City Slickers 2: The Legend of Cowley's Gold

...or 60 Minutes of Pyrite.

There is no "Golden Hour". There. I said it. Despite the fact that R. Adams Cowley, the BabyDaddy of modern emergent trauma care, made claims to the contrary.

"There is a golden hour between life and death. If you are critically injured you have less than 60 minutes to survive. You might not die right then; it maybe three days or two weeks later -- but something has happened in your body that is irreparable."[1]

Nosuh.

Realizing this subject has been touched upon many times before, I bring it up anyway. The previous authors are likely more suited, and better versed than I am.

The late, great, Dr. R. Adams Cowley is credited with coming up with the concept of the Golden Hour. Dr. Cowley apparently first discussed this concept as a military surgeon during World War II. After years of research and discussion, the Army awarded Dr. Cowley $100,000 to study shock. Thus, the first clinical shock trauma unit in the Nation was born. The unit consisted of two beds, and then later, four. By 1960, staff was trained and equipment was in place. He then used the idea of the "Golden Hour" to convince other physicians to refer and transfer sick patients to his revolutionary "Death Lab".

The "Death Lab" grew in popularity, and effectiveness. In 1968 an arrangement was made with Maryland State Police to start using military helicopters to get patients to the shock trauma unit more quickly. The first medevac occurred in '69 after the opening of the Center for the Study of Trauma, a 32 bed unit.

There is no denying that Dr. R. Adams Crowley accomplished a LOT for the emergency medical community. Just about everything we know about Shock and Trauma can be directly, or indirectly traced back to the work of Dr. Cowley and his associates. Pre-Hospital care exists largely due to the efforts of this man (Maryland had the first statewide EMS system). No one can take that away from him.

He accomplished so much, based largely on an inaccurate theory, that was back up by outdated data.

The original data set Dr. Cowley used to suport his "Golden Hour" buzz-word was from a 1918 study, observing casualties of World War 1.

"In World War I, there was a real appreciation of the time factor between wounding and adequate shock treatment. If the patient was treated within one hour, the mortality was 10 percent. This increased markedly with time, so that after eight hours, the mortality rate was 75 percent."[2]

The study reported the following mortality percentages:

1 hr 10 %
2 hr 11 %
3 hr 12 %
4 hr 33 %
5 hr 36 %
6 hr 41 %
8 hr 75 %
10 hr 75 %

Even looking at these statistics 90 years later, I don't see a strong case for using them to support a "Golden Hour" Theory. But he did, and it worked. People still continue to talk about "The Golden Hour". The Main Stream Media is convinced THAT is what saves lives in Iraq and Afghanistan.

Strokes and Cardiac Emergencies are Time Sensitive. Everything else is outsides the bounds of a time limit. A casualty can die on impact, bleed out in the first five minutes, or have an obvious injury inconsistent with survival. A casualty can also receive a significant injury/insult, render self aid, and sit-and-wait. There are casualties that occur in austere environments that survive significant Trauma, despite the fact that definitive care is hours away.

There is no research to conclusively support the existence of the Golden Hour. It doesn't exist. The deceitful buzz-phrase served it's purpose, but it's time has passed. Please Stop teaching it. Or don't. Whatever.

1 http://www.umm.edu/shocktrauma/history.htm

2. (Santy, P. Marquis Moulinier, Da Shock Tramatique dans les blessures de Guerre, Analysis d'observations. Bull. Med. Soc. Chir., 1918, 44:205)

The Legend of Combat's Cotton Dutchboy - Debunk'd

...or Pulling the Plug on Tampons in Trauma.

There is a frequently cited story of a package being accidentally sent to some Marines in Iraq back in 2004. This care package was intended for a female service member, but somewhere along the pony express, the shipment was rerouted to a Marine line unit. Contained in this package were some feminine products. Not mud masks and loofahs, but hygiene products, like sanitary napkins and tampons. Lo and behold, while out on a convoy, the Marines were ambushed, and took some casualties. Supposedly, some "quick thinking" Marine used his issued ration of critical thinking and crammed a tampon in the wound, thereby staunching the bleeding, and saving the casualties life.

*ahem* Where to begin?

First, a bit of History. In 1914 Kimberly-Clark developed an absorbent wadding product they called "Cellucotton". Made from processed wood, Cellucotton was five times as absorbent as cotton, and cost half as much to produce. This product was used to bandage wounds during World War 1. In 1919, after the War, Kimberly-Clark had the notion of marketing Cellucotton as disposable sanitary napkins. Their marketing agency suggested changing the name to Kotex®, short for cotton textile. Prior to this, women used washable rags to absorb their menses. This disposable alternative took a while to catch on...but catch on it did. Tampax hit the scene in 1936.

You see, lesson one is that first aid dressings evolved into disposable sanitary napkins, not vice versa.

Next, the prospective use of a tampon as a field-expedient dressing has been around for quite some time. So this talk of using them in 2004 during OIF II isn't the first mention. Veterans of Viet Nam, Panama, Grenada, and the Gulf War mention hearing of it. Back when I was PVT ParaCynic, a veritable sponge for the knowledge imparted by the fine non-Commissioned officers of the United States Army, the life-saving trauma tampon was brought up rather frequently by instructors. "Carry tampons, they're great for plugging bullet holes."

Bullshit.

Herein lies one minor dilemma. The "slick-sleeved" instructors that attempted to pass this information off as reputable had never seen Combat. They lived in a post-Cold War theoretical sand table. They had never seen an actual gunshot wound, let alone effectively treated one. Perhaps that's why they felt a birth canal and a bullet hole were interchangeable.

Does anyone reading this blog need me to draw a picture as to the difference between a high-velocity rifle entry wound and a vagina?

The two most commonplace sizes for high-velocity rifles rounds are 7.62mm and 5.56mm. Now, even when you factor in the tendency of the slug to yaw in flight, the hole created by a 5.56mm round is equivalent to the hole created when you push a Bic ink pen through a piece of paper. Although a 7.62mm is 27% larger than a 5.56mm, it's still not a very big entry hole.

Hardly large enough to push a finger into, without eliciting a painful response, and the associated cursing and threats upon your well-being. *pause*

When the Hell did we start encouraging people to [shove, cram, pack] fingers and foreign objects into open wounds? To all the folks that might say "well, it's ditch medicine", or "it's ghetto medicine": Those are two scenarios where we should discourage such practice even more fervently.

Now, the supposed practice is not to pack the wound with sterile gauze, or iodoform, or some other medically acceptable medium. No, they are talking about cramming a wadded piece of "cellucotton" into a hole that is 1/4 it's size, or smaller.


Next, what's the point? What are you trying to accomplish? Whether the entry wound is in an extremity, the chest, the abdomen, or head, it makes no difference. This is a terrible idea. You're not stopping the bleeding. The tampon will not "expand and exert pressure on the source of any bleeding". You are not "sealing the wound". You have now introduced a fibrous foreign body, into an otherwise "clean" wound tract.

Now, as a component of a dressing, I suppose it's not too terrible of an idea. They're absorbent, and might make a good addition to a pressure dressing, outside of the wound.

Mainstream media isn't helping matters. There was recently a video game trailer released, Army of Two, in which "buddy aid" consists of using a tampon to revive your teammate. ugh.

Satan's Little Cotton Fingers have no business in the management, [field, ditch, ghetto] medicine, or otherwise, of penetrating trauma secondary to high velocity lead poisoning. Much to my chagrin, however, this is another one that is not going to go away any time soon.

Back

I have returned from my brief [vacation, hiatus, escape]. I have a post in the works, but it's another rather long one, and unlike some of the people to the right, I can't do it all in one sitting. That is why they're Better than I...

Overheard

"As you can see from this lengthy, oft-photocopied document from my physician-healer-shaman, Dr. Web, MD, from www..., err, I mean, CANADA, I'll need 125mg of Demerol, 50mg of Phenergan, a turkey sammich, 14 blankets, some extra pillows, and the air conditioning turned up on blast. Also, I'll need access to an AC outlet, so I can plug in my laptop. I must resume flaming ERP, and flooding his Blog with my extensive experience and medical expertise. He just doesn't understand me. I'm in P-A-I-N. Ooooo, Springer's on."

Standing Trendelenburg on it's Head

He didn't work on Shock, and neither does his position, Dammit.

Friedrich Trendelenburg (May 24, 1844 – December 15, 1924) was a German surgeon and son of the philosopher Friedrich Adolf Trendelenburg. A number of medical treatments and terminologies have been named for him. He is perhaps best remembered for the Trendelenburg position in which the patient is placed on a bed which is put into incline such that the patient's head is lower than his feet. Trendelenburg first used this technique in 1881 for an abdominal surgery. (Wiki)

During World War 1, Walter Cannon, an American physiologist, and the same guy that coined "fight-or-flight", as well as developing the theories of homeostasis, popularized the use of Trendelenburg position as a treatment for Shock. 10 years later, he changed his mind.

Ladies and Gentlemen, in case you were absent, sleeping, or ignorant during that block of instruction, the First World War, the Great War, the War to End All Wars took place primarily in Europe from 1914 to 1918. The Treaty of Versailles was signed 28 June 1919.

WW1 ended Ninety years ago. So, at the latest, 80 years ago Dr. Walter Cannon decided he had erred, and rescinded his recommendation for the use of Trendelenburg position in the treatment of Shock. There are 12 listed surviving Veterans of that Conflict. Unlucky Thirteen if you count the Position that inspired this post.

Trendelenburg is still a fixture in initial management of Shock. Despite the fact that it doesn't work, and is potentially more harmful. The theory WAS that by elevating the lower portion of the body, either through Trendelenburg Position or passive elevation of the lower extremities, one could effect a form of autotransfusion, in which blood would be shunted "to the core". In the few studies that support this belief, performed on healthy subjects, these positions increased left ventricular filling, stroke volume and cardiac output, but the effects were transient and returned to baseline within 10 minutes. Conversely, numerous studies show that lung volumes are compromised by the weight of the viscera upon the diaphragm, and increased stress is placed upon the right ventricle. There is also evidence of increased risk of retinal detachment, brachial nerve paralysis, and of course, cerebral edema.

What's even more worrisome than the continued insistence of Trendelenburg, is the lack of elucidation. Individuals are taught to use Trendelenburg for Shock, but never which Type of Shock this nonsense supposedly works on.

Is it intended for Obstructive Shock? No, only relieving the obstruction will help. But you go right ahead, make that PE, tamponade, or pneumothorax dependent. It seems like a good idea to me.

Is it intended for Distributive Shock? As in neurogenic, septic, or anaphylactic shock. Nope, turning a patient upside down doesn't make "the Tank" any smaller. However, every patient with wheezing, urticaria, and profound angioedema LOVES being stood on their head.

Is it intended for Endocrine Shock? Does gravity have any effect on hormones?

Is it intended for Cardiogenic Shock? Like patients who can't breathe, myocardial infarction patients, and CHF-ers LOVE lying down. Even better if you can INCREASE the strain on their heart. Choke yourself.

Trendelenburg Position was intended for use during Hypovolemic Shock. Back in 1917-ish. Then Dr. Cannon changed his mind. Yet just about every where you go, "lay 'em down, raise their feet" is a given when it comes to initial management of a Shock patient. FR, First Aid, BSA, Brady, DOT, AAOS, NR, U.S. Army...

During the second stage of Shock, the Compensatory Stage, the body employs multiple physiological mechanisms in an attempt to reverse the condition. These include neural, hormonal, and bio-chemical mechanisms. I'm not going to get into Acid-Base balances, or renin-angiotensin, etc.

What I will discuss is the action of the carotid baroreceptors. The baroreceptors in the carotid arteries detect hypotension, and signal the release of adrenaline (epinephrine) and noradrenaline (norepinephrine). These are catecholamines with dual roles as hormones and neurotransmitters. Noradrenaline predominately causes vasoconstriction (α1) with a mild increase in heart rate, whereas adrenaline predominately causes an increase in heart rate (β1) with a small effect on the vascular tone; the combined effect results in an increase in blood pressure.

The body is an amazing machine. It manages to compensate, quite well. However, by throwing the legs up, or standing someone on their head, you manage to deceive the carotid baroreceptors into thinking the body has adequate blood volume, and pressure. In turn, they do not trigger the release of catecholamines. The body doesn't get the message to compensate. As soon as that Transient effect of standing them on their head subsides, you succeeded in helping the body skip right through Stage 2 of Shock, and right into Stage 3, the Progressive stage, or more ominously: Decompensation.

There are, however a few appropriate uses for Trendelenburg.

• Abdominal surgery (HOLY SHIT, that's what it was intended for!)
• Central Venous Line Placement in the jugular or subclavian veins. I'll extend that to EJ's for you Paramedics, but the arms of a stethoscope kinda work better.
• Reducing abdominal hernias. For the same reason it's used in abdominal surgery.
• Waterboarding. Yeah. Because of it's negative effects on breathing and airway. Fuckin' Terrorists.
• Various obstetric and gynecological procedures, or practices.

As Usual, Dr. Bledsoe knows what's up.

• Martin JT. The Trendelenburg position: a review of current slants about head down tilt. AANAJ 1995;63:29-36.
• Ostrow CL. Use of the Trendelenburg position by critical care nurses: Trendelenburg survey. Am J Crit Care 1997;6:172-6.
• Taylor J, Weil MH. Failure of the Trendelenburg position to im-prove circulation during clinical shock. Surg Gynecol Obstet 1967;124:1005-10.
• Sing RF, O’Hara D, Sawyer MA, Marino PL. Trendelenburg position and oxygen transport in hypovolemic adults. Ann Emerg Med 1994;23:564-7.
• Terai C, Anada H, Matsushima S, Shimizu S, Okada Y. Effects of mild Trendelenburg on central hemodynamics and internal jugular vein velocity, cross-sectional area, and flow. Am J Emerg Med 1995;13:255-8.
• Bivins HG, Knopp R, dos Santos PA. Blood volume distribution in the Trendelenburg position. Ann Emerg Med 1985;14:641-3.
• Sibbald WJ, Paterson NA, Holliday RL, Baskerville J. The Trendelenburg position: hemodynamic effects in hypotensive and normotensive patients. Crit Care Med 1979;7:218-24.
• Reich DL, Konstadt SN, Hubbard M, Thys DM. Do Trendelenburg and passive leg raising improve cardiac performance? Anesth Analg 1988;67:S184.
  
• Terai C, Anada H, Matsushima S, Kawakami M, Okada Y. Effects of Trendelenburg versus passive leg raising: autotransfusion in humans. Intensive Care Med 1996;22:613-4.

Needless ShoutOut, Rogue

Well, apparently it's going to be necessary to post a bit more often. Rogue Medic not only referenced my most recent entry, but he also placed my name in the subject line. AD read his post, and gave him some "linky-love" which has subsequently caused more than a few extra people to stumble upon my mutterings.

Now, more than 2 people read my writing. Accordingly, I must write more.

And so it begins...

Tourniquets, Trendelenburg, Tampons, Toilet Paper

...or Four Things that Get me fired up. This will likely be a three or four part post...

Certain subjects inevitably come up whilst discussing Trauma management. This is especially true when discussing such things with individuals in the Military. Two of the subjects I'm referring to are controlling bleeding from an extremity, and preventing/controlling shock.

It's common knowledge that exsanguination from extremity wounds in the Number One cause of preventable death on the Battlefield. The Military is finally getting away from it's complete and total fear of effective tourniquets. From the time we take our very first Boy Scouts and Brownies First Aid class, we're taught to apply a dressing, apply direct pressure, utilize pressure dressings, use pressure points, elevate, and as a very, very, OMIGOD Don't Even THINK about it, last resort, tourniquets are mentioned. Can tourniquets cause tissue damage? Yes. I'm not here to deny that. Is there the potential for neuropathies, necroses, and no-mo-hands-and-footsies? Absolutely. Shutting off distal blood supply is no joke. It's a very serious procedure, applied in some of the most dire of circumstances. Some First Aid guides don't even mention Tourniquets. FR, EMT, and even Paramedic courses skim over them. In Paramedic school they'll discuss "back in my day, we used to push enough epinephrine to give a rock a pulse," giving every code bicarb, or in the more recent past, stacked shocks. Science has shown that those practices aren't necessarily effective, and don't save lives. Yet more time is spent mentioning THEM, than the appropriate and effective application of a tourniquet.

Tourniquets Save Lives. You can read whatever studies you want about the harm done by a tourniquet. Paresthesia, amputation, worst case scenarios. People with those outcomes are Alive. It's common knowledge that a properly applied tourniquet can be left in place for greater than 4 hours before irreversible damage occurs. Ask a surgeon. They perform procedures all the time with tourniquets in place.

Properly applied. They save lives. Damage is minimal when properly applied. So why are we so afraid of them? Why don't we embrace the fact that they save lives, and spend time actually LEARNING how to apply them properly? I challenge you to go to your crew room, your next refresher, ask someone at the ER, or your new preceptee what they would use to appropriately apply a tourniquet, and how they would go about doing it.

You'll meet quite a bit of resistance. There will be people that insist that they'll never have to apply a tourniquet, and no one ever should. I mean, 4 liters of NaCl is a good replacement for 4 units of blood, right? Tourniquets are evil, right? They are harmful and too much can go wrong.

Now try to have a conversation with the same people about emergency airways, and worst-case scenarios. Discuss intubation, S.L.A.M., crichothyroidotomy, translaryngeal jets, retrograde intubation, bougies, etc. After all, those can be intense, but we're taught skills to manage the airway.

Painful Truth for all you heroes out there. Patients can often be killed iatrogenically by airway management, mismanagement and overmanagement. The same is not said about bleeding control. You don't kill patients by "overmanaging" their bleeding. This is not to say airways don't save lives. But I think I learned somewhere in Physiology that blood might be important too.

We are taught When, Where, Why, What, Who, and How to Intubate. We know the consequences of a poor intubation, and are taught to recognize when things don't go according to plan.

We are taught that tourniquets are a last ditch effort, and we should exhaust all other methods before resorting to a tourniquet. Well my friend, while you're holding pressure for several minutes to see if it will work, your patient has lost half their blood volume. We should be teaching people how to recognize when a tourniquet is necessary. You can assess bleeding fairly quickly, and figure out what tricks are going to work. If you can't, your training, and/or your experience, has let you down. Time is of the essence. When, Where, Why, What, Who, and How.

The answers are not Never, Nowhere, None, Nothing, No one, and Not. Quit teaching it that way. Common Sense has been discarded for Common Practice for far too long.

Outdated tip of the hat to TOTWTYTR

Two pair of boots.

Although at present I am a desk-riding, coffee swilling, paper-pushing, lamentable Pogue, I haven't always been. I have had the fortune of experiencing two very different worlds. I am a Medic, and I am also a Paramedic. When I say "Medic", I mean: ["Doc", Corpsman, Combat Medic, Healthcare Specialist, Medical NCO], that is to say, Military trained, combat tested. When I say "Paramedic" I mean the obvious. I am both. This is not to say this is rare, but it is certainly not the norm. The majority of my EMS counterparts have not seen the types of things I've seen as a Medic. On the other hand, not many of my Medic colleagues have the training, or the experience, or the background of dealing with the things we see and treat as an Advanced Life Support Provider on the streets.

The two worlds are very different, and not necessarily complementary. As a matter-of-fact, none of my jobs, though related, are necessarily complementary, but that's not the point right now...

My counterparts in both careers frequently discuss the advantages of being dually trained. For Me, it works. I enjoy both, I try to excel at both, I get a little taste of everything. However, I don't necessarily believe that being dually trained will make you better at either job.

Combat Medicine is, imagine this, predominately Trauma. Penetrating. Burn. Blast. Primary, Secondary, Tertiary impacts. Barotrauma. Life. Limb. Eyesight. Every incident is approached with Triage, and mass-casualty potential. GSW to the thigh? Hold pressure, self-aid/buddy-aid, return fire, I'll get there when I can. Scene safety is a little different in these parts. Quit whining, put rounds downrange. Suppressive fire for your buddies, gimpy. If you let them down, I have more patients.

Medical problems exist, but they are not the bulk of the load. Heat Exhaustion, Behavioral Emergencies, the occasional First Sergeant with Chest Pain. These are exceptions to the rule.

Street Medicine, as you all know, is Medical ailments, with the occasional trauma mixed in. ABD Pain, Asthma, COPD, CHF, CP, Diabetes, DOE, DK, FDGB, GIB, HA, LOL, N/V/D, SOB, Syncope, TMB, SI, NAD, WTF. Trauma is generally a small slice of the pie. And what trauma we do get for the most part is MVCs, assaults, Falls, various blunt trauma, and the occasional penetrating trauma.

Trench Medicine resides somewhere between where [PHTLS, ITLS, BTLS] left off, and ATLS begins. The Medic is trusted to do whatever it takes, in the absence of orders. Your assignment is to save lives. If you don't have a PA, or a MD, or a Senior Medic, you're It.

Street Medicine = ACLS + PALS + DOT + PEPP + AMLS + Protocols + OEMS x 'Handcuffs'. Patient needs a surgical crich? No way. Bougie? Not in your Protocols. This post is not about protocols though. They have their place, and they have their reasons. Besides, Rogue Medic does a better job talking about them.

To me, the differences between these two Worlds is abundantly obvious, crystal clear. Yet it seems to some folks, the difference between Urban and Rural medicine is more apparent than the difference between Military Medicine and Street Medicine.

Civilians, for the most part, don't suffer from shrapnel wounds. Their MVC wasn't caused by an explosive-formed projectile from an improvised explosive device.

Soldiers, for the most part, shouldn't have underlying cardiac conditions. They are not diabetic. They've never even heard of Fibromyalgia. They are otherwise healthy-ish, and between 17 and 40 (for the most part...)

Civilian ailments require thought. Differential diagnoses. (Sorry...clinical impression...) Their illnesses and plights run the gamut. Soldier's life threats are typically pretty obvious.

Trauma vs. Medical. Action-Thought vs. Thought-Action.

Discuss?

Sweaty, Inconsiderate, Offensive, Effeminate

...or "Things that Bother Me at the Gym".

Of late I've gotten off my lazy ass, and begun somewhat of a fitness regimen. Now, I use "lazy ass" somewhat relatively. I wouldn't categorize myself (past or present) as your stereotypical EMS Provider. I'm sure my readership (all 2 of you) will agree, that [Providers/Professionals/Employees/Workers] of Emergency Services [Public Safety] , in general aren't always in tip-top, peak, physical condition.

Conversely, I am not a Gym Rat. I don't work at the gym, I don't spend half my life at the gym, I don't receive my cable bill at the gym. Everything in moderation. Some of those freaks need a social life, or a hobby that doesn't involve rosin, full-length mirrors, and Bosu balance balls. But I digress. The following is a list of things that irk me at places of fitness, in no particular order.

Mandex. Pretty much self-explanatory. Chances are, if it was ridiculed 5, 10, 15, even 20 years ago, it's probably still a No-Go. Don't get it twisted, just because UnderArmour and similar product lines are all the rage, doesn't mean your lower half needs to be wrapped in painted on synthetics. Unless you're in contention for the Tour de France, involved in some sort of aquatics, or are an up-and-coming Luchador, leave the Lycra to the Ice Capades. Even if you participate in an activity where form-fitting clothing is appropriate (i.e. Triathlon, Greco-Roman Wrestling), it still does not belong in a gym. Sorry Mr. Unitard, but if you can buy your gym clothes at the same store that sells a man-sized Mr. Incredible costume, there's been some sort of disconnect. Hell, even Richard Simmons had enough common sense to wear man-panties to cover up the unsightly protuberance of his grapes.

For a moment, let's remain on the subject of the jewels. It's warm in the gym, you're going to get hot, and perspire. Your Boys are probably going to descend a bit lower than normal in an effort to keep your swimmers at the appropriate temperature. Please keep that in mind when making your apparel selection ante-workout, or when pondering whether "today is a good day to go Commando". I believe I speak for everyone when I state we'd rather not see your knackers pasted to your left leg in the middle of a workout. Find out where Spandex Guy bought his mantyhose and wear some support under your daisy dukes. Thank you muchly.


In MY society, where we shower regularly, cologne and perfume are purchased with two people in mind. The person who is wearing it, and the person They are trying to impress. Maybe some folks are trying to impress people at the gym, or trying to pick someone up, but the over-powering cologne is nauseating. In any setting it's inappropriate, but a gym should smell like sweat, disinfectant, rubber, and metal. Hey, Davidoff, it's a place of fitness, not the goddamn center aisle at JC Penney. Your eau de toilette is awful, tactless, and inconsiderate. And as far as the hottie on the elliptical is concerned, you'd be better off with chloroform. P.S., Let me know how that hair gel works out IF you manage to break a sweat.


Proceeding in the vein of attempting to impress folks, STOP Posing. STOP Strutting. You might look good. You might not. Yay! There're lots of mirrors. I understand that two large groups of people that frequent gyms are the insecure and the overconfident. EVERYONE wants to see their improvements, and their hardwork paying off. I don't hold that against you. Regardless, striking Mr. Olympia poses in the mirrors, or pacing laps across the gym while strutting like a peacock is obnoxious. Chances are, if people ARE looking at you, they will snicker, and make snide remarks. If that's what you're going for, drive on.

If YOU are the person who's attention has been captured, don't gawk. It's infinitely more sketchy to stare at someone at a Gym than it is at the mall. Seriously, people are half dressed, sweaty, and more vulnerable. You're are the very reason Curves, and other Female-Only gyms have opened.

Everything you need to know, you learned in Kindergarten. If you use something, put it back where you found it. It's not that difficult to place things in their proper place. Why is it that as soon as people enter a Gym they become Anal-expulsive? It seems like every weight rack has an odd number of each measurement, and there are weights randomly strewn about, in places they don't belong. I shouldn't have to go to the Spinning room to find a plate, nor should you have the curl bar in the pilates area. And quit leaving equipment on the floor.

Adam Sandler throw-back, you know, before he started doing romantic comedy. "Having Sex, or lifting weights?" Quit making so much damn noise during your workout. Grunting out the LAST rep in order to avoid moving your bowels is forgivable. After all, I wouldn't want you to soil those sweet control tops. But groaning and grunting on every repetition is not ok. It sounds like a tennis match in a roman bath house.

That's all for now.

A Lack Thereof

EE apparently misses reading my sweet voice, and has queried whether I would ever write again. Yes, I reckon I will. It's been a frustrating few weeks. Between battling the urge to throttle civilians, swearing at my baseball team, and trying to square away finances and paperwork, among other demons, I haven't exactly been in a blogging mood. My cynicism is palpable, but it's not FUN cynicism.

Hopefully, as I wander through other people's blogs, or get out a bit more, something will strike me as subject matter. Until then...

Would you like Blog Fodder with that?

Being from the Northeast, part of my morning routine typically includes a trip under the Pink and Orange sign of Dunkin' Donuts. Trips to any type of fast food, coffee shop, or convenience store will inevitably give you reason for pause. The service gets progressively worse, the [people behind the counter] get more and more "interesting", and for some reason the wait seems to get longer every day.

Whether I visit the drive-thru or the counter, my order is pretty standard, pre-meditated, and delivered clearly, concisely, and in some semblance of the English (perhaps an issue) language.

PC: "G'Morning. A Large [hot, iced] coffee, black, with 2 Equal, please."

Occasionally, I'll throw in a flavor shot. I might even double my order. I do not, however, deviate from the formula. I tell them what cup to grab, what temperature, and what to put in it. I intentionally order in that sequence because that's the sequence in which they will perform the tasks required. I do not speak quickly, and I intentionally annunciate (I remember my previous experiences). Further, I generally visit the SAME shops. Usually more than once a day. Now I'm not saying remember me, but shit, remember past orders that you've screwed up (MINE).

Somehow, I don't think the Franchise owners and Management take into account how important coffee is when they go through the hiring process. Seriously.

Ok, now on to what motivated me to write a post about my morning routine. As I placed my order in the drive-thru the other morning:

PC: "I'll just have a LARGE, ICED coffee, BLACK, with two(2) equal, please."

The tinny, electronic voice comes back with:

DD: "Would you like to try our new flatbread sandwich?"
PC: "Nope. Just the coffee. Thanks."

Now, I've noticed this is common practice just about every place you go. Little buttons that say "If I don't offer you a strawberry-mango smoothie, IT'S FREE". Drive-thru attendants "Want to try a muffin today?" That poor little "Ding-fries-are-done" kid offering "an apple pie with that". I get it, it's what they do.

But has anyone EVER been inspired via drive-thru to try something like that? Much less a "flatbread sandwich" from a coffee shop? Honestly? I've never heard something from that little speaker that just tickles me enough to say "Well, the picture turned my stomach, reading the description nauseated me, but now that you MENTION it, and I hear you asking me if I wish to try it, HELL YEAH, I'll take TWO!"

Poster Children

Are you fucking kidding me? I loaded the JEMS Web Site this morning, and was greeted by an "interesting" photo. Now, I'm not going to get into the finer points of splinting, or the fact that we "stabilize" C-Spine FAR too often. Those topics have been covered ad nauseum.

That being said, how is it that the Journal of Emergency Medical Services feels it is appropriate to use THIS photo for an article on splinting procedures:

Whiskey Tango Foxtrot, over.

Emergency Medical Slobs

You've all seen them. Shirt unbuttoned, t-shirt stretched out with the lapel mic, mustard stains, boots [un-tied, unzipped, un-laced], unshaven, unbathed...the list goes on.

Sometimes you'll see them in line at the Dunkin' Donuts. Sometimes at the ED charge desk. Sometimes sitting on the diamond plate of their [emergency response vehicle], smoking a cigarette. Looking like dogshit.

There is not a valid excuse that any of you creative writers could come up with for these people looking the way they do. I don't give a damn if they're on the back-slope of a 48 hour shift, I don't care if they just worked a code for 48 minutes, I don't care if the ambient temperature is 127 degrees Fahrenheit, and it's even hotter in the back of the [emergency response vehicle].

Don't get me wrong, if you're on scene for a prolonged extrication, I understand if your shirt comes untucked. I won't hold it against you if you're actively doing push-ups on the 350lb, 3 decker carry-down code, and you look a little 'tousled". If it's late one prom night, and you just got painted with the baked ziti and rubber chicken, mixed with a little Mike's Hard Lemonade and bottom shelf tequila, I understand.

But that's not the case.

At 0715 the other morning, I witnessed your stereotypical stretcher-slinging mule. I use derogatory terms to refer to this individual because that's the image they conveyed. Individual weighed in at a modest 300lbs. Shirt untucked, unbuttoned. Pants wrinkled, no belt, and dipping below the waistline. There is no reason to look like this coming out of Dunkin' Donuts at 0715. I know full-well that this particular [emergency vehicle] was going to a local post/detail assignment. Anyone wanna chime in with some possible reasons for looking like that?

I take pride in my appearance. It's how I was brought up. It's my background. It's one of my calling cards. There are times where I look a little disheveled, but only in the middle of a call.

-If you have time to light a cigarette, you have time to tuck your shirt in.
-Unbuttoned shirts DO NOT have a slimming effect, lardass.
-Wear a belt. There is nothing professional about plumber's crack, or a drag-chute.
-Laces and zippers are devices to fasten footwear to your feet, use them. If they're broken, replace them.
-You don't HAVE to shine your boots, but at least attempt to maintain their intended color. Scuffed up boots don't make you "salty", "experienced", or "old school".
-Your shirtfront is not a napkin.
-If you have holes in any part of your uniform, replace that component.
-T-Shirts stretch. Do not hang things from the neck of your t-shirt. No one wants to see your nipples through your neck hole.

Every single EMT or Paramedic has heard co-workers lambast (verbally of course) "newbies", "wackers", and "sparkies" for trying too hard to "look the part". They ridicule Bat-Belts, wacker pouches, and the habit of carrying too much gear. However, never has an over-enthusiastic trainee detracted from our professional image simply because they have 2 sets of trauma shears (...and a flashlight, and a rappeling harness, and a gas-mask...but I digress). It's not often enough that a fellow EMS worker makes a comment, pulls aside, or outright embarasses someone for looking like Roseanne's husband Dan in an EMS uniform.

But you're right. Calling the [emergency response vehicle] by a slang term is what truly detracts from our professional image. After all, REAL bus drivers would never look this sloppy.

David Bowers wrote an article back in '05, just saying.

Colloquialisms

TOTWTYTR doesn't like it when you call your Emergency response vehicle a "bus". In the spirit of sticking with topics presently in my head, I will discuss slang terms. Besides, I like discussions, and none really occur on this four day old blog. Maybe poking the hornets nest will bring me some more company.

Personally, I see no harm in such terms, I like colorful language, and slang. But then again, I come from a mixed Mili-Fire-Medi-etc background, and slang terms, like potty mouth, are a fixture. I do agree that in the wrong arena, or context, slang terms (just like f-bombs) can detract from a professional image, however, in other settings it is harmless.

Obviously, on-scene, using slang can come across as unprofessional. You generally wouldn't refer to a "patient well-known to your facility" as a "frequent flyer" to the patient, their family, or in your entry note, but they are what they are. In the [station, garage, quarters, crew-room, barn, base] you might discuss "LOLFDGBs", "welding", "skells", "tubes", "darting", "sticks", "jakes", and "blue canaries". When, on scene, you really mean "elderly woman s/p fall", "cardioversion", "less-fortunate, unemployed, unbathed citizen", "advanced airway", "needle thoracentesis", "intravenous attempts", "firefighters" and "law enforcement officers". No harm in the appropriate arena. I'm pretty sure none of your co-workers are going to gauge your professionalism based on verbage and dialect, just like they probably won't be offended if you say "fuck-fuckity-fuck-fuck". However, in a patients [house, apartment, car, scene of emergency, domicile] you probably ought to sideline such terms. Same thing with in the ED.

Other terms are harmless, regardless of the setting. Some terms that vary from region to region, job to job, person to person, are not offensive to anyone, but may cause some confusion. Despite the fact that NIMS and ICS are the standard, you'll never take the dialect out of emergency services. You do, however, need to be mindful of it, just as you need to be mindful of slang terms on-scene. I can think of a thousand examples of such dialect within my experience, I won't bore you with a list.

"Hey Tim, go to the [truck, rig, rescue] get the [jump-kit, first-in, aid-bag] the [monitor, defib, lifepak] and the [stretcher, cot, bed]."

Ambulances have MANY different titles. I call the various Units I run on "Ambulance-[Number]" or "A-[number]". "Paramedic-[Number]" or "P-[number]. [Town] Rescue, or Rescue-1. CJH in Brick City refers to his units as "MIC-4", or 2404 or some variation thereof. We all have our labels on the radio. As long as you know what vehicle to get in, and [dispatch, control, fire alarm] knows who is assigned, labels don't make much of a difference.

What you call the vehicle in the inner sanctum doesn't matter. Just don't be a jackass and act unprofessional in front of outsiders.

Personally, I am far more offended by the term used in some regions for a handicapped vehicle with a lift. We call them "chair cars" or "chair vans" in my region. I've heard the term "Handi-Van" utilized. But tell me, WHO THE HELL thinks it's OK to call them "Invalid Coaches". Yeah, this means you New Jersey. That shit ain't right.

Back to ambulances, maybe, growing up around the [industry, profession, lifestyle] I had a skewed perspective, but I always pictured a Wheeled Coach when I sang...

"The wheels on the bus go round and round..."
"The doors on the bus go open and close..."
"The suction on the bus goes swish swish swish..."
"The siren on the bus goes waaaaa-waaa-waaanh..."
"The Psychs on the bus go 'I AM JESUS!"

Oh wait.

Blogroll'd

EE over at Backboards and Band-Aid blogroll'd me. I was gonna inquire as to her reasoning, but then I read "bitch, don't fucking ask me why" and thought better of it.

Getting added to a blogroll is cool. But I don't have anything [entertaining, witty, enlightening, or intelligent] to say. Which is considerably less cool. Further, she categorized my mutterings as EMS-related. YES I AM. Just not now, or for the foreseeable future. It has been too long since I rode backwards. This fact bothers me. I have not obtained vitals, initiated an IV, dodged reverse peristalsis, or macarena'd with a psych patient, in what I consider to be an uncomfortably long time.

I am something I hate. I have a desk. I have a cup full of pens on that desk. I have a stapler (albeit not a Swingline, I wish Milton would burn this bitch down). I have one of those big blotter calendars. I have a whiteboard (that doesn't violate HIPAA). I work 0730-1730, Monday thru Friday, with occasionally weekends. What the hell am I supposed to do with a lunch break?

I miss the road.

Emergencies

emergency -

1. A serious situation or
occurrence that happens unexpectedly and demands immediate action.
2. A condition of urgent need for action or assistance:
a state of emergency

As a Paramedic-Firefighter, one might automatically assume I'm writing this post regarding definition #2. After all, that's what we do. However, in my present, lamentable, strictly administrative role, there is very little of what we would consider "urgent need for action". Definition #1 may very well need the word "perceived" wedged before "serious".

You see, despite the fact that I am currently in the aforementioned "administrative position" (read: POG, desk-jockey, etc) , people constantly use the word "emergency" to refer to their present situation.

*Cliche Alert*: Piss-poor planning on your part does not constitute an emergency on mine. Period. If you dropped the ball, this guy shouldn't have to pick it up for you. I can, and occasionally will, but do not assume that is my responsbility.

Further, do not call an emergency contact number, refuse to give your name, claim it's an emergency, and then expect further assistance. It doesn't work that way. If you have an emergency, answer the damn questions.

Next Post: DA Civilians

Blocks, big mouths, big livers, big problems

Hey, Dude, MOVE.

Ambulance Driver does a nice job breaking down AV Blocks in terms anyone with a pulse can understand.

Rogue Medic is right on with this Rant. Hell yeah.

Woman lie, apparently size does matter. Only after they both went their separate ways and spread their Hep C, though. Bravo.

I'm no mathematician, but this seems moderately problematic.

WTF? Is this for real? I can only hope that site is designed as a trap for such criminals. Debunked x2 via Snopes. Whatev.