Using Capnography in ACLS

You have a patient in SVT. (for more on SVT, see this post) How do you decide whether to cardiovert or use drugs? The ACLS classes recommend that you look for signs of poor perfusion, such as altered mental status or a systolic blood pressure below 90mmHg. The problem with waiting for these signs is that they are relatively late signs of cardiogenic shock.

A person with altered mental status or an SBP below 90mmHg is already decompensating, and is into the third (or possibly fourth) stage of shock. The blood pressure and mental status changes indicate that the brain and other vital organs are not being oxygenated, and as we all know, this leads to acidosis and cell death.

If only there were a way that we could determine that our patient’s SVT is reducing cardiac output due to Starling’s Law. Wish no more, here is your answer:

As cardiac output decreases, so does venous return to the lungs and heart. This lower blood flow results in less CO2 making it to the lungs to be exhaled. If your SVT patient is placed on capnography, and the CO2 is less than 37mmHg, you need to start thinking that your patient is having a bit of trouble perfusing, most likely to reduced cardiac output. This is the beginning of our patient’s journey to decompensation city. It is time to begin leaning towards cardioverting our patient before we reach the point where our patient has deteriorated so severely that he has begun to lose brain cells.

Don’t fall behind the curve. Be proactive, and you will do yourself and your patients a true service by catching problems earlier rather than later.

Pay, benefits, and career choices

I just began doing my taxes, and that is always a depressing time of year. I made 18% less in 2010 than I did in 2008, and 7% less than 2009. In all, it was the lowest pay since 2004. They take money out of my check for our retirement plan, and our plan is funded 31% by us, and 24% by earnings on investments, leaving 45% for our employer to fund.

Now the State is talking about reducing our retirement benefits. They want to exclude overtime and incentive pay from the calculations. They also want to reduce retirement benefits from 3.23% per year to only 1.6% per year. This means that I will see a net reduction of 62% of my retirement. On top of that, they will penalize you 5% per year for each year you retire before the age of 55. Instead of getting 71% of my pay upon retirement at age 50, I will get 20% of my pay. In other words, I will have paid in more than I will get back in benefits. 

So I have a choice to make:

1: I can retire this year before the changes take effect, and change careers. I would get 39% of my pay to go now with 15 years of service. I would maybe go get my master’s degree and be a Physician’s Assistant. I have some cash saved, and I could pull it off. Maybe I can even work part time while I am in school. I would even make more as a PA than as a FireMedic, and work fewer hours. The downside is that I will not be working for the two years it would take to complete the degree, and I am a little on the old side to be changing careers.

2: I can stay here for the next 8-13 years, but accept declining pay and hours, and reduction in my retirement pay. Under this new plan, I would have to work here for 13 more years to get the same retirement I can get by leaving now.

Seems like a no brainer. If this bill passes, I will have to take my education and skill set elsewhere. Maybe it is time to start getting my paperwork together so I can apply. I am not angry. Just remember that you get what you pay for. If a less educated, less experienced workforce is all that the taxpayer is willing to pay for, that is their choice to make. I just know that I also have other options, and I can choose to take my skillset where I can maximize my own earnings.

Extortion

The city of Kingsland, Georgia has a total area of 44 square miles spanning both sides of I-95, making it the seventh largest city in Georgia by landmass. I-95 runs through the city for 4.5 miles, near mile marker 9. The vast majority of that 4.5 mile span is sparsely populated. For its geographical size, the city is actually quite small. Kingsland only has a population of about 13,600. A large area of the interstate has been incorporated, even though there are not many homes or businesses in the area. Coincidentally, the city encompasses two exits and the 4.5 miles of highway between them.

The police department of Kingsland employs 46 sworn officers, meaning that there are 3.4 officers per 1,000 residents. This is significantly higher than the National average of 2.5 officers per thousand. Twenty five of those officers are assigned to the patrol division, with about 5 officers per shift. Those 25 officers write 13,000 citations per year. The city actually budgets for this. The police may not have a per se quota, but writing into the budget that you need 13,000 citations is a bit of a target number, wouldn’t you say? Now let me add that I did not receive a traffic ticket in this area, but I did see something that caused this post:

On that five mile stretch of highway, I saw three Kingsland Police officers with three separate cars pulled over for traffic infractions at 4:30 pm on a Sunday. That is more traffic stops than I saw for the rest of I-95 in Georgia COMBINED. Now I know that this is not proof that the city is padding the coffers with some traffic money, but it seems odd to me that a city with 5 patrol officers per shift, that more than half of the shift is dedicated to writing traffic tickets on a 4 mile stretch of highway. I mean, aren’t those 5 officers needed to patrol the 44 square miles of city that they are responsible for? Or is this just a means of revenue enhancement for the city?

According to the City budget, each officer is projected to write 500 citations per year for FY 2010/11, up from 286 in 2008/09 (page 105). This is an average including ALL officers, even the ones with desk jobs. If you recalculate that number using only the 20 patrol officers who are not supervisors (who generally don’t write tickets), that average shoots up to 650 per officer. Fines are the second largest source of revenue for the city, comprising 20.7% of the city’s general fund revenue (page 69).

Aren’t we tired yet of hearing how traffic enforcement is for safety, that there are no quotas, and that the traffic fines we pay are not legalized robbery?

Still in the Capitol

I went to the National archives yesterday. There is something about standing in the presence of our founding documents that is awe inspiring. These papers are the documents that are the basis of our Nation. I wonder how many of our Congressmen have looked upon and read the constitution and bill of rights. How many of them look at those documents as simply an obstacle to be overcome in carrying out their agenda?

Discussion with an Anti

The following is an electronic discussion I had with an anti gunner. The topic is the shooting in Tucson and how gun control will help or not help. This is the mentality we are dealing with: (He is in blue, and I am in red)

Anti: Tighter regulation would help keep guns in the right hands and out of the wrong ones. It’s not perfect solution but might be a move in the right direction. Holding a person accountable for their actions is reactionary, we need to be pro-active in order to better prevent these tragedies. There is obviously no perfect solution, and no matter what laws are in place bad people will always exist. I myself own a handgun for protection. I would never suggest that we make it so that good people cannot protect themselves, I’m suggesting that the government control what kind of guns and bullets are obtainable: like semi- automatic and automatic weapons and armor piercing bullets. Again, I never said that more regulation or better control would be a perfect solution, but putting this guy in the electric chair, although needs to happen, will not help prevent the next ass from shooting up innocent people. Tighter control can only a positive move for us as a society. The death penalty is to little to late for the innocent people affected by tragedies like this.

(note that he says waiting for people to actually break the law before punishing them is reactionary. They should be punished before they get the opportunity to harm others-DM)

Divemedic: One of the basic human rights is the right to exist and to defend that existence. A gun is the best way for a person who is weak to defend themselves against a stronger person. Guns enable a 100 pound woman to defend herself from a 200 pound rapist. If you could somehow wave a magic wand and remove every gun from the face of the Earth, do you think it would stop people from harming and killing others? In that vein, a gun is a human right, as it flows naturally from the right to defend one’s own life and there ARE many people trying to take away our guns. Diane Feinstein, a Democrat congresswoman said “If I could get 51 votes in the Senate, Mr and Mrs America, turn them all in, I would do it today.”

Anti: Sorry dude, but a gun is not a human right. Survival is, but owning a gun is not. It is an American privilege that we all should be proud to have and I would never want that taken away from good people. But lets say this 100 pound woman wants to buy a handgun for protection, the right regulations wont prevent that. I’m not so much worried about her as I am the adolescent with the emotional problems who finds daddies semi-automatic AR-15 and goes to the mall to seek his revenge on the society that has somehow done him wrong. Now, obviously if the kid really wants to hurt people he will find a way, but controlling what kind of guns are bought and sold at your local gun store will make it a little more difficult for him/her. Evil will most likely find a way, but we can at least try to make it hard for them. Diane has an extreme and unrealistic liberal idea that I personally do not agree with but I think there is a compromise somewhere in the middle of the extreme right and extreme left.

Divemedic: A gun IS a human right, as how do you expect that person to survive if you tell her she cannot defend her life? The Constitution was based upon John Locke’s theory of Natural Rights. To deny them is to deny the basic premise that our very nation are founded upon. It isn’t just me who says that, the Supreme Court has ruled that possession of guns is a fundamental Constitutional right (see Heller v DC, Supreme Court 2008)

The problem here is that it was already illegal for the AZ shooter to own a weapon (he was a drug addict) which means he broke two laws in obtaining the firearm. Murder is illegal, as is brandishing a firearm, and a dozen other laws that he broke. Do you think adding another law would have made a difference? How long has cocaine or pot been illegal? Does anyone have trouble getting those?

Anti: you ideal is a double edged sword brother, because then even drug addicts and rapists would have the “human right” to own guns.  If the right regulations and laws makes it a little more difficult for me to get a gun but a lot harder for a convicted criminal to get one, I’m all about it.  I personally would love to see psychological testing and more rigorous background checks. I think the law should be tougher on people who have guns illegally, and I think there needs to be more control on the types of guns sold in the US. I think we should start asking why we think people SHOULD have the privilege of a gun, not why they SHOULDN’T have one. Guns should be viewed and treated like privileges instead of rights. It just feels like its way to easy for the wrong people to get guns. But I don’t have all the answers. I think that conservatives and liberals can find a middle ground on the issue.

Divemedic: We could not be farther apart on this. The Second Amendment and Fourth Amendment both make your suggestions unconstitutional. We are at the middle ground now. Until 1934, it was legal to own whatever you want, including artillery and machine guns. Compromise ended that. Until 1968, it was legal to order guns by mail with no restrictions, including felons. Compromise ended that. No more compromise. Gun control is a failure. 

On the road

Posting has been light as of late, as I have been on the road. I am currently in our nation’s capitol. I spent the day yesterday wandering around, and I am left with a few impressions. First, let me start by saying that there are not many tourists here this time of year, and the result is that there is almost no one enjoying the monuments and other national treasures. This makes seeing things pretty easy. To show you how empty it was, here is a picture I took yesterday:

One of the monuments we went to see was the Washington monument. I use this as an example of one of the things that I noticed. There is a bookstore at the entrance, and it is small (about 300 square feet). It is filled with books that tourists would buy about the capitol, includeing about a dozen books about and written by our current President. That isn’t the story here. There are two employees in the bookstore. On the back wall of the outside of the store, there is a box office where another employee hands out free tickets to enter the monument itself. I am not sure what purpose these tickets serve, as they are free for the asking.

You walk about 200 yards to the base of the monument, and there are 3 police officers standing there with a man who takes your ticket so you can enter, four at a time. Not the monument, but a small building connected to the monument. This building is made of poured concrete and has thick armored doors and bulletproof glass. Inside of this building, you are xrayed, stripped, and searched by 3 unarmed security personnel, overseen by two more cops.

Moving on, you enter the base of the monument, where there are 3 employees to operate the elevator. This elevator has three stops, the base, the top floor, and the floor just beneath the top. These three employees are there to push the buttons for you. You board at the base, get out at the top, walk a flight of stairs to the floor below, and reenter the elevator.

Fifteen employees, not counting the maintenance and groundskeeping people. All of this for a small bookstore, and a monument with a total of three rooms, one of them being the lobby. In all, there were less than fifty people at the monument when I was there. Ridiculous waste of taxpayer money. It seems to me that this is a massive jobs project.

Repossessions

This post is in response to the laws as they pertain to repossession in Florida. Many of these laws are based upon the UCC, but since I am not aware of the laws of every state, your mileage may vary. This is my (non lawyer) opinion of what the law says. As usual, my advice is worth what you paid for it.

In Florida, statute 493.6118 prohibits a repossession agent from carrying a weapon:

9. Carrying any weapon or firearm when he or she is on private property and performing duties under his or her license whether or not he or she is licensed pursuant to s. 790.06.
 This makes carrying a weapon during a repossession a crime. If a recovery agent is on private property, they have NO RIGHT to use force to protect themselves, as they are not in a place where they are legally allowed to be. This means that force may be used by the owner of the property to defend themselves against the unlawful use of armed force against the owner of the property. Furthermore, any force that the recovery agent used is unlawful, since they cannot legally be armed on your property.


 Why do I dislike repo agents? Well, four years ago, my sister bought a used car. She paid $4,000 in CASH for the car. The car dealer told her that he had not yet gotten the car’s title from the state, and he would send it to her as soon as he got it. Four days later, her car was stolen. She called the cops, and the cops told her that it had been repossessed. The dealer refused to return calls, and had the police escort us from his car lot. 

We got a copy of the title application from the state, and the paperwork had been altered after the sale to show that my sister still owed $50 on the car, and that there was a lien on it in that amount. We called the cops. They refused to help, and told us it was a civil matter. So did the state attorney. We sued in small claims, as a lawyer would have cost more than the car. When we got to court, the dealer said that he had already resold the car, so the judge said that he was not going to cheat the new owner of the car out of his money, and dismissed the case.
 
The law doesn’t work. The cops don’t work. Our legal system is not about right and wrong, it is about who can game the system. It is broken. Get what you can, while you can. That is what our legal system has taught me.

This is why I don’t like the Fudds

In response to my post about SB234, I received the following Email: (all spelling errors are his)

I wonder with the recent shooting in Tuscon will these bill to be meet so hard times in becoming law? I love guns and shooting for pleasure and would like to take up hunting for boar and turkey for hobby in the near future but, I dont have a need to sling on my 6 shooter and walk down the street. The time of tumble weeds and horse drawn carriages are gone, the need for a weapon is now purely hooby intent.

Here was the reply I sent to him:

The shooting in AZ appears as if it will have very little effect, as most Americans realize that the shooter was a mentally unbalanced drug abuser, and was already prohibited from owning a firearm. This shooting is a statistical aberration, and is not an indictment of all gun owners. It is unlikely to have a great effect on this legislation. The shooter in the recent AZ case is the exact reason why I (and many others) carry a weapon, because no matter how many restrictions you put on gun ownership, criminals will ignore those laws and get guns anyway. In the case of SB234, the question is not whether or not citizens should own or carry firearms, as that has already been settled in Florida, but whether or not a citizen who is already permitted to carry a weapon concealed may also carry that same weapon unconcealed.
I disagree with your assertion that the ownership of firearms is restricted to being a hobby. There are those who could just as likely claim that in this time of easy food availabilty there is no need to go into the woods and blow away defenseless animals. Firearms are a tool, no more, no less. The fact is that private citizens use firearms to defend themselves millions of times a year, many times without firing a shot. I am not alone in this opinion, as even the Supreme Court of the United States is in agreement (see District of Columbia v. Heller, 554 U.S.; 128 S. Ct. 2783; 171 L.Ed.2d 637 (2008)) “The Court concluded that the prefatory clause [of the second amendment] described the purpose of codifying the [second] Amendment, which was “to prevent elimination of the militia” by taking away citizens’ arms. Self-defense, however, remained the “central component” of the [second] Amendment.”
The canard of the “wild west” is a fallacy that was brought about by fantasy fiction. The “wild west” was much tamer that today, and shootings were almost unheard of. Cities and towns in the west frequently went years without a single shooting. Even the infamous “OK Corral” shootout scandalized and shocked America when it was reported.
Using vitriolic rhetoric is not a way to make a logical argument. Using terms like “sling on my six shooter” and “tumble weeds and horse drawn carriages” does not advance the debate, nor does it bolster your argument. If you would like to talk about this based on facts, and not emotion, I would be happy to debate facts with you.

The facts of death

 Regardless of what the media will have you believe, guns are not a statistically significant cause of death in the United States. From the 2007 CDC National Vital Statistics report: (2007 is the latest year available to me)
The top ten causes of death account for 79% of all deaths in the US: 

1. Diseases of heart (heart disease)
2. Malignant neoplasms (cancer)
3. Cerebrovascular diseases (stroke)
4. Chronic lower respiratory diseases
5. Accidents (unintentional injuries)
6. Alzheimer’s disease
7. Diabetes mellitus (diabetes)
8. Influenza and pneumonia
9. Nephritis, nephrotic syndrome and nephrosis (kidney disease)
10. Septicemia
11. Intentional self-harm (suicide)
12. Chronic liver disease and cirrhosis
13. Essential hypertension and hypertensive renal disease (hypertension)
14. Parkinson’s disease
15. Assault (homicide) (less than .8% of all deaths)

The fact is, life expectancy in the US has been increasing. There are plenty of intrusive laws that would save more lives than gun control. Outlaw fatty foods, salt, tobacco, artificial foodstuffs, sugar, sweets of any kind, cars, alcohol, pointy objects, tall buildings, and then talk about guns. Perhaps we could outlaw obesity.

In 2007, 31,224 persons died from firearm injuries in the United States, accounting for 17.1 percent of all injury deaths that year. 55.6% of these deaths were suicides. Gun control would not prevent suicide, unless you also outlaw sleeping pills, tall buildings, and any other means by which a person could take his or her own life. 

Homicides are statistically insignificant at less than 1% of all deaths, especially if you are not part of the at risk demographic of being an African-American (5.7 African Americans were murdered for every Caucasian.) drug dealing male (3.8 males were murdered for every female) gang member between the ages of 15 and 25, who has never been married. That demographic accounts for nearly one quarter of all firearm homicides in the United States. Perhaps we could outlaw drug dealers, gangs, males, or African Americans. (<—That is SARCASM for those of you unfamiliar with the term.)

Even at that, firearms only accounted for 40.5% of all homicides. Overall, the rate of death by assault is only 6.1 per 100,000 for all demographics, and less than 5 per 1,000,000 for Non-Hispanic Caucasians. This small number is likely greatly decreased if you are not a drug dealer or a gang member.

A total of 38,371 persons died of drug-induced causes. This category includes not only deaths from dependent and nondependent use of legal or illegal drugs, but also poisoning from medically prescribed and other drugs. Perhaps we could outlaw drugs, or at least control access to them. Oh wait, we already do that.

Gun store and SB234

I went to the shooting range yesterday. While I was there, I had a discussion with the clerk about SB234. For those of you who are unaware, SB234 changes Florida’s laws concerning firearms and weapons in the following way: (full text of the bill here)

1. People with a license to carry a concealed weapon will be exempt from Florida’s prohibition against the open carrying of weapons. In essence, a Concealed Weapons permit will become a Weapons Permit.
2. Colleges and Universities are no longer off limits to Permit Holders  (Removed by an amendment to the bill)
3. 790.28, the statute allowing the purchase of Rifles and Shotguns in contiguous states requires that such purchases comply with Federal law and the laws of both the state of Florida and the state where the sale takes place. SB 234 would remove the requirement for such a sale to comply with Florida law, as long as the purchaser is subject to a NICS check.

When I mentioned this to the staff at Reig’s Guns, the clerk responded by saying that this was a scary proposition, that College students would have the legal ability to bring guns to school. I pointed out that I am a college student, and asked why I should have the ability to defend myself with a firearm everywhere I go, except college. Does crossing an imaginary line to enter College campus make me immune from attack, or is it that I somehow become less trustworthy?

I patronize Reig’s, because they are more firearm friendly than the Oak Ridge Gun Range, which prohibits customers with loaded weapons, even customers who are carrying concealed with a permit. I used to spend a large amount of money in the Oak Ridge store, until they discovered that I was carrying a weapon and berated me for it. Reig’s Gun Shop has a sign that says, “No loaded weapons allowed inside, except for concealed weapons. Remember that concealed means concealed.”

Seriously, you work at a gun store. How can you be so obtuse when it comes to guns and gun rights? Are there any gun stores that respect your rights? How can a gun store support gun owners, and talk about how gun owners are a trusty bunch, and then turn around and hypocritically ban them in their store?