Thursday, December 29

the Crossover Show - Episode Eighty Eight

In this episode, brief though it may be, MC takes the helm because apparently HM was too busy “working” or some such nonsense.

At any rate, the winner(s) [spoiler alert] of the Be the 50th Reviewer on iTunes Challenge is announced and Surprise! more than one fits the bill. Give it a listen to find out who the lucky fools folks are.

From both HM and MC, have a safe and festive New Year’s Eve/Day and we’ll catch you in 2017!



Wednesday, December 28

Eminence Based Medicine

Eminence Based Medicine is a phrase I heard on one of my favorite podcasts, Freakonomics, which was talking about "Bad Medicine" and the fact that the more we actually investigate what we're doing, the more we find out we don't know what we're doing.

The episode starts by investigating 98.6 and the methods used to determine the "normal temperature" of humans.  Fascinating story short, the methods were flawed, the tools were flawed and the conclusions shoddy at best.  Have a listen for the full story.

As they point out in the 3 part series, we think of medicine as being highly scientific but, it turns out, we have only really embraced evidence based treatments in the last 20 years.  Within my service time.


That should frighten everyone.


Dr Vinay Prasad, a Hematologist-Oncologist and Assistant Professor of Medicine at Oregon Health University was a guest on the show and uttered the phrase that titles this post.  He was comparing evidence based medicine to previous practice, demonstrating that until recently we went with what the oldest, most experienced person in the room did and assumed that was the thing to do.  Eminence Based Medicine.


We in EMS LOVE our war stories, our observations passed along as fact and the EMS Anchors who spin yarns about the old days when things used to work, long before all this new fangled BS came along.

EMS is an expert in Eminence Based Medicine.

How else can you explain most of the "treatments" we apply to patients, specifically trauma and cardiac arrest, arguably the places we can make the biggest difference in patient condition?  Or can we?  Have we become so entrenched in a skill set that we have forgotten to review what we do for effectiveness?

Or do we know, deep down inside, that most of what we do has no basis in fact?


If data was properly collected and reviewed that showed that cardiac arrest patients had better outcomes if a peanut butter sandwich to the chest was just as effective as a mechanical CPR machine, how quick would EMS implement it?

If no evidence existed for said intervention, say if it only mirrored the outcomes for patients without it, would we still be so quick to make sure it is on every rig?

Do you think I'm still talking about the peanut butter sandwich?


Evidence Based Medicine will drastically change the EMS landscape.  Yes, skills will be decreased in favor of more specific interventions and application of technique.  Some of our brothers and sisters will cling to their laryngoscopes so tightly, citing bad studies and flawed data, instead of hitting the airway lab to maybe get better.  Cardiac arrests filled with drugs and drips and cooling and tubes may be reduced to BLS calls, not because the ALS is hurting, but because we'll learn that most cardiac arrests did not start in the heart and can not be addressed with our narrow arsenal of cardio toxins.


"We've always done it that way" are he 6 most dangerous words in EMS and yet are the basis for most of what we do.  Don't believe me?  Look at the push back against eliminating long spine boards, the sudden reversal on pre-hospital cooling (although the data has always been the same) and the fact we are still transporting patients in cardiac arrest to the hospital.

If we demand evidence for new treatments we must also demand evidence for existing treatments.  All of them.  Perhaps it is not the poorly educated EMS masses we complain about that are leading to poor outcomes but instead our blind devotion to the comfortable, time honored tradition of looking to the oldest, most experienced person in the room and asking them what to do.


Demand Evidence.

Reject Eminence.

Otherwise, what are we even doing anymore?

Monday, December 19

If You Don't Give Him Insulin He's Going to Die

The title of this post was a statement made to me in a crowded airline terminal.  It was said by a bystander, sitting across the way from a family having a bad day.  The dispatcher called me on the phone about 10 minutes before this all began and asked me if we carry insulin on the rescue trucks.

"No, why do you ask?"

A woman was calling stating her son was insulin dependent, had been delayed many hours and he didn't have his insulin. "Put me on it," was my reply and out the door I went, hoping that all they needed was maybe a syringe or perhaps some lancets to check his sugar.

Holding his baby brother, this teenager is feeling fine, telling me how they had lunch not long ago but it didn't taste good because he didn't take his insulin.

His glucometer, insulin and supplies were all in the giant carry on they tried to get on the plane.  When it didn't fit in the little case near the jetway it was checked through and placed under the plane.  When the flight was cancelled due to weather at their destination (nasty storms on the east coast) the bag sat in the belly of the airplane while his sugar slowly crept higher and higher, no insulin to unlock it.

As I explained my lack of insulin and a number of options for obtaining some, the police officer left to get an airline agent to retrieve the bag from under the plane.  This is no easy task, especially since they were looking for a "black rolly carry on"  I grabbed my glucometer and tossed it to the boy after he passed baby brother back to mom.

"Show me how you check your sugar," I told him and he clearly had never been instructed on how to do so.  A quick inservice on location selection, lancette use and strips and he's a pro.  Probably had to be a quick learner when baby brother came along.

"If you don't give him insulin he's going to die" is suddenly said over me shoulder in a tone and volume to ensure most of the 250 people waiting in the 150 chair waiting area heard her.

"He'll go into a coma and you'll be liable.  Just give him the medicine already."

"Thank you for your concern for your fellow traveler, we'll be making sure he has a healthy plan before we leave."

"Do you even know what diabetes is?"

The boy smiled and tried not to laugh, understanding my role in the healthcare system, while the clearly inebriated woman sipping the iced coffee behind me just wanted to stir the pot.

As the glucometer came back with the ever concerning reading of "HI" meaning over 600, the officer emerged with a number of black carry ons to choose from.  The proper bag is found and I send the boy off to do his usual mid day dosing in the privacy of the rest room.  He has lost his glucometer so my extra has to fill in.

"I can't believe you refused to help him," she chimes in.  I grabbed one of my cards and handed it to her telling her that if she is as concerned she can feel free to lodge a formal complaint with the airport, Fire Department, County and State.

Just then mom chimes in, "I want one of those cards too please. If she's gonna get all bent out of shape by you helping us out I want to make sure all those people know what you really did for us today."


We'll see who's letters actually arrive.  Now, if I can only learn what diabetes actually is...

Sunday, December 11

Lost Cause Strikes Again

I spoke not long ago about a Medic that got under my skin for not wanting to complete a secondary assessment on a patient.

On a recent call he had me frustrated again, for almost the opposite reason.


55 year old male, chest pain, diaphoretic, history, pretty much every patient you got during your cardiology portion of Paramedic School.  Lead II and III look fine but of course we're placing the 12 lead and opening up the ASA as the wife gives us a better idea of his history.  Out of the corner of my eye as I check the BP I see Lost Cause (LC) approaching and his step slows as he sees me.

A report is given as I fish out the nitro and prep a spray.

"Does he want to go?" LC asks casually.

"Not exactly, but we haven't ruled out an acute MI here, so let's play it safe, shall we?" I respond as the 12 lead analyzes the pronounced ST elevations in V2 V3 and V4.  I know what the strip will say before it finishes printing.

As the O2 is transferred to the Ambulance the patient is beginning to calm and asks me what I saw on the ECG.  Before I could answer, LC jumps in and says one of my least favorite things.  If you've read anything here you know what he's about to say and you're proud of me for not screaming.

"Well, Sir, we don't diagnose, we're just Paramedics, you'll need a Doctor to diagnose your problem."

"Some parts of your heart are having trouble being their best.  It's the first sign of trouble, but we caught it in time." Was my swift response, pointing out that the medicine we had administered had cleared the pain, his color was back and he wasn't sweating through his shirt anymore.

"Thank you," the patient says and is loaded into the ambulance after being wheeled by silent LC and the ambulance EMT, me also silent nearby.


Friday, December 9

the Crossover Podcast - Ep 85 - Florida Cry Baby

crossoverlogo300In this week's episode, MC and HM talk about a Florida man (because, of course it's Florida) having his picture sent out on the interwebs and the Florida agency taking some heat about it.

You can read the piece and, more importantly, see the photo here.

What do you think? Any issue posting this photo? Does the copy accompanying the photo matter?

Let the guys know in the comments!


RIP Ron Glass

Motorcop's new YouTube Channel


Monday, December 5

"I Can't Breathe!" you keep using those words...

blog engineI don't think they mean what you think that they mean.

It has been a long time since I asked "You called 911...for this?" mainly because I moved on from that attitude and learned to embrace my inner adult.  No in a creepy way though.


Units dispatched for the 62 year old male, trouble breathing. 0510 hours.  Rescue and Ambulance are responding code 3, I add myself as the Captain just in case we have a serious case.  Hey, sometimes it is and I'm glad I'm there.

This was not one of those times.

We arrive and I grab the suction unit from the rescue and we all head in, still wiping the sleep from our eyes as we weave through the long line of people at the security checkpoint.  When we reach the front the TSA supervisor indicated that he has no idea who we're there for when I spot a man waving to us holding a tissue in his hand.

He sneezes.

"Ah, everytime I fly I get stuffed up, I can't breathe," he says, nose clearly clogged.  He looks like the exaggerated cold and flu commercial;  Red nose, slightly watery eyes, sad look on his face. "I need something for the pressure. I can't breathe."

"What medications are you taking right now?" I asked casually as we slowed the ambulance and set down all the gear nearby.

His answer will not surprise you: "Nutting, why?"  I smile as he is unable to pronounce certain syllables.

We impress upon him the need for common medicines for congestion as all assessments reveal a healthy 62 year old suffering from flu like symptoms.

"Is not da flu, I got my shot." Another wipe of the dry, red nose.  I cringe just thinking about it now.

"It doesn't work that way," my Medic tells him listening to his lungs and giving me a nod.  All clear.

Each time I walk past a shoppe in the airport, I note who carries what medicines, especially for the kiddos.  Out comes the notebook and I indicate shoppes nearby who sell medication that could help his symptoms.

"So you can gib me sumping?" he asks, wiping his dry, red nose...again.  "No," I reply, "how about we walk over and I'll help you choose the right medicine?"

He refused, citing the need to make his flight to avoid missing his connection.  Despite my warnings that the change in pressure while flying may lead to discomfort, pain and an increase in symptoms, he signed our form and went through the checkpoint.

I truly hope he stopped into the shoppe near his gate and got something, otherwise my counterpart at his destination is going to have the same conversation with him.

the Crossover Show - 84 - TN Bus Crash

crossoverlogo300 In this week’s episode, HM and MC talk about the recent tragedy in Chattanooga, TN, in which six children lost their lives in a fatal bus crash.

Please to keep in mind that this happened many hundreds of miles from CA, but has that ever stopped the guys from waxing philosophic and/or offering their insights into what could be at play?

Of course not!

As with many current events, the guys imagine themselves at the scene and they talk about what steps they would take if they were on scene/incident command.

And what about seat belts on buses. Some states require them and some don’t. What about your state? Are your children safe on their bus?


Nope! Enjoy another round of #AskMC!



Saturday, December 3

Happy 150th Anniversary San Francisco Fire Department!

On March 2nd, 1866, after the bustling gold rush port City of San Francisco had burned to the ground not once but twice, the California State Legislature approved "An Act to Establish a Paid Fire Department for the City and County of San Francisco."

Multiple volunteer companies were in place but had not been able to handle the increasing load of fires in the rapidly growing City.

According to the Department's Museum and Anniversary organizing group, April 1866 saw 6 Engines, a hose wagon and 2 ladder trailers ordered from back east, costing a jaw dropping $17,655.  17 horses were also purchased and a full time staff was hired.

When incorporated on this day, December 3rd 150 years ago, the apparatus were staffed as follows:

Chief Engineer Frankilin ER Whitney

First Assistant Chief HW Burkes

Second Assistant Chief Charles H Ackerson

Superintendent of Steamers Daniel Hayes

Corporation Yard Keeper Tom Sawyer (A writer friend of his you likely know)

Fire Marshal John L Durke


Each Engine Company was staffed as follows:





8 extra call men


Each Truck was staffed as follows:




12 extra call men

(No Fireman assigned to the Truck...hmmm)


The first 7 months of operation saw 159 working fires.


I always wanted to be part of an organization with a deep rooted history and I think this timing is perfect.

Happy Birthday, San Francisco Fire Department!