Divemedic

A week and a half ago, I was at the Apopka location of the Shoot Straight gun range. They wanted to inspect my firearms before I entered the range. They have a sign on the door that reads: “No loaded weapons allowed inside. (Concealed carriers welcome, but concealed means concealed.)”

When the employee was shown my carry weapon, he had a cow. I sent an email to the store, to see if he was correctly following policy. This is what I got in reply:

Thank you for bringing your
concerns to our attention. In answer to your question, it is our store policy
to make sure that firearms are unloaded while in the store. We visually inspect
firearms to ascertain whether or not they are well-maintained and in a safe
working condition. We also check ammunition to make sure that reloads are not
used, and/or that range users are not using birdshot (which is not allowed in
our ranges). We work hard to make Shoot Straight ranges safe for all users, and
inspecting range user’s firearms and ammunition is just one part of the many
steps we take to provide a pleasant, healthy and safe environment. Thank you
once again for taking the time to write to us, and please let us know if you
have any other questions, or if there is anything else with which we can help. 

 So, I am sending another email that reads:

Is it also policy to inspect lawfully carried concealed weapons? If so, it seems to me that the handling of a weapon always increases the chance of a negligent discharge, and therefore a weapon that remains holstered is much less likely to discharge than one that is being fumbled with. I assume that concealed weapons are not a part of the “no loaded weapons” policy you are alluding to, since the sign on the door says,
“concealed means concealed.”

How can a gun store, a business that nominally supports gun rights, be as hypocritical as this. I can see not wanting people wandering around the store handling loaded weapons, but isn’t asking CCW carriers to unholster INCREASING the risk of an ND?

Reality. The reality is that the Patient Protection and Affordable Care Act, also known as Obama Care, is here to stay. There is not any real chance of the Act being repealed, regardless of what the Republicans are saying on the campaign trail.

Even though many people are focused on the individual mandate, that is actually one of the least important changes in the Act. One portion that is going to change health care as we know it, is the provision that states if a person is treated at a hospital for the same illness more than once in a 30 day period, the provider doesn’t get paid. This one provision is going to change health care as we know it.

You see, there are a lot of patients out there who are not compliant with the requirements of their disease. There is the patient with high blood pressure who won’t take his medication, the COPD patient who won’t stop smoking, the drug abuser who won’t stop taking heroin. Any paramedic will tell you that this is going to really impact EMS like no other provision. We have frequent flyers who are sometimes transported 4 or 5 times a day. Reimbursement for EMS services and for ER visits already hovers at 40% as a nationwide average, and this threatens to make that number even worse.

This means that the delivery of acute care will be more costly than ever. Hospitals are already looking at ways to control these costs. In a lecture at the Florida EMS conference this past weekend, Dr Ray Fowler was the keynote speaker. As a member of the Eagles society, an organization of medical directors of the country’s largest cities, he jokes that you cannot be a part of the eagle society unless the city whose services you direct is visible from space. During the speech, Dr Fowler stated that there is already an effort underway to redefine the role that prehospital providers play.

To minimize costs, there is going to be a need for paramedics to triage patients in the field, taking the truly sick patients to the ER, and taking minor complaints to walk in clinics, and to CHF management centers. Other times, paramedics will deliver care in the field and not transport the patient at all. Also gone will be the days when ambulances sit on the corner waiting for a call. Instead, between emergency calls, ambulance crews will conduct in home follow up visits on patients who have been recently discharged from the hospital, to ensure that they are compliant with medications.In short, there will be a larger push for preventative and maintenance care, and a shift away from emergency care.

The specific skills suggested for the APP above and beyond those encompassed by lower levels of care are:
 -Rapid sequence intubation (RSI)
– Surgical cricothyrotomy
– Central venous access
– Blood product administration
– Local anesthesia
– Anterior packing for epistaxis
– Dislocation reduction
– Trephination of nails
– Wound closure (sutures)
– Urinary catheterization
– Alternate disposition of patients (treat and street, or take them to places other than the ED)

In other words, APPs would gain some skill sets and training, while “regular” paramedics would lose others.

To those of you who have been in EMS any amount of time know that this is nothing new. Many of these proposed changes have been rumored for years, but have never come to fruition, mostly due to resistance from the nursing and physician communities. The difference is that now there is a real financial incentive for it to happen. If and when it does, the demand for paramedics will skyrocket.

Already in Texas, Minnesota, Colorado and  are beginning programs called “Community Paramedic” or “Advanced Practice Paramedic.(pdf alert)” The thought here is to provide a level of care that is sufficient for many routine and preventative care scenarios that enables $15 to $20 an hour paramedics to do jobs that are currently handled by expensive physicians, nurse practitioners, and physician assistants- all of whom make $50 to $200 an hour.

I know that the agency that I worked for planned for this when the last fire station was built. There is an area of the building that is set up and designed to be a walk in clinic that will be staffed by paramedics. The prediction during the design phase of the structure was that this clinic would be a reality within the next ten years. Firefighter paramedics will staff the clinic 24 hours a day while not actually on emergency calls. 

Whether or not this will degrade care is still to be seen. The answer to that depends on how the program is done. There are a lot of lazy, incompetent medics out there, and if the selection, training, and hiring of these newly needed medics is not done well, it will be a disaster. On the other hand, done correctly, it would control costs and enable more advanced providers to spend more time on patients who are actually sick.

From the view of paramedics, this will greatly increase work loads of an already  hectic and busy EMS personnel, even as it eases the workload of hospitals. Medics will demand and receive more pay, and if not, there will be a mass exodus of good medics into other fields.

Interesting times.

Let me establish a bit of a knowledge base for you all. I spent six years in the military, as a part of a fire crew. We spent 20 or 30 hours a month “sucking rubber” in gas masks and breathing apparatus. I have also spent over twenty years since then working as a firefighter/paramedic. I also did HAZMAT and SWAT responses. I literally have spent thousands of hours in various gas masks and respirators.

I am an avid shooter and gun collector. Not as good as many, but I still shoot. A LOT. 

There are many that claim that the shooter in Aurora was virtually invincible, due to body armor and the tactical situation. I say otherwise. For starters, the vest he bought was NOT a ballistic vest. It was a tactical vest, and was bought online from a Missouri store. One of the things that surprises me is that the owner of a store that makes his living selling to the gun community would throw gunnies under the bus like he does:

We play a supporting role for law enforcement guys and military and
we’ve been doing that for years and we’re kind of proud of that role we
play in supporting them,” explains Andrew Hoefner, COO of Tacticalgear.com. 
“I think if any additional scrutiny needs to be paid, it needs to be
ammunition sourcing online and firearms and how those are purchased.”

 Fuck you AND your store, you asshole.

Next, there is the issue of the shooter wearing a gas mask. This means that he had very limited peripheral vision. Anyone approaching him from the side or rear would have been unseen by him. Since he was shooting, his hearing would be diminished (as anyone who has ever fired a weapon indoors without hearing protection can tell you). The limited sense of hearing and sight would make him vulnerable, indeed.

No, what made this unwinnable was the fact that Cinemark theaters bans people with concealed weapons permits from the most effective means of self defense. This, combined with the fact that they couldn’t be bothered to make sure the exit doors weren’t propped open means that this theater should be sued off the planet. Of course, the courts will never let that happen. We can’t let a silly thing like dead bodies interfere with corporate profits.

To all of you who work in the health care professions:
I know that we sometimes get caught up in ourselves, and with the call loads, large amounts pf paperwork, and drug seeking frequent flyers, we sometimes find ourselves becoming burned out and jaded. In some cases, we may even begin to resent our patients. This goes for my nursing friends as well. When you feel that happening, remember this story:

When an old man died in the geriatric ward of a nursing home in an
Australian country town, it was believed that he had nothing left of any
value.
Later, when the nurses were going through his meager
possessions, They found this poem. Its quality and content so impressed
the staff that copies were made and distributed to every nurse in the
hospital.

One nurse took her copy to Melbourne. The old man’s
sole bequest to posterity has since appeared in the Christmas editions
of magazines around the country and appearing in mags for Mental Health.
A slide presentation has also been made based on his simple, but
eloquent, poem.

And this old man, with nothing left to give to
the world, is now the author of this ‘anonymous’ poem winging across the
Internet.

Cranky Old Man

What do you see nurses? . . .. . .What do you see?
What are you thinking .. . when you’re looking at me?
A cranky old man, . . . . . .not very wise,
Uncertain of habit .. . . . . . . .. with faraway eyes?
Who dribbles his food .. . … . . and makes no reply.
When you say in a loud voice . .’I do wish you’d try!’
Who seems not to notice . . .the things that you do.
And forever is losing . . . . . .. . . A sock or shoe?
Who, resisting or not . . . … lets you do as you will,
With bathing and feeding . . . .The long day to fill?
Is that what you’re thinking?. .Is that what you see?
Then open your eyes, nurse .you’re not looking at me.
I’ll tell you who I am . . . . .. As I sit here so still,
As I do at your bidding, .. . . . as I eat at your will.
I’m a small child of Ten . .with a father and mother,
Brothers and sisters .. . . .. . who love one another
A young boy of Sixteen . . . .. with wings on his feet
Dreaming that soon now . . .. . . a lover he’ll meet.
A groom soon at Twenty . . . ..my heart gives a leap.
Remembering, the vows .. .. .that I promised to keep.
At Twenty-Five, now . . . . .I have young of my own.
Who need me to guide . . . And a secure happy home.
A man of Thirty . .. . . . . My young now grown fast,
Bound to each other . . .. With ties that should last.
At Forty, my young sons .. .have grown and are gone,
But my woman is beside me . . to see I don’t mourn.
At Fifty, once more, .. …Babies play ’round my knee,
Again, we know children . . . . My loved one and me.
Dark days are upon me . . . . My wife is now dead.
I look at the future … . . . . I shudder with dread.
For my young are all rearing .. . . young of their own.
And I think of the years . . . And the love that I’ve known.
I’m now an old man . . . . . . .. and nature is cruel.
It’s jest to make old age . . . . . . . look like a fool.
The body, it crumbles .. .. . grace and vigour, depart.
There is now a stone . . . where I once had a heart.
But inside this old carcass . A young man still dwells,
And now and again . . . . . my battered heart swells
I remember the joys . . . . .. . I remember the pain.
And I’m loving and living . . . . . . . life over again.
I think of the years, all too few . . .. gone too fast.
And accept the stark fact . . . that nothing can last.
So open your eyes, people .. . . . .. . . open and see.
Not a cranky old man .
Look closer . . . . see .. .. . .. …. . ME!!

Roger Ebert says that the recent shootings at the Cinemark Theater prove that concealed carry doesn’t help prevent crime, because no one at the theater took out the shooter. That is a major disconnect with logic. That is like saying that a building that has a fire proves that fire extinguishers don’t work. By that same logic, police don’t prevent shootings either, so we should get rid of police.

Ebert also overlooks that Cinemark Theaters have had a long standing policy of posting their property as off limits to legal concealed carry since at least 2004. Here is an encounter that happened in 2009. Here is another that occured in 2004.

Here is a picture of the signs that are posted today. As of last month, the Cinemark closest to my house was posted as not allowing carry.

Signs demanding that guns not be brought into a store only guarantee that a killer will not be facing armed resistance. After all, if he is willing to commit murder, a sign isn’t going to stop him.

The BioLite camp stove appears to be a handy little piece of gear. This is a stove that has a heat powered, forced air fan that allows you to burn any twigs you find, and also provides enough electricity to charge small USB devices. I don’t have on yet, but I am planning on buying one as soon as possible.

Ego. That is what you get when you get a room full of paramedics together. Needing CEUs, I was sitting in an advanced airway class today. During an in-class discussion, the subject of intubation came up, and I remarked that I often use airways like the King tube for intubation, because it allows a provider to manage the airway of a cardiac arrest victim without stopping chest compressions, and there is no worry about missed intubations. This increases survival rates.

A medic in the row in front of me said that he gets enough intubations that he isn’t concerned about that, because he is confident in his abilities. He also told me that he performs RSI in his agency, and he feels like he is good enough that he doesn’t usually bother to prepare a back up airway in the event that he cannot secure a tube. Later in the day, during a break, I asked him how many intubations he gets.
He replied, “Three or four.”
I asked: “A month?”
He says, “No, a year.”

How do you think that you are proficient in performing a very complex skill that takes 30 seconds, and that you perform once every three months? You are so confident that you will give a drug to a patient that makes it impossible for that patient to breathe on his own, without making sure that you have a back up plan in place, in the event that your primary attempt fails to secure the airway?

Later in the afternoon, we had the opportunity to intubate a METI man. (This is a computerized high fidelity mannikin that reacts to medical procedures like a human would.) This medic and his partner were given a scenario where the patient stopped breathing, and were expected to intubate the patient before he desaturated to the point where his heart began to malfunction.

They failed, because they spent over three minutes trying to intubate, and were not ventilating the patient. He blamed the other paramedic that he was partnered with for the failure.