Bureaucratic nightmare. That is what I am in. You see, I want to till some of my lawn, to prep it for the laying of new sod. The amount of paperwork that is required is crazy. I am required to call the number and then wait for no less than 2 power companies, a water company, the city, and 4 telecommunications companies to inspect the property. I already know what they will say.

When they mark utilities, they get within a 24 inch margin of error in the horizontal. They cannot tell you the depth of the service. They are going to make me hand dig this. Guess what? I am tilling. Total depth is less than 4 inches.

Ridiculous. I think that if they put utilities that shallow, it is their own fault if it gets damaged.

Axis deviation

The 12 lead EKG. It is a useful tool that is largely misunderstood by the street medic. Today, a former student of mine was involved in a call where he had a patient with signs and symptoms that seemed cardiac in nature, and when he ran the 12 lead, there was no visible ST segment elevation or depression. One of the things that WAS noticeable, was that the QRS axis was deviated to the left. (-36 deg) and when the patient was given NTG .4mg SL, the axis shifted a little to the right (-21 deg).

The paramedic in this case notified the receiving hospital that his patient was experiencing an acute MI. He was chastised by the other paramedics he was on the call with, and told he over treated the patient.

It turned out that the patient WAS having a cardiac event, and the patient was admitted to the hospital. At this writing, the exact nature of the event is unknown.

QRS axis can be used to spot the following cardiac anomalies:

Conduction defects---for example, left anterior hemiblock, or electrically dead areas

  • Ventricular enlargement---for example, ventricular hypertrophy
  • Broad complex tachycardia---for example, extreme axis suggestive of ventricular origin (like VT) This can help the clinician distinguish between VT, and SVT with an aberrancy.
  • Congenital heart disease---for example, atrial septal defects
  • Pre-excited conduction---for example, Wolff-Parkinson-White syndrome
  • Pulmonary emboli

Since the QRS in this symptomatic patient experienced a shift of the QRS axis in response to NTG administration, one has to wonder why this shift occurred. Chronic conditions like hypertrophy, atrial septal defects, WPW, and tissue that is already infarcted will not see EKG changes as a result of the vasodilation effects of NTG. This leaves the clinician with the impression that the event is acute and cardiac in nature. Be suspicious any time you have a patient showing EKG changes with NTG. If vasodilation causes changes in the EKG, it is a good idea to ask why.

Today in history

The Mayor of Nagasaki placed himself in the history books by calling the Mayor of Hiroshima and exclaiming: “Did you see that shit? What the hell was that?”

For those apologists that think we should apologize for dropping the bomb, I remind you that the empire of Japan was a savage, warmongering people, whose soldiers killed 200,000 people and raped over 20,000 women and young girls during the winter of 1937-1938 in “The rape of Nanking”. Japan was hardly an innocent victim.

I am off to fill young minds.

Be careful who your friends are

Another fine day in my city. We respond to a female complaining of abdominal pain. We arrive at the Section 8 housing complex, and enter one of the second floor apartments.

As we enter, we are directed to a bedroom by a woman in her early 30’s. She tells me that her 15 year old daughter has been having cramps. Mom tells me that she originally thought they were menstrual cramps, but now her daughter looks really sick.

I enter the bedroom to see the teen curled up in a ball, holding her stomach.

I run through the standard questions.

DM: “Point to where it hurts.”

Pt (points to lower stomach, near her pubis)

DM: (rolls teen onto her back, gently pushes on her stomach in several locations) “Tell me when it hurts.”

Pt: “OW! Right there”

DM: “Does it hurt more when I push, or when I let go?”

Pt: “When you push.”

DM: “I need you to walk to the stretcher.”

Mom: “I can carry her.”

DM: “No, I need her to walk.”

The daughter walks with small, gentle, shuffling steps. She gingerly walks the distance, and gently sits down, all the while holding her stomach.

Once in the truck, and away from Mom, I ask a new line of questions. I note that she has a temp of 100.2.

DM: “Your mom isn’t here now, so I need you to HONESTLY answer some questions for me. Can you do that?”

Pt: “OK.”

DM: “Is there any chance you might be pregnant?”

Pt: “What do you mean?”

DM: “Are you sexually active?”

Pt: (stalls) “Well… The other night, my BFF and I snuck out to a party at this guys house, and they let us have some beer. I guess I drank too much and passed out. My BFF told me the guys there took turns having sex with me. I don’t want my mom to know”

DM: (tries to maintain poker face, glances at partner- significant looks exchanged) “When was this?”

Pt: “About a week ago.”

DM: “When was your last period?”

Pt: “Two days before the party.”

DM: “Do you have a bad smelling discharge coming from your vagina?”

Pt: “It started 2 days ago.”

DM: “You know that your mom is going to find out, don’t you? I think she would rather hear it from you than a stranger.”

We took her to the ER. Just as I suspected, PID, brought on by this. I hope she isn’t sterile.

“Free” Healthcare, again

Like I said in my earlier remarks about the socialized medicine plans, the only way to keep costs down is to either ration health care, or put in price controls. From the telegraph, we hear a story about people who drink, smoke, or are obese being denied health care. It seems that the government gets to create a “master race” of people, based on how they look, alcoholics, and smokers. Where have I heard that plan before?

In an apparently unrelated story, the people of the (formerly) Great Britain who actually HAVE jobs are leaving in record numbers.

Another pair of EMS stories


The call came in around supper time. It was for a man having chest pain. On arrival, the man was pale, cool, and he just didn’t LOOK well. He was complaining that he was short of breath, having chest pain which radiated down his right arm, and also said he felt “weak.”

A 12 lead EKG revealed that he was having an anterior wall MI, which is the medical term for a heart attack in the front portion of his heart. I started an IV, and gave the standard medications: nitrates, aspirin, oxygen, and morphine.

Once stoned on the morphine, he was an extremely funny man. We all had some big laughs when we got to the hospital. The cardiac alert I had issued while we were on the way to the hospital had worked just as intended- the man was taken to the cath lab, and he was operated on and the clogged artery repaired in less than hour.


Two years later, the same man walked into an emergency room and collapsed in cardiac arrest. The ER team was able to restart his heart after only a few minutes of effort, but due to a 4 minute delay in beginning CPR while they moved him from the lobby to the ER, he had permanent brain damage. He never regained consciousness, and died ten days later.

This man had a family, he was important to them. This man taught me the value of money, taught me to fish, taught me to play baseball. He taught me how to live my life. He wasn’t always there, but then again, I wasn’t always there for him, especially when he needed me the most, the day he died. That man was my father.

I don’t blame anyone for his passing, but I use this case to illustrate that we are responsible for the things that others take for granted.

I tell my students that becoming the best practitioner that you possibly can is more than just pride in your job. Those skills are not just for your patients. They can be for your family. Ask yourself a question: “If my father or mother had a heart attack, would I be comfortable knowing that I was the one working to save them?”

If the answer is no, then why are you here? Every patient you see is SOMEONE’S mother, father, brother, or sister.

It has been more than two years since the day he left. I still miss him every day.

Dad, I still remember that day when I was 12 years old, and we were standing in the back yard burying my pet. You put your arm around me as we dug the grave together, and you said to me, “I know it’s hard, but he knew you loved him.”

Speaking of taxes

I know I meant this to be an EMS blog, but I was taking care of tax issues this morning, and I noticed something:

Lets say I make about $72,000 a year. According to the IRS, I am in the top 25% of wage earners in the US. That makes me one of those evil “rich” people that deserves to be taxed more, because I am not paying “my share.”

Last year, I paid:

$12,193 in payroll taxes (includes SS tax, Medicare, and FITW)
$3,200 in property taxes
$2,374 in sales tax
$1,322 in utility taxes and fees
For a total of:
$19,087 in taxes that I paid last year.

Not counting the taxes built into the things you buy (import taxes, excise taxes, etc) and other taxes, like car registration, driver’s license fees, and the like.

But, according to many of the current Presidential candidates, I am not paying my fair share. That really ticks me off.

More EMS stuff to follow, I promise.

For this, we double our taxes?

Government Health care. I keep hearing people bleat on about how the government should pay for our health care, and these people frequently point to the (formerly) Great Britain as an example. These people complain that the rich get the best care, while the poor get poor care. To those people, I give you this story. That is right. This lady has to wait 18 months for a hearing aid.

A hearing aid. That isn’t all. Apparently, this is more than common. According to the article:

A spokesman for the Royal National Institute for the Deaf said: “I am afraid this is a common problem. In some parts of the country there are over two year waiting lists, which is shocking.”

Digital hearing aids can be had on the open market for as little as $1500. With no wait.

Free health care isn’t free. The US spends 15% of the GDP on health care. That means that “free” health care would mean increasing taxes by a corresponding amount.

So, the rich still get the care they can afford, the poor still get crappy care, and we all get to pay higher taxes, especially the rich. We sure punished those rich guys with those higher taxes, which I suppose was the point. Or was it just another vote buying tactic? I can’t remember.

Scene Safety

When we teach new paramedic and EMT students, we frequently have them role play to improve their patient interview skills. Every student learns that the first thing to come out of their mouth better be “scene safety” or it means an automatic failure of the scenario. This is done to make sure that they are always watching out for safety. The safety of themselves, their crew, and their patient.

Some years ago, I was involved in a discussion about this subject, because a man whose mother was living with him called 911. When the paramedics arrived, they noted some firearms sitting nearby, and had a law enforcement officer take control of the weapons for the duration of their visit. The weapons were returned to him as soon as the call was concluded.

This gentleman wanted to know under what authority the EMS crew confiscated his firearms. I tried to point out to him that his guns were not “confiscated,” but merely held temporarily for the safety of the crew operating there. The gentleman told me that if EMS crews were THAT afraid, perhaps we should find another line of work. He then called me a “jack booted thug.” When I tried to point out that this is standard procedure nationwide, he got really angry.

When EMS responds to a call, they do not know what they are going to be facing when they get there. I personally have stumbled upon numerous scenes that included rape, robbery, murder, and suicide. If I do not know you, I am going to have someone hold your weapon for a little bit, until we get the scene under control.

Not only are there people who want to kill, but people who are REALLY sick tend to experience an altered level of consciousness. Part of that altered LOC is a tendency to become combative. A head injury, seizure, stroke, low blood sugar, poor perfusion, any one of these problems can cause combativeness. When an EMS crew holds on to your weapons, it isn’t because they are trying to be a JBT. It is because they want to see another sunrise. Just because you are not dangerous when you are healthy does not mean you will remain so when injured. I have news for you- we even disarm cops when they are hurt. ( I have seen a cop with a head injury repeatedly try to draw his weapon)

Since many EMS personnel are not trained to handle weapons, this procedure is usually left to a LEO. You still get your firearm back- as soon as the call is over. 30 minutes, tops.

The other world

I am flying over an alien landscape. Gliding effortlessly with the current, I steer towards a small, rocky outcropping with small movements of my feet. The sand and rocks of the surface slide by only 7 or 8 feet below. I feel like Superman.

Just ahead, I see another creature approach.

The largest shark I have ever seen glides silently by. He is longer than I am from the top of my head to the tip of my fins- at least 8 feet.

Same planet, different world.