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I got a call from a paramedic at 1 in the a.m. this morning. She works for an ambulance service that responds as a second tier to the fire department, and transports any patients that the firemedic deems is not serious enough for them to handle. The call went like this:
“I need your help. My supervisor won’t answer the phone, and I don’t know how to handle this. I am on scene of a single vehicle rollover that shattered a telephone pole, and the driver is a 26 year old female who woke up in the grass and didn’t remember the crash, or how she got out of the vehicle. She states that she had a single glass of wine, is otherwise appropriate, and is refusing medical care and transport. She states that she doesn’t want to be on a backboard or have a C collar. Her vitals are: HR 162, BP 126/78, RR 16. The fire department allowed her to sign a refusal, but I don’t think that’s right. The other medics here from the fire department are telling me that I’m being too much like a “rookie.” What should I do? She is in SVT, and had an accident.”
The first thing that you need to know is that this particular medic only got her license 4 months ago. She is a very bright woman, but has no experience. I advised her to talk the lady into going, and if there was no other way, agree to not immobilize her if she agrees to go, and just document that she refused being immobilized. I also told her that she was not likely dealing with SVT, the patient was likely bleeding internally, was in compensated shock, and getting her to the trauma center was a high priority.
Enroute to the hospital, the woman began complaining of abdominal pain, and her abdomen became rigid and distended. It turns out that she had some significant bleeding.
Medics: This is one of the dumbest refusals I’ve heard of a medic taking. Lazy medics make me angry. Make fun of the new medic for confusing shock and SVT all you want, but at least she was smart enough to know what a sick patient looks like.

Every person who works EMS has a story about a patient who had an object stuck in an orifice. It never ceases to amaze me how many people cook or clean their home in the nude, and wind up with household items wedged in an orifice.
I saw a man with a birthday candle wedged in the end of his penis, where he had placed it for his boyfriend’s birthday, so he could blow out the candle. There was the guy with the wire coat hanger, the woman and the glass Coke bottle, and the guy who claimed that a home invader held a gun to his head, and forced him to insert the wooden handle of a BarBQ fork in his rectum, leaving only the metal tines protruding.
By far the winner in this is the unknown medical that we ran to a house only two blocks from the station. We arrived to find a man holding his groin, and it turns out that he had a keyring wrapped around the base of his penis. The member had swollen to the point where it was nearly the diameter of a grapefruit, and was an angry purple color. He said that the ring had been on there for nearly 16 hours. We tried ring cutters, but the keyring was spring steel, and wouldn’t even scratch it.
We took him to the hospital with an ice pack for pain, and turned him over to the staff. We found out later that they had to send a nurse to the local hardware store for some metal cutters to get the thing off of him.

On Friday night, I broke one of my main computer rules: I turned off the system. It seems like anytime a computer breaks, it happens when you turn it off. That is exactly what happened. The computer that I built on January 10 decided to go dead after I turned it off on July 27.
Dead. The power button doesn’t do anything. The power light is on, but that is the only indication of life. The power supply checks out fine, so a 6 month old EVGA motherboard is dead, the second to die like that this year. I don’t think lightning is the cause, as I run the system over a WiFi internet connection, and it is powered with a UPS, which is working fine.
I ordered a new MoBo(an AsRock this time), and it will be here by Thursday. In the meantime, I am tryping this on an older system.
This computer is a Pentium 4 with 512 MB of RAM.
Slow is not the word. At least it is better than the old days, when I had a 4800 baud modem. At any rate, I am checking email on an iPhone, and since the system I have is so slow, no internet and no blogging until my system is back up. That should be Thursday night or Friday.

As a part of my ongoing email exchange with Shoot Straight, here is the latest reply that I got from the store:

Please excuse our lack of clarity on the point you raised. Shoot Straight certainly respects the right to lawfully conceal a firearm. As long as the firearm remains concealed, and is not exposed, our staff will not seek it. However, if a staff member sees a firearm, then they may check it to make sure that it is unloaded. The meaning of our door sign that says “concealed means concealed”, is that store patrons that choose to conceal their firearms must keep them concealed at all times throughout their stay – even while on the range. It is against Shoot Straight policy for a customer to unholster their concealed firearm, or draw from concealment on our ranges. We hope this more detailed explanation clarifies any remaining questions. However, please do not hesitate to contact us again if there should be anything else that you might need.

 My remaining question is this: If I enter the store with a lawful concealed weapon, and I want to shoot at the range, are they saying that I must unload it prior to entering the store? I am not sure how to take this.

This post goes out to Robert Hewes, who said in comments to this post:

The only incident I can think of off-hand (where a CCW carrier thwarted a mass shooting) was the New Life Church shooting that was ended by a parishioner.

These incidents happen all of the time. They just don’t make the news. A mass shooting that doesn’t happen thanks to a CCW holder just isn’t bloody enough to make the news.

For example, Aurora had another attempted spree shooting two weeks before the Batman shooting:

There is also this shooting, where an armed robber was herding the employees into the rear of the store, and was stopped when the manager shot him in the face. While we don’t know that the robber intended to herd them into the back in order to massacre them, it is certainly probable.

In the last twenty years, there have been numerous mass shootings worldwide.

– July 22, 2011: Anders Behring Breivik kills 77 in Norway at a youth camp
outside the capital. The self-styled anti-Muslim militant admitted both
attacks.

– April 16, 2007: Seung-Hui Cho, 23, kills 32 people and himself on Virginia Tech campus in Blacksburg, Va.

 
– April 28, 1996:
Martin Bryant, 29, kills 35 people in the Port Arthur massacre in Tasmania, Australia.

– April 26, 2002: Robert Steinhaeuser, 19, who had been expelled
from school in Erfurt, Germany, kills 13 teachers, two former classmates
and policeman, before committing suicide.
This killing happened in a country where guns are strictly controlled, in a school where victims are guaranteed to be defenseless.

– Nov. 5, 2009: Thirteen soldiers and civilians
were killed and more than two dozen wounded when a gunman walked into
the Soldier Readiness Processing Center at Fort Hood, Texas, and opened
fire. Army psychiatrist Maj. Nidal Hasan is charged with 13 counts of
premeditated murder and 32 counts of attempted premeditated murder.
The incident happened on a military base, where in a seeming paradox, soldiers are disarmed and defenseless.

–
March 13, 1996: Thomas Hamilton, 43, kills 16 kindergarten children and
their teacher in elementary school in Dunblane, Scotland, and then
kills himself.
Defenseless victims in a school.

– July 20, 2012: At least 12 people are killed and 58 are
injured when a gunman enters an Aurora, Colo., movie theater, releases a
canister of gas and then opens fire during opening night of the Batman
movie “The Dark Knight Rises.”
 Cinemark theaters are posted as off limits to concealed carriers. 

– April 20, 1999: Students Eric Harris, 18, and Dylan Klebold,
17, opened fire at Columbine High School in Littleton, Colo., killing 12
classmates and a teacher and wounding 26 others before killing
themselves in the school’s library.
Another defenseless school where the teachers and students are disarmed by the law.

– June 18, 1990: James Edward Pough
shoots people at random in a General Motors Acceptance Corp. office in
Jacksonville, Fla., killing 10 and wounding four, before killing
himself.
 GMAC has a “no weapons in the workplace policy” that ensures that the victims would be unarmed.

– Sept. 23, 2008: Matti
Saari, 22, walks into a vocational college in Kauhajoki, Finland, and
opens fire, killing 10 people and burning their bodies with firebombs
before shooting himself fatally in the head.

Why don’t we hear about mass killings where guns are not off limits? Is it the criminals picking places where killing is easy? Or have their attempted killing sprees been thwarted by an intended victim who was armed? Mass killings make national headlines, but a wanna be mass killer who gets his ticket to Valhalla punched by a person who is legally carrying a weapon don’t. That is why I carry.

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.