRU did an initial assessment to see if the patient needed ALS. Unsurprisingly (to me) FDNY found out that only 30% of their patients actually needed ALS. They also found out that much of the time first response engines were not needed and provided no significant medical care.

Neither is a surprise to anyone who has spent any amount of time working in EMS, especially in a city of just about any size.

There is a lot of number crunching going on in this report, but I get the feeling that no one talked to anyone who actually provides EMS care in New York City. Some of what the committee recommends probably would work, but won’t be implemented for a number of reasons. Some of what they recommend might be implemented, but won’t have the intended affect.

In ten years or so, someone will be putting out another report that will point out the same problems and make similar recommendations.

Read the report and please comment either here or on Facebook. If you work for FDNY as an EMS provider, I’d really be interested to hear your thoughts on this.

Catching Up


Some random thoughts because I haven’t had time to post much of late. A combination of travel, work, and laziness when I’m not traveling or working.

Random thoughts, in no particular order.

November 10 was the 243rd birthday of the United States Marine Corps. Here’s hoping for many, many more.

By the way, the US Navy was born on October 13, 1775, a little less than a month before the US Marines. No coincidence, that.

November 11, was Veterans Day. It was also the 100th anniversary of the end of World War I. The “War to End All Wars” as it was called. As if.

Thank you to veterans past and present. That includes my late father, all of my uncles, and several parents of friends, including a couple of older women who enlisted in World War 2 and later wars.

Our county is only what it is, and still here, because of their dedication, hard work, and sacrifice.

I’m off to Texas for the Texas EMS Conference. If you’re in EMS and can afford to travel, it’s a very good show. It’s almost as large as the two “national” EMS shows and for my money much better. Even though most of the attendees and some of the speakers are from Texas, there are people from all over there as well.

Plus, it’s a time of year when I get to reconnect with people I don’t see nearly enough.

I won’t get to be there all that long this year as I have to be back in the frigid northeast to help Mrs. EMS Artifact set up for Thanksgiving. We’re hosting for the first time in several years. We’ll have some close friends and relatives over for the day. That includes my 99 year old Mother in Law who can’t travel to see her other daughter for the holidays.

It also includes my daughter, who lives in Texas and who we don’t get to see often enough.

Speaking of EMS. It seems to be continuing along apace without my active participation as a field provider. Which is what we should expect when we retire. The number of people that I worked with who are still there dwindles by the day. Now, about six years after my retirement, fully half of the people there wouldn’t know me if they saw me. And Vice Versa. I still see some of my old co workers from time to time. A couple even thank me for teaching them a thing or two about EMS in the real world.

Ironically, I see more of them at client agencies from time to time. People who moved on to other jobs and brought their EMS skills with them.

I like to flatter myself that by doing teaching and consulting, I’m still contributing to the advancement of EMS.

EMS still has pretensions of being a profession, but it’s more likely to be a trade. It’s most likely to be a skill set, especially at the BLS level. Think about how many people are EMTs as part of, but not a primary part of, their job. A smaller number, but probably larger percentage of paramedics fall into the same category.

There are Fire Fighter/Paramedics, whose jobs consist of 80% EMS and 20% fire suppression and HazMat mitigation. Yet, I’ve never met one who calls him or her self a “Paramedic/Fire Fighter.”

The same goes for the much smaller number of police officers who are also paramedics.

If you look at organizations that purport to represent EMS providers, many of them operate on the premise that EMS providers are also something else. I’ve seen organizations that have a Star of Life and a Maltese Cross blended together in some fashion.

Because there aren’t any organizations that represent fire fighters, right?

So, the Democrats took back the House. Good luck to them, as they appear to be as organized as a dumpster fire. I have complete faith in them to screw up and lose control of the House in 2020.

Speaking of dumpster fires, what the hell is going on in Florida? They can’t seem to get voting right no matter what they do. Maybe it’s time to seriously reconsider how voting is administered and votes are counted. The state is a national laughing stock. Maybe it’s an international laughing stock. Far less developed countries seem to be able to manage their elections with less drama.

Okay, I’ve vented my spleen enough for one day. I expect I’ll find some good blog material at the conference. In the mean time, visit some of the fine bloggers on my blog roll.

Roy Clark


One of the greatest musicians in Country Music died today. Best known as a virtuoso guitar player, he also played the banjo, fiddle, mandolin, harmonica, and other instruments.

And he could sing as well.

Best known as the host of “Hee Haw”, first on CBS and then in syndication, he performed all over the world in concert.

Here is a nice story about him on Fox News.

Here is an example of his talent with the guitar.