September 2010

I support the Muslims who want to build a Mosque near ground zero. If they buy the property, they pay for the building, and they want to worship there, then that is their right to do so, and I support that. After all, it does not infringe on the rights of one single person. With that being said, the only possible reason for them to do this, is so they can be “in your face” and provoke outrage. I disagree with them. It is still their right.

I support the Preacher who wants to burn Qurans today. If he buys the books, has the burning completely on his own land, and that burning does not infringe on the rights of others, then it is his right to do so, and I fully support that. With that being said, the only possible reason for him to do this, is so he can be “in your face” and provoke outrage. I disagree with him. It is still his right.

The First Amendment protects your right to say what you want, and to worship as you please. I will defend your rights under that Amendment, even when I do not agree with you. That is the real test of freedom: will you defend the rights of someone with whom you do not agree? If you will not, then you are not for freedom, you just want freedom for those with whom you agree, and that is not freedom, it is conformity.

For those who cry that the military will be placed in harm’s way because of the speech of the preacher, I say to you that our military is SUPPOSED to be in harm’s way to protect the rights of her citizens. When I enlisted, I swore to support and defend our Constitution from all enemies, foreign and domestic. That was not an idle promise.

For those who are opposed to book burning, I say to you that book burning is stupid, but in this age of instant publishing, I say that burning a book is more a statement than it is a real threat. I cannot state it any better than Breda has:

In an age where I can carry the complete works of William Shakespeare on a device small enough to fit in my pocket, book burning is primitive and irrelevant. I can download and delete the Qur’an over and over, all day long. It means nothing. And in the end, all books will succumb to the rot of time, crumbling to dust, without the help of a zealot’s flame. There are no sacred objects.

Book burning is wrong, because it has been used in the past to stifle free speech. In this case, it is the opposition to this preacher that concerns me. The police and FBI threatening a man with prosecution for speech is far more chilling and worrisome than his act of burning a few of his own books that he purchased with his own money in a mutually beneficial transaction.

Who could doubt that this looks suspiciously like threats and intimidation?

– Police announce that they are taking down license numbers of all who attend the church’s Koran burning
– Eric Holder states that Terry Jones (the preacher) will be charged with a hate crime if he burns the Korans.
– The FBI meets with Jones on Thursday
– Thursday afternoon, Jones announces the burning is off.

There have been some complaints about.. irregularities at gPal. They have a section over at Calguns where people’s posts are reportedly being edited and deleted. At this point, I cannot recommend that anyone do business with them.

Proving to me that CalGuns.net and GPal are criminal enterprises, they have deleted the thread at CalGuns where customers were posting their complaints that gPal is not paying out funds, and is not responding to emails and telephone calls.

This proves, at least as far as I am concerned, that I will never do business with either party, and will advise everyone I know to refuse to deal with them. Dirty business, indeed.

I want to take a couple of minutes to follow up on my tachycardia post from the other day. I left off on wide complex tachycardias, and I feel like this is a follow up that needs to be done.

As I said in the other post, we assume that all wide complex tachycardias are VT unless proven otherwise. The first question that we need to know is: does this wide complex tachycardia have a pulse? If the answer is no, then we work the patient as if it was a VF/VT code. If there is anything that a person with an ACLS card in his pocket should know how to do, it is work a VF/VT code. For crying out loud, they train cashiers at WalMart how to do most of this, and if you can’t, then maybe you should turn in that ACLS card and throw in an application to WalMart.

Anyway, if the patient has a pulse with this tachycardia, the next question we should ask ourselves is whether or not this patient is critically unstable as a result. There is only one thing that counts: Are we perfusing the brain? There are two fairly reliable indicators that we can use to determine this: mental status and blood pressure.

If the patient has altered mental status, or has a systolic blood pressure of less than 90mm Hg, then this patient is critically unstable and needs immediate intervention. Synchronized cardioversion is the way to go here. Time is tissue. Going with drugs at this point is costing you brain tissue: time to get the IV, time to drip amiodarone over 10 minutes, or time to push the lidocaine is going to cost the patient brain tissue.

If the patient is not critically unstable, then we have time to find out what we are dealing with: Is this VT or is it SVT with an aberrancy? We can tell by running a 12 lead. Run a 12 lead EKG, and if leads aVF and I are both showing negative deflection, then your QRS axis is in the upper left quadrant, meaning XAD or Indeterminate axis. This is an indicator that your patients heart is experiencing retrograde conduction. The foci, or pacemaker, in this heart is in the ventricles, and you are dealing with VT. Otherwise, it is SVT with an aberrant conduction.

Hope this helps. Good luck out there!

After all, it is hot out there, so the union workers hire non-union labor to picket in their place. At minimum wage, with no benefits. They are everything they accuse the businesses of being. Hypocrites.

I have two children. I divorced my wife when they were young. My son was eight years old, and my daughter was six. I know it was hard on them, and I always regretted that. When my ex wife and I divorced, both of the kids took it pretty hard.

I paid my court ordered child support, which in Florida is a punishing amount (payroll deducted). My child support was $1400 a month, and that left me only $800 a month after taxes. I was always broke.

The actions of my ex wife didn’t make things any easier. When I would go to pick the kids up for visitation, the ex-wife would refuse to let them see me unless I gave her more money, and when I refused, she would tell the kids that I didn’t take them with me because I didn’t love them. My son wouldn’t believe it, and would tell his mother to stop badmouthing me.

When the kids were allowed to come over, they always came without clothes, and the ones they were wearing were so worn as to be unsuitable for going anywhere. When I would ask about that, she told me that if I wanted to take them anywhere, I had to buy them clothes.

The kids would come to me and tell me that their class was going on a field trip, or they needed supplies for school, or some other event that required money, and their mother told them if I didn’t pay, they would do without. Of course I paid.

Once, the mother’s new boyfriend called me at home and told me, “Your daughter just called me daddy. Just thought you should know,” then laughed and hung up. That incident alone shows how restrained and in control I am, since I did not go down there and… well.

Just before my son turned 15 and he started costing more to raise, his mother threw him out- she said he was too hard to control. He came to live with me, got straight A’s, and graduated high school two years early, at the age of 16. He graduated college and the fire academy, all before he turned 20.

When my daughter turned 15, her mother caught her hanging around with a ne’er do well boyfriend with an arrest record, doing drugs, and skipping school. She sent my daughter to live with me. It was three years of fighting. Three years of school skipping, catching her with drugs, her being brought home by the police, her getting arrested, and me being threatened with violence by her boyfriend for interfering. The cops were not help, and neither were the courts. Three years of being told that she couldn’t wait to move out and be rid of my “bullshit rules” so she could live with her “soul mate.”

On her eighteenth birthday, she left and went to live with her boyfriend and his parents. A few months after she left, I was at her high school graduation. That was the last time I saw her until Christmas, when she came by to ask if I had bought her a present. She had broken up with her “soul mate” and he stalked her for six months or so, until she got a restraining order.

That was over two years ago. My daughter now lives in an apartment with 8 roommates, and has another skeezy boyfriend who uses all sorts of mind expanding chemicals. They both wait tables for a living. Still, I try not to express my displeasure, after all, I remember what it was like to be 20. We have been speaking, off and on for about the last year.

Until this morning. She had friended my brother and my nephew on a social networking site, and it seemed like family relations were improving. Then, my daughter began posting pictures of her illegal substance use, pictures of partial nudity of her and her friends partying, and other mature themes. My brother asked her to tone it down, as her 9 year old nephew could see it. She replied that she would not censor herself for anyone.

I jumped in and asked her to keep in mind that what goes on the internet can hurt you later in life, and also reminded her of the importance of family. She promptly told all of us to f- off.

They joys of parenthood. Why am I expected to endure behavior from relatives that I would never tolerate from strangers?

54 year old golfer who was struck by lightning 3 years ago and now lives in a local nursing home. We get called to the establishment for a report of rapid heart rate. Nevermind that he had been convulsing for over 45 minutes, they were worried about his heart rate of 160. The fact that the seizure was causing the poor, bedridden man to run a marathon never crossed her mind. She was locked on to the fact that his heart was racing.

At that point the RN was trying to explain to me that a HR over 140 is SVT. For all of you who are rhythm challenged, we will have a quick ACLS review here:

SVT means Supraventricular Tachycardia, or literally “a tachycardia occurring above the ventricles.” Theoretically, it means any tachycardia that is not ventricular in nature, and this would include a Sinus Tachycardia that is a part of the body’s normal response to physiological demands.

In reality, when people talk about SVT, what they are really referring to is a tachycardia that is caused by an electrical problem within the heart. This can include Multifocal Atrial Tachycardia (MAT), Atrial Fibrillation (Afib), Atrial Flutter (Aflutter), Atrioventricular Nodal Reentrant Tachycardia (AVNRT), and a few others.

 How do we tell the difference? Assessment is the key to medicine. If the patient is exerting himself and placing major metabolic demands on his body, the problem is not in the heart. Seizures, heavy physical activity, trauma, as well as other metabolic and neurological conditions will cause the heart to beat rapidly. A man watching TV who experiences sudden tachycardia is not responding to metabolic demands.

Don’t let anyone tell you that a HR over 140 is automatically SVT, and below that is not. A good example of why the “140 rule” is a bad one is Aflutter with an atrial rate of 330 and 3:1 conduction. That will give a heart rate of only 110, yet such a patient is in SVT.

In the call we are talking about at the beginning of this post, the man has a heart rate of 160 because of the heavy metabolic demands that the 45 minutes of seizure activity is placing on his normally sedentary body, not because he has a heart problem.

We treat a sinus tachycardia that is caused by metabolic demands in a simple way: we correct the metabolic problem. In this case 10mg of diazepam by IVP stopped the convulsions, and within 15 minutes his heart rate was back to normal.

But how do we treat PSVT? This is an abnormal condition, and should be treated as a cardiac rhythm disturbance per the ACLS tachycardia card. We can consider synchronized cardioversion, and if we don’t know the origin, just start at 100 joules.

If we don’t go with electrical therapy, the problem gets a bit stickier. Narrow complex tachycardias are usually AVNRT, and we can just try Adenosine (6mg initial dose, followed by 12mg and 12mg more if unsuccessful) to see if that corrects it. Be sure to run a strip while you are giving the drug, so you can perhaps see if the rhythm is actually Afib or Aflutter.

If that narrow tachycardia turns out to be Afib or Aflutter, then you can try a calcium channel blocker like Diltiazem. I would not go with a calcium channel blocker in AVNRT though, because that rhythm is caused by an accessory pathway, and giving these drugs to a patient with AVNRT will shut down the calcium driven  AV node, and make the sodium driven accessory pathway the king of the highway. Now you have converted a patient from Aflutter with 3:1 or 2:1 conduction into a patient with 1:1 conduction, and a HR of 300!

You can also try cordarone, which is pretty effective on wide and narrow tachycardias, just watch out for cordarone’s most common side effect: hypotension.

Speaking of wide complex tachycardias, they are a bit different. First, determine if that tachycardia comes with a pulse. If not, it is VT. If it does have a pulse, we consider synchronized cardioversion, and if we don’t go that way, we need to consider drugs. All wide complex tachycardias are to be treated as ventricular tachycardia until proven otherwise. More on determining that in a later post. For now, we can just try antiarrhythmics like cordarone or lidocaine for treating wide complex tachycardia. (Important caution: corddarone and lidocaine should not both be given to the same patient. Since cordarone lengthens the refractory period by blocking potassium channels, and lidocaine blocks fast sodium channels resulting in a slower conduction velocity, the two together can cause asystole.)

This post is long enough for now, so good luck.

Edited to add: Here is the wide complex post

Excuse the lack of posting lately. I work two jobs, and I am taking 22 credit hours of college this semester. I am trying to get in to school to get a Master’s degree, so the prerequisites are eating up my time. More details on that later.

Last week’s schedule was 48 hours at my fire department job, 12 hours teaching classes, and my time in school TAKING classes.

This week I work 64 hours at my fire department job, and 10 hours teaching, as well as classes.

On top of that, I have to mow the lawn each week. No time left for posting.