Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

One Right Answer – Crisis Patients

Also posted/to be posted as part of the Handover over at EMS in the New Decade. Go check out the rest of what is there.

The topic is Crisis Patients.

There is a quiz.

Not for you as much as for those contributing blog posts, but these are important questions to think about when dealing with patients we label as crisis, and/or behavioral, and/or psychiatric, and/or agitated, and/or uncooperative and/or something else. They are not all the same thing. Uncooperative and behavioral may be easy to throw into the same category and think about the same way, but they may require very different handling.

I hope someday to have enough money that I am not described as any of those, but as eccentric. I’m not there yet. I don’t have the money.

– How do you approach these patients? How conscious are you of your body language around these people

Approach cautiously and respectfully.

We sometimes often forget that we are being invited into their homes/businesses/cars/et cetera to help them deal with their emergencies. We are accustomed to dealing with emergencies. We may be dispatched to several emergencies in a shift.

We act as if all emergencies can be easily put in categories, such as Medical or Trauma. We then use subcategories like Medical – Cardiac, which may just be the title of the protocol we used to treat the patient.

We rush to categorize, even before we have any idea of what we are contributing to dealing with. I used to work in one county, where forming a treatment plan based on dispatch information was encouraged. Some medics would call dispatch and throw tantrums if they did not receive extensive information from dispatch on the way to the call. Assessing the patient first, before considering treatment, was considered to be setting some sort of bad example.

Sentence first – verdict afterwards.[1]

If we update and modify this stuff and nonsense for EMS:

Treatment first – assessment afterwards.

I only want to know if there are reports of violence on scene, number of reported patients, and anything unusual (dog in yard, entry code for front door, neighbor has key, et cetera).

But what about pediatric patients?

What if we don’t have our pediatric bag?

There is no good reason to have a separate pediatric bag.[2]

In my opinion, a separate pediatric bag is a clear demonstration of just not understanding EMS.

Making decisions about the way a call will be handled before even making patient contact is dangerous. We tend to try to stick to our plans, no matter how inappropriate they may turn out to be.

Approach cautiously and respectfully.

I try not to approach patients with any attitude, language, or body language that is less than respectful.

Prejudice, means to prejudge. Judging based on superficial evidence is a bad idea. Prejudging/stereotyping just encourages the mistake of relying on confirmation biases.[3] This is the opposite of understanding, although even JEMS suggests that You can judge a book by its cover.[4]

The most important approach is to listen to patients. Patients, even crisis patients, will generally tell us what they want. We may need to be a bit more creative than our protocols permit than is specifically written into any of our protocols.

We are there for the good of the patient – not for the good of the protocol, not for the good of the medical director, and not for the good of the company.

– When a patient is resistant or reluctant to receive treatment and transport, how do you like to handle that?

Ask questions. Find out what is going on.

The answer is to use critical judgment, not to abandon communication and just tackle the patient.

– In your time with these patients, how much do you dig into their history, and reasons for feeling depressed, suicidal or just “not right?”

I don’t really dig.

First, I ask them what is going on.

Then, I listen to their response(s).

I try to get them to focus on what is relevant, but it is not always clear what is relevant.

I do not worry about scene time. EMS is about taking care of the current patient, not the potential save that might get away. While this may happen, focusing on the future patient is going to lead to problems with the current patient much more often than it is going to lead to any kind of improved outcome for the future patient.

Crisis patients will generally tell me enough about what is going on, so that I can get them to agree to go along with me without any threats or restraints.

If the patient is unreasonable and truly violent, then there is rarely any harm in attempting to talk first. We just need to avoid getting into a situation where we put the patient, bystanders, or ourselves in danger.

– Finally, when it comes down to it, what techniques do you use for subduing and restraining a patient?

That depends on the patient. I have restrained a lot of patients. I have never broken any patients’ bones or dislocated any patients’ joints, but I have had to release joint locks, because I felt that I was close to dislocating or breaking something of the patient’s. I have never hit a patient.

Dealing with Crisis Patients is more about listening to patients, than about fighting with patients.

Medications for sedating patients would require more than one post, even with the length of my posts, but restraining patients without sedation is wrong. Let me repeat that.

Keeping patients restrained without sedation is wrong.


[1] Alice’s Adventures in Wonderland
Chapter 12
Lewis Carroll
The Literature Network
Link to Chapter 12

[2] A Pediatric Bag Separate From the Adult Gear
Rogue Medic

[3] Confirmation Bias and EMS
Rogue Medic

[4] You can judge a book by its cover? – JEMS.com
Rogue Medic


And that’s when it all came together

Also posted as part of the Handover over at The EMT Spot. Go check out the rest of what is there.

I was working for a company that did a lot of cardiac catheterization transports. We had two main hospitals that we would transport from, so we knew the nurses pretty well. We knew which ones to trust and which ones to take with a grain, or two, of salt.

One day, one of the really good nurses gives us a report on the patient we will be transporting from her cardiac ICU to the cath lab.

Nurse – I am so sorry to do this to you.

RM – Do what?

Nurse – Well, . . . .

RM – We’re going to find out, because we are going to have to transport him some time before the end of the shift. We are happy to hang around and chat with you, but our dispatch doesn’t understand the meaning of understanding.

Nurse – Well, this patient is going to drive you crazy.

RM – Too late.

Nurse – He is a constant nag. We have had to take the call bell away from him, but he still complains about everything. Non-stop.

RM – And this does not appear to be a new symptom?

Nurse – No. His kids confirm that they used to have to compete with him when they were going through their terrible twos.

RM – OK. It’s only a 15 minute ride. How bad can it be? 😉

Nurse – I gave him as much Ativan as I could talk the doctor into writing for, but I don’t think it will even touch him. We have been dosing him as often as we can get orders. He seems to be immune to sedation meds.

We move the Happy Patient (no known relation to the Happy Medic) to our stretcher. We have all of our toys hooked up to monitor rhythm, sat, and blood pressure. My partner and I are exchanging glances, because Happy Patient actually appears to be happy. He has not complained about anything except the move to the stretcher. This is not at all what we expected.

After moving out to the ambulance, I take another blood pressure and the systolic number is in the 80s. He had been in the 130s. He is now snoring and his heart rate has slowed to the 50s – it had been in the 80s. My partner wants to take him back inside, but I have not finished my reassessment.

RM – How are you doing.

Happy Patient – I   ‘   m       O   K   . (But this comes out over about 5 seconds.)

RM – What is your name.

HP – H   a   p   p   y       P   a   t   i   e   n   t   .

This takes about 15 seconds and my partner steps around the side of the ambulance to hide his giggling from the patient. HP is fully oriented. He knows where he is, when he is, and where he is going. He is not alert. He is responsive to voice on the AVPU scale, where A is for Alert, V is for Voice, P is for Pain, and U is for Unresponsive. His GCS (Glasgow Coma Score) is 14. Eye opening is to voice, so one point off for that. I’m happy, the patient is Happy, and my partner is giggling. Only the patient being happy is any kind of new symptom.

Here is an accurate example of the way HP was speaking. No, I did not ask HP to say, Come back here, you rabbit.

We transport. My partner uses lights and sirens and giggles. He manages to control his giggling for long enough to have dispatch notify the cath lab. During transport, I add some oxygen, some fluids (only about 100 ml of future urine), and I continue reassessments. The only change is that his systolic pressure drops into the 50s, which is not reported to be good for coronary circulation.

His vital signs are closer to normal by the time we arrive at the cath lab about 15 minutes later. At all times, he responded to questions appropriately, even if slowly and sedately. His systolic pressure at the cath lab was back up in the 80s.

Should I have gone back in to the hospital and up to the ICU?

We are still in the parking lot of the hospital, so we have not left the hospital.

His vital signs are not normal and there is the possibility of this being an atypical presentation of a new cardiac event or some other new onset of an illness.

He could deteriorate and his blood pressure did drop en route. The blood pressure also did return to where it was before transport. Was this due to a moving ambulance making it difficult to hear? I confirmed the BP by palpation, but that can also be affected by the movement of the ambulance.

For me the decision was based on the following.

HP apparently will be better off with a cardiac catheterization sooner, rather than later.

The time to get back upstairs to the nurses familiar with this patient is probably 5 minutes. Another possibility is to go to the ED, which is about 3 minutes, but they are probably not at all familiar with him and are even less likely to do anything to expedite HP’s arrival at the cath lab.

I chose to transport. I think that the greatest priority was the catheterization. In EMS, we can never be certain that what we do is, was, or will be the right thing to do for the patient. We can do everything wrong – give the wrong drugs, intubate the esophagus, et cetera, and some patients will still survive to the hospital. Not because of us, but in spite of us.

Could his blood pressure have dropped even lower?


Could this blood pressure have led to cardiac complications?


What would they have done in the hospital?

I expect that they would have continued the oxygen at the same flow rate. I had turned it up.

I expect that they would have continued fluids.

They may have considered flumazenil, but I don’t think it would have been a good idea.

After his pressure had recovered and he had become more alert, they might have had us continue with transport.

I was transferring him to a hospital considered to be capable of delivering a higher level of cardiac care. When do we reach the point of no return on such a patient?

What if the patient had a major complication, en route?

For example, if HP had an arrhythmia, such as VT (Ventricular Tachycardia) or VF (Ventricular Fibrillation), what would have been the response of everyone to my decision to transport?

I would expect that everyone, or almost everyone, would blame me for the cardiac arrest – regardless of ultimate outcome.

If I had gone back into the hospital, would VT or VF have been any less likely?

Probably not, but this is EMS and we do not think that way. We live by the protocol and some of our patients die by the protocol.

Part of any criticism is likely to be a statement that by taking the patient back into the hospital, I am relieving myself and my employer of responsibility for the patient.

Is the ultimate goal of EMS to avoid responsibility?

Is that good medicine?

Is that even good defensive medicine?

I decided to continue with the transport. It seemed to be the right thing to do.

I decided to continue with the transport. It seemed to be the right thing to do for the patient.

So what about this has to do with the theme of the Handover – And that’s when it all came together? This post seems to be closer to that’s when it almost came apart.

What about the respiratory depression and vital sign depression? These are things that we are so worried about when giving sedatives and/or opioids. I had never had a good opportunity to assess and treat a patient who had received an iatrogenic dose that unintentionally produced these effects. If I had, I would have spent more time keeping the patient talking to me, rather than letting him nap. I was using a combination of medications to try to treat his depressed vital signs. His vital signs would probably have improved more, if I had just kept asking him questions to keep him talking. A combination of the oxygen, the fluids, and keeping him talking would probably produce the best results.

This contradicts all that I had been taught about respiratory depressant medications. He cried in a whisper at some image, at some vision—he cried out twice, a cry that was no more than a breath—”The horror! The horror!”[1] I am sure that it was not presented in quite that manner to our class, but who is telling this story?

Where is this essential evil that is central to the supposed need for excessive restrictions on appropriate treatment of patients in need of sedation or in need of pain relief?

Do we need to adopt the morality of Kurtz to be able to treat our patients ethically?

Is this any less contradictory than the excessive restrictions on the use of opioids and sedatives?

Why is it that we are treated as if the doctor giving the order is doing us a favor, rather than just giving appropriate (assuming the orders reach the level of appropriate) orders to treat our patient.

Why is it that we are treated as if the doctor giving the order is doing us a favor, rather than just avoiding neglecting (assuming the orders reach the level of appropriate) our patient.

What would you have done differently?

Does anyone disagree with me?

Why do you disagree?


^ 1 Heart of Darkness
By Joseph Conrad
Link 1 and Link 2 to Free Full Text at Gutenberg.org.
Links to Free Audio Download at LibriVox.org.



Also posted as part of the Handover over at Life Under The Lights. Go check out the rest of what is there.

Over at A Day In The Life Of An Ambulance Driver, there is a post titled R-E-S-P-E-C-T. There is a lot to say about this, but I will try to keep it short.

Ambulance Driver highlights the problem with the EMS entitlement attitude. We have cards that reads EMT (A, or B, or D, or I, or P, or whatever). We feel this entitles us to some kind of respect.

Is respect an entitlement?

Is respect something that is earned?

Is respect something we should worry about?

Next they’ll be taking our blessed intubation away!

Without the ability to administer our Laying on of the PVC, how will any of our patients survive?

Why is it that so many of us crawl out from under our rocks when we feel that our image has been impugned?

Why is it that so many of us seem to put more effort into demanding respect than we do into earning respect?

Why is it that so many of us cannot intubate safely, but can’t stand the thought of having that skill taken away from us?

Where are we when there is an opportunity to practice intubation?

Why aren’t we demanding that we be allowed to practice intubation, even if it is on our own time?

Why aren’t we trying to protect our patients from the deterioration of our skills?

Why do we feel that adding RSI (Rapid Sequence Induction/Intubation) to the ways that we can mismanage an airway will make us more professional?

We have pathetically low standards, but we wish to punish medics who were canceled; medics who were out working non-stop in a disaster; medics who were expected to also do the job of the snow plows; medics who did transport many more patients than usual; all without any help and short staffed.


Because we are to believe the claims of these armchair critics, that they would have disobeyed dispatch, walked to the patient, and waited in the residence for over a day for some backup to arrive, or would have safely carried Mr. Mitchell out through a quarter of a mile in snow and ice without any help, because that is the respectable thing to do. In the mean time, the other crews are making up for this canceled crew being out of service.

And because some inappropriate language was used on a recorded phone line, because that is not the respectable thing to do.

As if Curtis Mitchell died from inappropriate comments. The autopsy results have not yet been released, but I think it is safe to say that will not be the official cause of death. If there were never any inappropriate comments, would Curtis Mitchell be alive?

Well, Ambulance Driver gets the same kind of grief, just toned down, because nobody seems to be claiming that his use of Ambulance Driver in the title of his blog has killed anyone – yet.

I have known Kelly since before he began writing A Day In The Life Of An Ambulance Driver. We may not always agree, but the only criticism I have of him is that there are not enough people like him in EMS.

There are too many whiners in EMS, not enough leaders.

There are too many people satisfied with our ridiculously low standards in EMS.

There are too many of us demanding respect for having a card that suggests that we met the ridiculously low standards in EMS.

There are too many people worried more about protecting our image, rather than worried about caring for our patients.

There are not enough people demanding higher standards in EMS.

Why are we worried more about phone calls than about our patients?

Why are we worried more about skills than about our patients?

Why are we worried more about tiles of nobility[1] than about our patients?

I am a paramedic.

I am an EMT.

I am an ambulance driver.

I occasionally make inappropriate comments.

I do not ask for respect from anyone.

At some point, I will write something that will anger every one of you.

Maybe I already have.

I’m OK with that.


^ 1 Title of Nobility Clause
Article I, Section 9, Clause 8
US Constitution
Full Text

No Title of Nobility shall be granted by the United States: And no Person holding any Office of Profit or Trust under them, shall, without the Consent of the Congress, accept of any present, Emolument, Office, or Title, of any kind whatever, from any King, Prince, or foreign State.



Also posted as part of the Handover over at A Day In The Life Of An Ambulance Driver. Go check out the rest of what is there.

The theme is the call that made the shift.

We are dispatched to an assisted living community for a woman who fell in the lobby. We bring the stretcher in and leave the immobilization equipment outside until we know what is going on.

She’s over there.

Not the most informative comment, but it is progress.

When we look over there, we see a white poodle laying on its side and hear people saying –


Don’t move!

My partner mentions that they may have dialed the wrong number. We are limited to human patients, even if certain humans are no better behaved than many dogs, and even if some humans might not be able to claim victory in a battle of wits with some dogs.

Oh, no. That’s not her. She’s around the corner.

Sure enough, around the corner from the entryway, there is a 2 legged patient laying there, being told to Stay! and Don’t move! Things are beginning to look more normal. She appears to be old enough to be retired. Later, we learn that she has been around since the first world war. I start talking to her, and as I take her hand I like to palpate for a pulse.

I’m not dead!

Airway is clear. Breathing appears to be controlled and adequate to deliver oxygen to the lungs. The circulation appears to be adequate for most of the organs. Even the brain is receiving enough circulation to keep her near the top of the Glasgow Coma Scale.

Her speech is clear. Her statement is accurate. Even without assessing her pulse, nobody seemed to be suggesting that we transport her to a mortuary. It appears that she is from the Reflections wing. This is somebody’s idea of a politically correct name for their Alzheimer’s unit. I think they should have reflected on the name a bit longer, but they didn’t ask me, and they don’t seem to appreciate my unsolicited commentary. As it turns out, the more mobile residents of the wing were having a pleasant breakfast together in the dining room. Until gravity went and spoiled things.

We have a witnessed fall. Remember that we were dispatched for a fall. Here is where it becomes interesting. One of the witnesses is a doctor, and could be Katherine Hepburn, if Katherine Hepburn were still alive, had continued to age, and had shrunk, a lot. Dr. Hepburn takes command of the scene.

I was sitting here and she was sitting there and . . . Dr. Hepburn begins by describing the seating positions of all of the people, which does not seem to be important in this case, but she is/was the doctor. Doctor of what, I do not know and, the way things are going, I am not going to ask. I return to the patient, you know, the not dead one I haven’t had a chance to talk with, yet. However, Dr. Hepburn will not be discouraged from presenting her information to me directly. Why me? Well, my ex-wife will tell you, that where ever we go, the craziest person in the room second craziest person in the room will seek me out. It is as if I had been abducted by aliens and been implanted with a homing device for all of the maddest hatters on the planet. All I can say, is that the device works. Anyway, Dr. Hepburn begins again with a description of the seating arrangements. I interrupt and point out that my partner is the only one authorized to take report from doctors, which cheers my partner right up.

I finally begin to talk with the actual patient, not the dog and not the doctor. I am tempted to just mutter to myself and wonder how long it would take for anyone to notice. I know my partner would notice me mumbling more than usual. He is, after all, authorized to talk with doctors.

I’m not dead!

I understand. If you were dead, you wouldn’t be talking to me.

I’m not dead!

Why do you think that I think that you are dead? (Yes, I did start to follow her down the rabbit hole, but I am trying to stay out of the express lane.) Do I look like the kind of person to talk to dead people?

I’m not going to the hospital!

(This appears to have been a shallow rabbit hole. Not going to the hospital is better than not dead, although maybe she is working her way around to telling me she wants to go to the morgue.) Why don’t you want to go to the hospital?

You can’t make me go to the hospital!

Generally, it is not worth arguing with people who tell me that I cannot do something. I find that their argument becomes moot after I have done whatever it is that I cannot do. I confirm with staff that she has not had the capacity to make decisions for herself for a long time. I ask some questions to determine orientation, but never do I ask, Who is the President? What would be the point? It is a question that interferes with assessment more than it contributes.

I ask her name and kind of expect her to say Randle Patrick McMurphy.

I explain that her doctor, not Dr. Hepburn, insists that she be seen at the hospital. We immobilize her for transport. One of the failures of the spinal clearance rules is that there is no accommodation for patients who are disoriented all of the time, but do not appear to be showing any signs of spinal injury. Another failure is the lack of evidence of any benefit from immobilizing even those with unstable spinal fractures, but that is a different post.

As we are immobilizing her, she begins a beautiful a cappella rendition of Somewhere Over the Rainbow. The rest of the patients are sensible enough to not try to provide accompaniment. In between songs, she chats with the audience – I am the solo audience in the back of the ambulance with her. She is very pleasant company.

When we prepare to lift her, she complains that she is too heavy to lift. I respond that she is light as a feather, or maybe a large bag of feathers, but that she is certainly not heavy compared to many of the patients we move.

We arrive at the hospital and find out that her hip pain – pain that would come and go, is even more versatile than initially suspected. Her hip pain is also migratory. Now the pain has moved to her other hip.

I ask – How did that happen?

I don’t know. You’re the doctor.

No. He’s the doctor. (And I point at where the doctor had been standing, but he has stepped out of the room. I’m not even going to try to win that debate.)

After the doctor finishes with the medical command call, he comes back. Now the pain is back where it was to begin with. A few minutes later the pain is once again gone. I take advantage of this lull in the activity to sneak away.

Through all of the time we were on scene, the staff were standing around and mostly giggling at the way things were progressing. Before we left, the staff explained to me that she is pleasantly confused, to which I give my standard response – Then we will get along wonderfully. And we did, except when she accused me of being a doctor.

If a tree fell in a room full of dementia patients, yesterday, did it make a sound?

If a fall is only witnessed by dementia patients, is it a witnessed fall?

Is it a witnessed fall for a minute, for ten minutes, for an hour, for ten hours? What do we use to determine this?

The theme is the call that made the shift. We couldn’t stop giggling for the rest of the shift. Perpetual giggling is not unusual, but this time we actually had a reason.


Correlation vs. Causation – repost for the Handover

This is a repost to fit in with the theme of the Handover over at Life Under the lights. Some coverage of research in comics by xkcd:

One of the amusing parts of xkcd is the mouse over text. It does not transfer to my blog (the text doesn’t transfer, the humor increases tremendously, or maybe not), but this is what pops up at the xkcd site:

Correlation doesn’t imply causation, but it does waggle its eyebrows suggestively and gesture furtively while mouthing ‘look over there’

Correlation is when things happen together. The whole purpose of the scientific method is to try to differentiate among the different correlations. Some will be purely coincidences. Some will be related, but some will not be the causes of what comes after them. And some will be causes.

All of the links in this are from the original article. The author trying to make his point, not me criticizing his points.

Cows with Names Make More Milk
By Robert Roy Britt, Editorial Director
posted: 27 January 2009 09:05 pm ET

Researchers in the UK say cows with names make 3.4 percent more milk in a year than cows that just feel, well, like cows.

There seems to be more than just names involved, however.

This sounds as if it is common sense. Call a cow by name and the cow will be more productive. People seem to prefer to be called by name, so why not cows?

Is this an example of anthropomorphic fallacy? Anthropomorphic fallacy is attributing human qualities to other creatures without any evidence to support these traits. Do cows feel happy? Do they feel sad? Do they feel unique? If they do, which is a big If, how do we recognize that the cow is feeling that feeling? What about an appearance that resembles a human expression of happiness, or sadness, or uniqueness (which would almost always be wrong)? Does that appearance mean the same on a cow as on a human?

The study, involving 516 dairy farmers and published online Tuesday by the journal Anthrozoos, found that “on farms where each cow was called by her name the overall milk yield was higher than on farms where the cattle were herded as a group,” write researchers Catherine Douglas and Peter Rowlinson of Newcastle University.

Nobody likes to be herded. Even a cow, one might presume. Indeed, the findings in fact point to an overall personal touch that — just a guess here — might say as much about the farmers as it does about the cows.

Precisely. There does not seem to be any attempt to control for variables in this study. Is the only difference between the farms that, some farmers called their cows by name, while other farmers did not? I called up Jimmy The Greek and he would not give me any odds on that bet. It seems that Jimmy The Greek, with no scientific research training, is able to recognize a major flaw in this research. And Jimmy The Greek has been dead for a dozen years.

Nobody likes to be herded?

I think that the economy is demonstrating exactly the opposite. There are a lot of people just begging to be herded. Tell us what to do! Save us! Is that not herd mentality? Nobody likes to be herded is what we would like to believe about ourselves, but a lot of people sure do seem as if they like to be herded. That freedom from the responsibility of having to think. They do seem to love it. Even the link provided does not support the claim that nobody likes to be herded.

“Just as people respond better to the personal touch, cows also feel happier and more relaxed if they are given a bit more one-to-one attention,” Douglas said. “By placing more importance on the individual, such as calling a cow by her name or interacting with the animal more as it grows up, we can not only improve the animal’s welfare and her perception of humans, but also increase milk production.”

Improve … her perception of humans?

This is not doing much for my perception of this human they call Douglas. Excuse me for taking a bit of a speciesist view of this, but what evidence do we have that cows’ perception of humans has anything to do with life as a cow on a farm? Do they view us as benevolent creatures, more so if we call them by name? Do they view us as soft touches, to be manipulated as much as possible? How would we know?

Happy cows. Okay. Well, if you are a farmer (especially one with a small farm that struggles to be profitable by milking only a handful of cows) you probably would not argue with success. Cows, after all (and in case you thinking of judging them as dumb animals) are known to have a magnetic sixth sense and are not as prone to cow-tipping as you might have heard. Who knows what else they are capable of?

A magnetic sixth sense?

Birds have a similar ability to sense magnetic north. Comparing a cow brain to a bird brain is not making a case for intelligent cows.

Not as prone (a pun?) to cow tipping?

Again, this has nothing to do with intelligence. Cows do not sleep standing up. If the cow is standing, the cow is awake. Not being completely oblivious to one’s surroundings correlates with intelligence. Awareness is not the same as intelligence. A Venus Flytrap has enough awareness to catch flies, but that does not make it intelligent.

Dairy farmer Dennis Gibb, who co-owns Eachwick Red House Farm outside Newcastle with his brother Richard,

The Brothers Gibb?

Milkin’ the Cows sung to the tune of Stayin’ Alive. You know, the CPR song.

Well, you can tell by the way I name my cows,
I’m an udder man: no time to talk.
Bowels are loud and teats are warm, I’ve been excreted on
Since I was born.
And now it’s all right. It’s OK.
And you may milk another way.
We can try to understand
Callin’ their name’s effect on cows.

Whether you’re a twister or whether you’re a squeezer,
You’re milkin’ the cows, milkin’ the cows.
Feel methane breakin’ and everybody shakin’,
And were milkin’ the cows, milkin’ the cows.
Ah, ha, ha, ha, milkin’ the cows, milkin’ the cows.
Ah, ha, ha, ha, milkin’ the cows.

Naming cows is one thing, but do they teach them karaoke? Do they teach them to dance? How can you have a proper control group without these groups?

Sorry. I get just a little bit silly at times. Just a little bit.

Dairy farmer Dennis Gibb, who co-owns Eachwick Red House Farm outside Newcastle with his brother Richard, says he believes treating every cow as an individual is vitally important. “They aren’t just our livelihood — they’re part of the family,” Gibb said in a statement released by the university. “We love our cows here at Eachwick and every one of them has a name. Collectively we refer to them as ‘our ladies’ but we know every one of them and each one has her own personality.”


The findings:

* 46 percent said the cows on their farm were called by name.
* 66 percent said they “knew all the cows in the herd.”
* 48 percent said positive human contact was more likely to produce cows with a good milking temperament.
* Less than 10 percent said that a fear of humans resulted in a poor milking temperament.

* 66 percent said they “knew all the cows in the herd.”

Isn’t that shepherds. . .

Have I mentioned that you should try the veal? Badump bump.

* Less than 10 percent said that a fear of humans resulted in a poor milking temperament.

Are they claiming that fear results in poor milking temperament?

Or are they claiming that fear of humans results in poor milking temperament?

I don’t have a big problem with categorizing certain responses as indications of fear. We cannot ask the cow what she is feeling, but we can guess. All that this would be is a great big guess. OK, I guess I do have a problem with this. Now, if you take that great big guess, not only take it for granted, but attribute a specific cause to the presumed fear, that’s just silly. Even sillier than my little rewrite of Stayin’ Alive.

Unless you have John Edwards reading the minds of these cows for you:

John Edwards – I sense something from over here. Something that begins with an M. Is it Moo?

Cow – Yes. That is what my mother, an unnamed cow, always used to say to me.

After all, the lack of continuing success for his show isn’t because John Edwards is a fraud. He’s just misunderstood by the cows in the audience. Yeah. That’s the ticket. He’s just misunderstood. By the cows.

“Our data suggests that on the whole UK dairy farmers regard their cows as intelligent beings capable of experiencing a range of emotions,” Douglass said. “Placing more importance on knowing the individual animals and calling them by name can — at no extra cost to the farmer –— also significantly increase milk production.”

The cows are intelligent beings?

Compared to what? Bacteria?

Maybe these intelligent beings should be allowed to vote.

This is at no extra cost to the farmer?

Clearly, these farmers do not understand cows. You call a cow by the wrong name and no milk for a week.

* Amazing Animal Abilities
* My Big Beef with Cloned Cattle
* Love of Milk Dated Back to 6000 B.C.

Robert Roy Britt is the Editorial Director of Imaginova. In this column, The Water Cooler, he takes a daily look at what people are talking about in the world of science and beyond.


Cows called by name.


Cows produce more milk.

This is a correlation.

Does this equal causation?

Does calling the cow by name mean that the cow will produce more milk, than if you do not call the cow by name?

To quote from the xkcd comic – Well, maybe.

Just because the research does not exclude the obvious, and even less obvious, variables, does not mean that one does not cause the other. It is possible.

However, because of the lack of control of variables, and other flaws, it would be a huge mistake to suggest that there is evidence to support that conclusion. For all we know, it could be an error of measurement – there may not be any real difference.

This isn’t research. This is comedy.


the Handover for August 2009


The current edition of the Handover is now up. Medic999, one of the founders, is the host this month. Give these blogs a read.


Ride-Along as an EMT Student


When I was in EMT school, we had to ride along with EMS for 3 shifts. The school arranged for us to ride with the San Francisco Department of Public Health. This was before the take-over by the fire department.

Friday evening 1600-2400 shift. I arrive and meet the crew I will be riding with. they check out their gear and we head out on the road. One of the medics asks me if I know what AEIOU TIPS[1] stands for. Golly. A chance to impress them with my ability to repeat something we memorized, rather than understood.

A is for Alcohol. And E is for . . .

That’s all you need to know. Alcohol is all we do. All night. Every night.

I don’t mention that they appear to be a pretty sober pair of medics. One of them seems to be reading my mind, and states that they are referring to alcohol consumed by the patients. We won’t be getting drunk on duty.

Well, there was some devastation at the lack of iterest in my ability to fetch a mnemonic that we had been told would be so important. Another Charlie Brown moment.

That was only the beginning of the Skinner Box effect.[2] Something to addict even the most resistant to the appeal of anecdote – the rogue EMT student – which I most certainly was not. Not yet. By the end of the shift, with 2 codes, 2 traumas, and a few other patients, I was ready to go audition for NBC’s show Trauma.[3] Mayberry EMS was not going to cut it for me. This was EMS. This is the way we set students up to become the Barney Fifes of EMS. Stress the emergency at the expense of the medical service.

The shift turned out to be one that could have been written for TV. 2 cardiac arrests (1 regained pulses – AEIOU TIPS = A – chronic alcoholic homeless person). Not showing any signs of mental function, but he had a pulse. A SAVE. Hazel Motes couldn’t have been prouder.

2 critical trauma patients (both were pedestrians crossing the street together, when struck by the same truck – AEIOU TIPS = A – most alcohol involvement in auto/pedestrian incidents is on the part of the pedestrians.[4] Drunk pedestrians do a pretty poor job of looking both ways before playing in traffic. Looking both ways is a simple technique, that is very effective at preventing all kinds of auto/pedestrian incidents.

Looking both ways helps the pedestrian to avoid a bad driver. The driver with too much whatever to pay attention to the road: Too much confidence in his/her ability to handle alcohol/other drugs and a motor vehicle at the same time; Too much confidence in his/her ability to handle text messaging and a motor vehicle at the same time; Too much confidence in his/her ability to handle a cell phone and a motor vehicle at the same time; Too much confidence in his/her ability to just plain handle a motor vehicle; And too much motor vehicle.

Do racoons look both ways before playing in traffic?

No. Raccoons are road meat/street pizza/speed bumps/. . . .

Do skunks look both ways before playing in traffic?

No. Skunks are more aromatic road meat.

Do deer look both ways before playing in traffic?

No. Deer are also road meat, but they occasionaly take a driver/passenger/both
along with them. Road meat and front seat meat.

The most effective way to reduce auto/pedestrian injuries/fatalities is to not walk in front of moving motor vehicles. Green light? Look both ways. Maybe you have never run a red light, but others are not so well behaved, or even so observant. A bunch of people are crossing the street at the same time, so no need to look both ways? No, but you may have company in the ED, or in the morgue. Won’t that be a consolation?

Meanwhile back at the busy shift, we had an odd drug reaction. He stated that he had taken something to help him relax. It was not his. There was no more left. It was not in a marked pill bottle. His heart rate is on the fast side. His neck is on the side. His tongue is on the outside. I had no clue. We did not cover anything like this in EMT school. One of the medics called command and asked for permission to give diphenhydramine (Benadryl), but medical command was uncomfortable with the idea and just wanted the patient transported. We arrived at the hospital and they gave the patient benztropine (Cogentin), which does the same thing that the medics could have done a while earlier with the diphenhydramine. The patient was having a dystonic reaction.

Then we had a surprise for all of us. None of us had met this guy before, even though he would go to the hospital every day for chest pain or difficulty breathing. The local newspaper even wrote about him in good old politically correct San Francisco. They called him the Million Dollar Man. Over a 3 year period, with daily 911 calls and full work-ups in the hospitals, they calculated that he had cost the city over a million dollars in unreimbursed care. And that was just the cost to the city. 404 pounds (according to him) and he wanted to be carried. One of the neighbors pointed out that he has no problem walking every time he calls the ambulance, so our backs appreciated that. He also does not want to go to the closest hospital, because They were mean to me yesterday. By the time we arrived at the hospital, he had alienated another 3 people. The guy has at least one talent and it isn’t charm.

Since then, I have not had many shifts that were as eventful as that. That was my first time working on an ambulance.


This is a mnemonic to help remember the causes of a change in mental function.

I have repeated several of the words, since there are several ways to use this mnemonic. You may eliminate the ones that are duplicates, that do not help you remember. Endocrine, Insulin, OverDose, UnderDose, and Pharmacy overlap. Infection, Sepsis, and Temperature overlap, too – but they get you to think about similar things differently. That may be helpful.

A – Alcohol

E – Electrolytes and Encephalopathy and Endocrine

I – Infection and Insulin

O – OverDose and Oxygen

U – Uremia/UTI and Underdose (not taking medications that should be taken)

T – Temperature (Hypo/HyperThermia) and Toxidromes (OverDose) and Trauma

I – Infection and Insulin, again

P – Pharmacy and Psych and Porphyria

S – Sepsis and Space occupying lesion and Stroke and Subarachnoid Bleed and Seizure

^ 2 Superstition in the pigeon
The root of many superstitious beliefs, such as full moons being busy in the ED, black clouds, white clouds, causing bad things to happen by saying, Slow or Quiet, . . . . Skinner’s experiments demonstrated that we behave no better than birds, when dealing with intermittent reinforcement. So, it is perfectly appropriate to refer to superstitious people as bird brains. The scary thing is that some are doctors, nurses, medics, et cetera. These bird brains are responsible for making decisions that affect patients’ lives. And these bird brains vote.

We should end this through education, but as TOTWTYTR repeatedly states, You can’t cure stupid.
Wikipedia (part 10 in contents if the link does not take you directly to this part of the page, or click refresh).

^ 3 Trauma – New NBC Drama To Ridicule EMS
Rogue Medic

^ 4 Age, sex, and blood alcohol concentration of killed and injured pedestrians.
Holubowycz OT.
Accid Anal Prev. 1995 Jun;27(3):417-22.
PMID: 7639925 [PubMed – indexed for MEDLINE]