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Wal Mart. You can do everything there. The Wal Mart in our response area sells the normal Wal Mart stuff, plus groceries, and automotive repair services. Inside, there is a pharmacy, an eyeglass store, two restaurants, a bank, a photo studio and a Walk in Medical Clinic.

How poorly do you have to do in medical school to be the Wal Mart doctor? We responded to this “Doctor’s” office three times yesterday. One of these visits was telling.

A man here was on vacation, and sitting near the pool eating is vegetarian submarine sandwich. Less than thirty minutes later, he developed shortness of breath, a tickle in his throat, and a rash known as urticaria. He complained that he “felt bad.” What does the family do? Call 911? Rush him to the hospital? No… They took him to Wal Mart, in the process driving past two fire stations and a hospital.

When he arrived, the Doctor gave him 50mg Benedryl, 1mg Epinephrine, and 125mg of solumedrol. When all of this failed to work, she called 911. When our heroes arrived, we noted that she had given everything except tagamet, so we talked about starting a tagamet infusion (300mg over 10 minutes). The Doctor told us that she would rather we did not, because the patient had been seen a month ago by his doctor back home for chest pain, and that he would need cardiac monitoring before we gave any drugs.

Uhhh- she doesn’t even have a cardiac monitor (we do) and she gave him epinephrine, which was the correct thing to do. However, epi has far more cardiac effect than tagamet does. Yes, there are rare instances of arrhythmias and hypotension with tagamet, but then again epi is to be used with caution in patients with a history of hear disease due to the increased myocardial oxygen demand that epi is sure to cause. The fact that the patient was orthostatically hypotensive was more of a concern to me than an anginal episode of unknown origin a month ago.

We got him in the truck, did a 12 lead, IV, oxygen, tagamet, and went down the road. He had no known allergies, so eating a sandwich will be an adventure for him in the future. Heck, it may not have even been the sandwich. We DO have a lot of biting insects here.

A Para-fetus came to me yesterday with a question. It seems that the young one was in paramedic class yesterday, and the instructor asked them if they knew when it was appropriate to use a Kendrick Extrication Device. The student replied, “To move patients while stabilizing the spine, for example, to remove a patient from a car after the roof has been cut off.”

To which the Instructor replied, “If you have to cut the roof off, the patient is probably too critical to bother using a KED.”

Ummm, it is called the Kendrick Extrication Device. You know, to extricate patients with. This is plainly an instructor trying to impress his class with his encyclopedic knowledge. If you want to get into the discussion of hemodynamic instability, and the decision to perform rapid extrication, fine. What I don’t understand is why you would make a blanket statement like that.

Some people who instruct need to think carefully about what you are teaching students before you speak. For reference, here is how I make the decision:

All patients die from the same cause: hypoperfusion. Every death is caused by a failure of the body to perfuse the brain. Therefore, anything that threatens that is a serious concern. A good rule of thumb is to perform a rapid extrication on a patient who is critically unstable and in danger of hypoperfusion.

These patients are easily spotted:

Altered level of consciousness
Systolic BP <90mm hg (in other words, lack of a radial pulse)
Breathing rate less than 10 or more than 30
Serious, uncontrolled hemorrhaging

Most other patients can wait the extra 3 minutes or so to stabilize the Cspine, especially if the patient’s mechanism of injury or clinical signs suggest Cspine injury.

A couple of years ago, I got DirecTV. I wanted to get the high definition, and I wanted to have digital recording capability. When I originally got the service, the operator told me that the HD DVR’s were too expensive for them to lease, and if I wanted it, I would have to buy it. I did, for $425. I leased two other receivers, for which I had to sign a one year contract. All was well.

20 months later, I bought a new house and decided to move. In order to transfer the DirecTV, they told me that I would have to pay for the installation. Since my house was wired for CATV and not satellite, this was going to be expensive. My year was up, so I canceled and got CATV instead.

My final bill comes, and lo and behold, they charged me $187 in cancellation fees. They tried to say that the DVR was a lease. I pointed out that I was only billed for two leased receivers. The reason I wasn’t charged the $5 a month for the lease was that the first leased receiver is not billed, according to them. Think about this- $425 plus a $4.99 a month for 20 months, plus a $187 cancellation fee= total cost for the leased receiver of $711.80, AND they wanted me to return the DVR.

The paperwork they gave, the hidden service agreements, referenced in fine print, and the confusing terms made my head spin. Large amounts of double talk and half truths made me feel like I was buying a used car. When you deal with these guys, look for the asterisks and the escape clauses.

When I produced the receipt for the DVR, along with the credit card statement, instead of doing what was right, they sent me to a collection agency. I threatened to sue. Three months later, they finally send me a letter, canceling the fees. I now have a DVR that I can sell, along with a resolve to never try DirecTV again, and I will urge others to do the same.

While my coworkers and I were discussing the previous post, one of them remarked that no one should be allowed to own any gun that the police do not own. I told him I was fine with that, because the police own machine guns, tanks, and rocket launchers. He said no, he meant what the average officer on the street has. He then gave the standard line about the constitution being out of date.

When I pointed out that his opinion would apply to the other amendments as well, and asked him to tell me how he felt about that, he told me that the Constitution was unneeded in this day and age, and he felt that too many people “hid” behind the constitution. He thinks that society is falling apart because we let people have too much freedom, and they abuse it.

He used Child pornography as an example. He said that under the First Amendment, child porn would be legal. I told him that if I want to write stories about children in those situations, that would be protected speech, however repugnant it may be. When a child porn FILM is made, you would be prosecuted. Not for a speech crime, but for having sex with minors. The speech is protected, the act is not. That is like saying a book about bank robberies is legal, but robbing one isn’t.

He ranted on about how it should be illegal to slander the President (citing the TV show “Lil Bush”) and how we should eliminate the separation of church and state, so that we can declare Christianity the national religion, thus preventing Muslims from taking over the world.

People scare and amaze me at the same time.

From Orlando, this is a story about a “guns for sneakers” program. In this program, the police offer sneakers, or $50 for anyone who brings them a gun- no questions asked. Read some quotes from the article:

An unblemished 1903 .32-caliber Colt pistol caught the eye of a knowledgeable deputy who checked the Internet and found it was worth about $1,400.

or this one:

Despite being more than 100 years old, it and dozens of other old handguns in various calibers still worked and would be deadly, deputies and officers said. Few of the exchanged weapons were late-model 9 mm and .45-caliber pistols, the sort used in many of the more than 100 murders last year in Orlando and Orange County.

one man brought in three valuable rifles.

Worth more than $3,000, the three military-style target rifles will be destroyed just like the rusted guns worth less than $50 that were turned in, organizers said. Before going under cutting torches, guns that work will be test-fired so the bullets and cartridges can be compared to evidence in unsolved murder cases, they said.

“Somebody took really good care of this,” said Williams, holding a .308-caliber M1-A Springfield rifle worth about $1,500. “I’d bet a body part this was never used in a crime.”

One man even turned in a fiberglass tube that he claimed was a missile launcher.

– Wasted, valuable guns that have never been used in a crime will be destroyed. Criminals don’t use M1A’s to commit crimes.

– Junk guns that probably don’t work, the owners paid $50. Probably more than twice what they are worth.

– The guns being used in crimes? Nowhere to be found.

This program cost us over $32,000. It will have exactly ZERO effect on crime. Those are our tax dollars at work.

Yet the cities in Florida, when faced with tax cuts, loudly complain that there is no fat in the budget.

We get a call to assist law enforcement with a subject that had been tazed. These calls are usually interesting. When we arrive, we find 2 injured Deputies, an uninjured Sergeant, and one handcuffed female, who is writhing on the ground and squealing about various medical complaints.

On further inspection, the female has at least 4 darts stuck in her legs and torso. She is telling us about her chest pain, about the fact that she cannot feel the left side of her body, and repeatedly telling us that she NEEDS to go to the hospital, or she is going to die.

The police are telling me that she has been tazed 5 times. She pulled the darts out twice, and managed to injure the two cops. She can’t weigh more than 150 pounds, and is certainly NOT as large as the three deputies that she was roughing up. She is now wearing TWO pairs of handcuffs. It makes it hard to get to her radial pulses.

One of my fellow medics reminds her that she is going to jail whether she goes to the hospital or not. I move to take her pulse, and it is humming along at a healthy clip- 174 beats per minute. My first assessment question:

DM: “What drugs did you take tonight?”
PT: “I didn’t take nuthin’.”
DM “Then how did that crack pipe get on your living room floor over there?”
PT: “Sumdood musta left it there.”
DM: “Oh. Him again.“

You hear about people dying in police custody after being tazed multiple times. After my own admittedly narrow experiences, I have a theory. These people are dying because of a combination of things. The massive exertion of fighting the cops, positional asphyxia (from being handcuffed in restrictive positions), combined with the tazing and the drug use, all combine to place stresses on the heart that it is not designed to take. I believe that the tazer use is the least important of these factors.

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.

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 defectsfor example, left anterior hemiblock, or electrically dead areas

• Ventricular enlargementfor example, ventricular hypertrophy
• Broad complex tachycardiafor example, extreme axis suggestive of ventricular origin (like VT) This can help the clinician distinguish between VT, and SVT with an aberrancy.
• Congenital heart diseasefor example, atrial septal defects
• Pre-excited conductionfor 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.

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.

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.