Man With Swollen Arm That Wasn’t Actually Swollen: “Not a drop. I been sleeping all day.”

AD: “You’re slurring your words, unsteady on your feet, and your breath could knock over a moose. Plus, there’s a nearly empty half-pint of Taaka in your pocket. You wanna try that answer again?”

MWSA (insistently): “Man, I ain’t had a drop to drink all day. I got drunk off my ass yesterday, but I been sleeping it off all day today.”

AD: “And what day is today?”

MWAS: “Wednesday night!”

AD: “I’ve got bad news for you, Sir. It’s Tuesday afternoon, and you’re still drunk.”

You know, most people that drink heavily tend to lose big chunks of time when they’re drunk. It takes a special talent to gain 30 hours when you’re in the bag.

Ron and I discuss the bane of his existence, the NREMT pediatric airway skills station, talk about medic math, and answer a few listener questions.

We're looking for a new Newbie, folks. As you may have noticed from the infrequency of new episodes, Ron and I are running out of new things to talk about.

So if you're an EMT student (we'd like real newbies, not people with years of experience just entering medic school) with an engaging on-air personality and the time to commit to a weekly podcast all the way through paramedic school, drop us a line.

Better yet, send us your listener questions and express your willingness to discuss it on air, and we'll treat it as your live audition.

So make with the clicky and send us your questions!
 

KatyBeth (hitching up her pants): “I can’t help it, it’s genetic.”

AD: “Genetic… how, exactly?”

KB: “Mom says I inherited the Grayson butt.”

AD: “There is no such thing as the Grayson butt.”

KB: “Uh huh. No butt, bad math skills and no rhythm. That’s my curse from your side of the family.”

AD: “Remind me to have a talk with your mother when I bring you home.”

By way of Mostly Cajun, I learned of Calibre, a freeware e-book reader and converter that is capable of converting other e-book formats into Kindle’s format.

So hit up Barnes and Noble, Sony or iTunes for a copy of the book, and then use Calibre to covert it for use on your Kindle.

And thank you for your contribution to the Double Wide Fund.

(Click on the book cover for the purchase link.)
 

For those of you unfamiliar with the history, the book was published by Emergency Publishers in fall of 2005. It was written in first person, present tense narrative, much like a journal. My wife left me unexpectedly in September of 2004, and in the next four months I needed some way of passing the nights on an ambulance between calls, without driving myself crazy over the demise of my marriage.

The book was it.

The blog started in December 2006, mainly to promote the book and to polish my writing style. About a year after my blog started, an editor from Kaplan Publishing, a dvision of Simon Schuster, happened across my blog, and offered me a publishing contract. When told that I already had a book in print, he asked if I could get out of my contract with Emergency Publishers, and allow Kaplan to publish the book under their own imprint.

Lou Jordan, my friend and publisher, gave me his blessing and terminated my contract, and I signed with Kaplan. Lou had accomplished his stated goal, which was to give me my start, and get me noticed by the big boys.

Kaplan cleaned the book up a bit, changed everything to past tense, and published it in hardcover as En Route: A Paramedic's Stories of Life, Death and Everything In Between. They included a story from the blog as an epilogue, which I think really wrapped up the book well.

But they also deleted a dozen or so chapters, because my editor at the time (since gone from Kaplan) felt that they were too controversial, and that their deletion would not hurt the book.

I disagreed, because I felt that a) the chapters on the chopping block weren't that controversial, and b) they contained most of the narrative thread that wove the rest of the chapters together. Without them, the book read like a collection of short stories.
 

I was overrruled, and the book was published without the deleted chapters. Since then, my concerns were validated because most of the criticism of the book centers on exactly what I and Kaplan's own proofreaders warned; it felt like pieces of the book were missing.

A year later, they released the book as a trade paperback under yet another title, A Paramedic's Story: Life Death and Everything In Between, causing some of my readers to buy it, mistakenly thinking it was a new book.

So if some of you out there have two copies of my book, I apologize. I just wrote the darned thing, someone else markets it. If you'd like to have your copies signed, drop me a line and I'll tell you how to send it to me for an autograph, provided you pay for the shipping.

I don't make any royalties from sales of the original book, but if you've already got a copy of En Route or A Paramedic's Story and wondered what was missing, this one will answer that question. 

And you can't beat the price.

Enjoy!

In my Lines In The Sand post that torqued TJIC enough that he equated me with a Nazi death camp guard, I stated that words have consequences, and that the consequences of threatening to kill yourself may include the cops or EMT's holding you for a psychiatric evaluation against your will. Still, let's talk about how it happens.

When commenter Aaron suggested that I need to find a new line of work that doesn't require me to violate people's civil liberties, I replied that being a paramedic isn't just a line of work for me, it's who I am.

TJIC's rejoinder:

How is this argument not exactly the same one that a member of the religious police in Saudi Arabia would make?

"Worshipping Allah through my work is the most important thing in my life. Don't want me to beat you with a stick? Fine. Just don't speak your theological doubts out loud."

Why, exactly, is your self actualization more important than my liberty?

I see that you still haven't developed any sense of proportion to go along with your lack of manners, TJIC.

Because beating someone with a stick for apostasy is exactly like taking a psych patient to the Emergency Department for evaluation.

Because saying "1 down, 534 to go," is exactly like actually firing a shot at the President, right?

Still, let's talk about how it happens.

I have to have a credible threat, first of all. The patient has to admit to threatening self harm, or a credible witness has to attest to it. That means someone willing to sign an affidavit or otherwise give a sworn statement to police, or identify themselves by name on a 911 tape, etc.

Louisiana law carries substantial criminal penalties for swearing falsely in this regard; up to one year of imprisonment, which may include hard labor, and up to $1,000 in fines. I have seen people charged with this, when their part in the drama play included making false statements to the police.

But if the patient himself says, "Yeah, I said I was going to cut my wrists, but I didn't mean it," we have no way of knowing which part of that statement is false. You don't get to take it back.

Words have consequences. And no, those words have to constitute a credible threat, not something like the example you cited, "If I have to eat one more bite of this leftover soup I'd be better off dead."

There's your absolute lack of proportion again.

Likewise, if I have a specific threat but reported by an anonymous source - "Hey, 911? I just heard somebody shouting at 123 Anywhere Street that they were gonna off themselves by taking all their pills at once." – and I find a patient with slurred speech and lethargy denying they made such a claim, but with an empty vodka bottle and an empty bottle of prescription painkillers nearby that should still have 28 pills in the bottle…

… then yeah, I am going to cart that patient's lethargic ass off to the hospital, no matter what they say. And I'm going to sleep like a baby afterwards. If that makes me a moral coward and a tool of government oppression in your eyes, so be it. Your approval isn't necessary to my sense of self-actualization, either.

The law is messy, and it doesn't always work like it should. There are aspects of it that I am personally uncomfortable with, like transporting cutters to the hospital, for example.

I fully realize that, for some people, cutting themselves is a coping mechanism for stress. It helps them maintain clarity and focus. They are no more suicidal than the rest of us.

To my mind, it's a damned poor coping mechanism and there are plenty of healthier ways than self-mutilation, if for no other reason than to avoid getting taken to the hospital for a psych evaluation because someone who doesn't understand your coping mechanism thinks you're insane.

Still, I don't get to make that decision. A doctor does.

And in this situation, I am acting as a physician extender. In Louisiana, involuntary psychiatric holds can last up to 15 days. The physician usually orders it via a mechanism known as a Physician's Emergency Certificate. When *I* take you to the ED for that evaluation, it's done under that physician's auspices. You must be evaluated by a physician, psychologist, or mental health nurse practitioner within 12 hours to determine if a PEC is warranted. If one isn't warranted, or they don't evaluate you within 12 hours, you get to go free, with nothing more than an ED visit to show for it.

If the cops take you, it's generally under the auspices of the elected parish coroner. The effect is the same: to get you to the hospital for the PEC evaluation.

There are checks and balances, too. If the PEC orders you involuntarily committed – again, for up to 15 days – you are required to be evaluated by the elected parish coroner or designated deputy within 72 hours of admission. If their evaluation does not agree with the physician's, you go free. If the original involuntary commitment came from the coroner, you have 72 hours to be evaluated by a psychiatrist. If his evaluation does not agree with the coroner's, you go free.

So, effectively speaking, the most a sane person is going to be held against their will is 72 hours.

If an additional stay is required beyond those 15 days, you must be evaluated within 72 hours of the end of that 15 day period by the coroner and the psychiatrist, who both must be in agreement to extend the hold for another 15 days.

Beyond 30 days, the bar is set far higher, which brings us to my next subject:

Line 11f of ATF Form 4473 asks:

Have you ever been adjudicated mentally defective (which includes a determination by a court. board. commission, or other lawful authority that you are a danger to yourself or to others or are incompetent to manage your own affairs, OR have you ever been committed to a mental institution?

Note the phrases I placed in bold print.

This is NOT the same thing as a temporary psychiatric hold, or even a temporary involuntary commitment.

Note the term "adjudicated mentally defective."

Adjudicated, as in court proceedings. Judges, lawyers, juries and all that. In most cases, it requires more than a hearing before an administrative law judge. That means you get a civil hearing complete with jury, a chance to respond to the petitioner, your own choice of lawyer or a guardian ad litem appointed by the court, and time to prepare a case.

A 72-hour Physician's Emergency Certificate doesn't even come close to meeting that legal standard. In my state, court proceedings are usually required to hold a person beyond 30 days.

The instructions for Form 4473 define "Committed to a Mental Institution" as: 

A formal commitment of a person to mental institution by a court. board, commission. or other lawful authority. The term includes a commitment to a mental institution involuntarily. The term includes commitment for mental defectiveness or mental illness. It also includes commitments for other reasons, such as for drug use. The term does not include a person in mental institution for observation or a voluntary admission to a mental institution.

Louisiana RS 28:53 states:

A.(1)  A mentally ill person or a person suffering from substance abuse may be admitted and detained at a treatment facility for observation, diagnosis, and treatment for a period not to exceed fifteen days under an emergency certificate.

(2)  A person suffering from substance abuse may be detained at a treatment facility for one additional period, not to exceed fifteen days, provided that a second emergency certificate is executed.  A second certificate may be executed only if and when a physician at the treatment facility and any other physician have examined the detained person within seventy-two hours prior to the termination of the initial fifteen day period and certified in writing on the second certificate that the person remains dangerous to himself or others or gravely disabled, and that his condition is likely to improve during the extended period.  The director shall inform the patient of the execution of the second certificate, the length of the extended period, and the specific reasons therefor, and shall also give notice of the same to the patient's nearest relative or other designated responsible party initially notified pursuant to Subsection F.

After that, further detainment at the treatment facility requires that you be adjudicated mentally defective. The Form 4473 instructions go on to state:

A person who has been adjudicated as a mental defective or committed to a mental institution is not prohibited if: (I) the person was adjudicated or committed by a department or agency of the Federal Government. such as the United States Department of Veteran's Affairs ("VA") (as opposed to a State court, State board, or other lawful State authority); and (2) either: (a) the person's adjudication or commitment for mental incompetency was set-aside or expunged by the adjudicating/committing agency; (h) the person has been fully released or discharged from all mandatory treatment, supervision, or monitoring by the agency; or (e) the person was found by the agency to no longer suffer from the mental health condition that served as the basis of the initial adjudication. Persons who fit this exception should answer "no" to Item 11.f.

So much for the belief that Leviathan can deny you your 2nd Amendment rights if I haul you off for a psych evaluation. I know that those of you who live behind enemy lines in May-Issue Land are subject to the whims and capriciousness of local police chiefs, but out here in Free America, it's pretty cut-and-dried.

If it was only a 72-hour hold, you have nothing to worry about.

If it was only a transport to the ED, and a 72-hour hold was deemed unnecessary, you have nothing to worry about.

If you were committed for even 30 days, and fully discharged with no court-mandated requirement for outpatient care, you have nothing to worry about.

If the court determined that you were crazier than a shithouse rat, and that even though you committed no crime for which you could claim not guilty by reasons of mental defect, that the safety of yourself and society was deemed preserved by locking you up for six months or six years, after which you were deemed competent to manage your own affairs and were set free… you have nothing to worry about.

This is the United States of friggin' America. Even as bad as things are now, we don't just lock people up in the gulag because they're a little odd. If that were the case, TJIC would be writing his little anarchist missives in crayon, snail-mailing them to me and begging me to post them in my comments section.

So don't let the fear of Big Brother confiscating all your guns deter you from seeking mental health counseling, calling a Suicide Hotline, or deter you from calling 911 because you legitimately fear a loved one may harm himself, yet you don't want to see his civil rights trampled on.

The bar is set a lot higher than that.

And what did they find?
 

But an I-Team review of disciplinary records for paramedics and EMTs across North Carolina for the past five years uncovered alleged behavior that may leave some wondering exactly who is in that ambulance coming to help.

We found multiple reports of misconduct in four key categories:

• Cheating on exams
• Criminal activity
• Drug and alcohol problems
• Misconduct on the job

The list of criminal charges that caused paramedics and EMTs to be stripped of their credentials includes:

• Felony death by vehicle and driving while impaired
• Felony indecent liberties with a child
• Sexual exploitation of a minor
• Child abuse
• Felony embezzlement
• Identity theft and credit card fraud

Clearly, if those paragons of journalistic integrity and investigative diligence at ABC11 are to be believed, North Carolina EMS systems are a hotbed of criminal activity. Buried deep in the article is the real number of disciplinary actions against EMT's in North Carolina: 40 out of 38,000.

That's 40 out of 38,000, over a period of eleven years.

That's 0.1% of North Carolina EMS personnel disciplined over 11 years.

I think it would be instructive if we looked at some other professions in whom we place a great deal of trust, and see what their rate of arrests and convictions are.

Let's have a look, shall we?

In one study of 535 people:

• 29 were accused of spousal abuse.
• 7 were arrested for fraud.
• 19 have been accused of writing bad checks.
• 17 have bankrupted at least two businesses.
• 3 have been arrested for assault.
• 71 have credit reports so bad they can't qualify for a credit card.
• 14 have been arrested on drug-related charges.
• 8 have been arrested for shoplifting.
• 21 are current defendants in lawsuits.
• In 1998 alone, 84 were stopped for drunk driving, but released after they claimed immunity.

And who was this den of hooligans, thugs and miscreants? The United States Congress, that's who.

I guess Mark Twain was right when he described Congress as the only distinct American criminal class.

Of another group of 606 people, 15, or 2.48%, were arrested or convicted of felonies.

Those 606 people were Michael Bloomberg's group, Mayors Against Illegal Guns. However, since Bloomberg is famous for listing people as members of his group who have explicitly stated that they have never joined and do not support MAIG, those 15 may be members of a significantly smaller pool of people.

Let's compare this wretched hive of scum and villainy group of stalwart defenders against gun violence against their sworn enemies, those evil gun totin' rednecks:

… the Tennessee Department of Safety and Homeland Security has been issuing Handgun Carry Permits since October 1996 (before then, individual county sheriffs handled them), and between then and the end of 2010, they have issued somewhere around 393686 permits (including four years’ worth of county sheriff renewals, and all duplications, free permits (how do you score those?), and new resident permits, but not counting overall renewals, for obvious reasons). In that same time period, only 4248 permits have had to be revoked due to court orders, administrative revocations, and felony convictions. As such, over the course of 14 years and change, the handgun carry permit holders of Tennessee have only had a failure rate of around 1.08%.

On the other hand, if we take the Mayors Against Illegal Guns members’ statistics (15 convictions over 5 years) and extrapolate them over 14 years, we find that they have had a failure rate of around 7% even. Amusingly, this indicates that MAIG members are 6.5 times more likely to break the law than TN HCP holders.

So much for the scourge of gun violence, it's time we put an end to the scourge of activist mayors.

I wonder, if we ran criminal background checks of all credentialed journalists and media personalities in North Carolina since 2001, how many arrests would we find? Perhaps substantially more than 0.1%?

Anyone? Anyone? Bueller?

The kid was in good spirits, smiling and laughing. The tooth seemed in good shape, too, despite it’s less-than-desirable storage receptacle of the mother’s lint-filled pocket.

So, I gently took the tooth from her, handling it by the crown only, and wrapped it in saline-soaked gauze while I called the local hospitals to get confirmation on what I already suspected.

None of the local hospitals have the capability of re-implanting a dislodged tooth, and none of the local dental clinics that take Medicaid answer their emergency numbers, or even have emergency numbers, for that matter.

So, I whipped out my smartphone for a consult to Dr. Google, to refresh my memory on just how long a dislodged tooth is viable for reimplantation.

I learned a couple of things:

1. Milk* is still the best preservative if you don’t have a Sav A Tooth kit. I had been taught that milk had fallen out of favor as a tooth preservative.

2. The fibroblasts on the root of the tooth that are the “glue” that make reimplantation possible start dying after 30 minutes.

Our little girl’s fibroblasts were already dead, buried, and the remaining fibroblasts in her socket were having a rollicking Irish wake.

Looks like our patient will be channeling her inner hockey player for a while, until a dentist can fit her with an artificial implant.

* I asked Siri, “Does the milk have to be Pasteurized?” and she answered, “No, just deep enough to cover the tooth should be sufficient.”**

** Not really. I’ll be here all week, folks. Try the veal, and be sure to tip your server.

Go read, and weigh in with your comments. We'd love to hear them.