Thursday, January 25, 2018

Rinella's Sign

The dashing yet pigment challenged
Captain Halleman demonstrating Rinella's sign.

A couple few years ago I ran on a typical geriatric sick person call. The patient was experiencing general weakness which caused him mobility difficulties, and had suffered several ground level falls in the prior week without seeking treatment. Upon exam the pt had a mildly sore neck; jaundiced skin;  and a large, distended belly. He was unaware of being diagnosed with any liver issues. He did not have any numbness or paralysis in his extremities.

We helped the patient onto the stretcher and I kicked the call down to the BLS level. As the EMTs wheeled the patient out to the ambulance on his bumpy, unimproved driveway I noticed the patient gripping his neck with both of his hands as if to brace his head upright. I recalled a friend of mine from medic school miming one of his patients with a broken neck doing this, and so I threw a c-collar on the patient before leaving, just in case.

I later received a follow up that the patient was diagnosed with a neck fracture, and cancer which had presumably weakened his bones (in addition to causing liver failure). After pulling this case for review I began speaking with other people who have observed this similar phenomenon, including Dr. Jamie Karambay who once diagnosed a neck fracture after observing a patient holding up her own forehead while drinking from a water fountain. 

Sometimes people with broken necks, who don't yet know they have broken necks, self splint their fracture by creating an anatomical c-collar with cupped hands on either side of their neck. After scouring the internet I have been unable to find reference to this behavior, and so I now unashamedly dub this Rinella's Sign. The combination of neck pain, trauma mechanism, and Rinella's Sign creates a syndrome now called Rinella's Triad

I am not aware of anyone having named this medical sign prior to me, but if you do see it mentioned somewhere in the literature please let me know. Also, if you are reading this and believe yours to be the rightful name of this sign, then I see no other way to resolve this...... I challenge you to a duel,  and God will decide.

Sunday, January 21, 2018

Brilinta Tattoo

Reader submission from Ox at

I've seen this goofy iteration of the EKG tattoo before. I'm told it's really difficult to do the sharp corners of the QRS complex correctly without the ink running. Otherwise all the other correct elements are there.

Brilinta is a fine medication, with greater 1-year survival rates post STEMI over Plavix, which doesn't work on something like 14% of the population due to a genetic anomaly that prevents affected people from metabolizing Plavix. They should vet their ads better.

The American Jubilee Book Review

This book - The American Jubilee - alleges that a round of biblical style debt forgiveness is inevitable and imminent, and that the nation will soon be plugged into chaos. I read this book at the request of a friend, and the following is an email I sent to her this morning reviewing the content of this book.

I just finished reading the American Jubilee book, and I am completely puzzled by its Dr. Jekyll and Mr. Hyde combination of good advice and completely dangerous advice, leaving me to wonder what the true goal was of the author. 
The opening portion of the book attempts to convince the reader - through a series of confusing non-sequiturs, false dichotomies, and out of context statements & figures - of the dire state of the nation's economy, and that a debt jubilee is imminent. Although I think debt forgiveness may be on the table in the future on a limited basis for things like student loans as a political promise of the left, I seriously doubt our nation's leaders from either side of the aisle would intentionally plunge the nation into the deflationary chaos which would follow a complete jubilee of all corporate and consumer debt in our current economic system and scale.
However, were a person for some reason completely convinced of an impending nationwide debt jubilee, the only acceptable place for their wealth would be gold, silver, domestic cash, foreign cash, land, weapons & ammunition, food, fuel, communications equipment, and other supplies to weather the coming megastorm, the unprecedented scale of which we could only imagine. But the book then goes on to recommend that readers put their cash into the stock market, purchasing such companies as American Express. To be clear: this book, which just dedicated an entire section to convincing the reader that the end is nigh and that all debts are about to be wiped clean, instructed its readers to purchase shares of a credit card company which would be completely bankrupted by the ensuing chaos of a debt jubilee.
The book's advice on purchasing junk silver is good, but dated. Junk silver is available in denominations as small as $1 face value (not $1,000 as the book states) from several online retailers like, and as small as individual coins on eBay. The stock market investment advice in the front half of the book is quite dangerous. Advice to short the stock market is completely inappropriate considering that this book is clearly written to the novice investor. The back half of the book then happens upon some very good stock market advice, instructing the reader to invest in dividend aristocrats (which it calls "elite dividend payers"). These payers of growing dividends are truly the path to investment peace, as the book describes, since they continue to pay you increasing amounts of money no matter what the panicky stock market does. Dividend growth stocks comprise the majority of my investing strategy for this reason. 
It wasn't an altogether bad read, and it did get me thinking about purchasing some Loonies and Twonies as an additional hedge against US dollar weakness. Overall I think it's very important to research this or any investment advice before pulling the trigger, as this book does present a confusing mixture of good and bad information. 

Wednesday, January 10, 2018

Requirements for Learning

Years ago while discussing Sudden Infant Death Syndrome at a case review meeting, our chief at the time - a newer paramedic and a single man with no children - announced that we would launch a campaign to teach parents not to co-sleep with their babies. Righteously, an EMT - an actual mother who was educated on the subject - spoke out against the proposal, citing conflicting recommendations and schools of thought from multiple sources. The chief had no parenting experience, and therefore no foundational knowledge on which to form an understanding of the needs of a baby or the needs of an exhausted mother, and could not have spoken on the subject with anything greater than specious authority, parroting controversial advice from other entities. In the end, his well-meaning but ill-advised proposal was dropped.

Lately I have been thinking about the prerequisites for ethical instruction and legitimate learning. I have developed a two question test to determine if an instructor is acting ethically, and a subsequent two question test to determine if learning will take place.

Requirement for ethical instruction:
1) The instructor must have a thorough knowledge of the subject, and teach the subject correctly, and
2) The education must be delivered in a constructive (i.e. nonviolent) manner.

Requirements for legitimate learning to take place:
1) The instruction must be ethical, and
2) The instructor must have credibility with the students.

Case Studies

Case #1: Ethical instruction, but no credibility.

While visiting Nazareth, where He was raised, Jesus went to the synagogue and began teaching the people there. Although Jesus had a thorough knowledge of the subject matter, the people proclaimed, "Is this not Joseph's son?", indicating that Jesus had no credibility with them since they had known Him as a boy. Jesus noted, "No prophet is accepted in his own country," and escaped right before the people attempted to hurl Him off a cliff. 

Despite His ethical instruction, no learning took place among the people of the synagogue due to Jesus' lack of credibility among His Nazareth audience.

Case #2: Unethical instruction, with positive credibility.

Marshall Applewhite was the leader of the Heaven's Gate cult and claimed to be God. He held a great amount of credibility with his followers, to the point that the men willingly underwent surgical castratration in Mexico at Applewhite's instruction. In March of 1997 Applewhite told his followers that an alien space ship (hidden from sight by a government conspiracy) following Comet Hale-Bop would transport them to heaven. In order to reach the space ship, Applewhite and 38 of his followers took barbituates and placed plastic bags over their heads in the largest mass suicide of US citizens since Jonestown.

Despite Applewhite's clear credibility with his followers, his instruction was unethical because he was unable to comprehend or correctly advise his followers about the subjects he taught, which finally caused them harm. No legitimate learning took place. 

EMS Implications

There is an idiom in EMS, and I'm sure elsewhere: Those who can't do, teach. People who are incompetent or inexperienced in a subject, and who don't have credibility with their peers, can often achieve  the acceptance they crave from impressionable students who don't know any better. Their instruction is often incorrect, and the instructor lacks a thorough enough comprehension of the subject matter to answer complex questions and advise students appropriately. I once observed a training captain boast to a student, "you know... female, fat, forty... That means diabetes." The student was amazed by the new piece of information gifted to him by his instructor. When I advised both of them that those were  in fact risk factors for gallstones and not diabetes, the instructor attacked me as too young to know what I was talking about, and vehemently defended his incorrect position by claiming to have learned it before I was born. The instructor was willing to continue teaching false information to new EMTs in order to maintain his credibility among his students - a testament to the power of social acceptance as a motivator.

On the other hand, even when the subject matter of the instruction is correct, the education can be delivered in an unethically destructive manner, such as by means of the public embarrassment and emotional flogging characteristic of traditional case review meetings, which leads to no learning taking place. Additionally, some inexperienced EMS leaders may lean on hospital RNs to provide instruction to their paramedics. Even if those RNs end up teaching correct material, few medics will have faith in the nurse who consistently treats them like inferior garbage during patient care hand-offs. This is exacerbated in systems where EMS leaders treat paramedics as inferior providers to those RNs. Consequently, no learning occurs. 

All educators should make an interospective evaluation of their motives for teaching, and test if their actions are ethical. Organization leaders should evaluate their continuing educational systems to determine if actual learning is a realistic expectation of their students. 

Saturday, December 23, 2017

Bitcoin: Are you being pumped & dumped?

The price of Bitcoin, as measured in US currency, has recently skyrocketed. Over the past several weeks I've observed this generate a significant amount of interest in Bitcoin among my work contacts and colleagues. For most of those people, the recent attention being given to bitcoin is their very first introduction to any type of investment vehicle. Although I applaud them for their desire to grow their wealth and change their future, the current Bitcoin frenzy is exhibiting several similarities to both a Pump & Dump scam, and a speculative bubble.

The Pump & Dump:
"Pump and dump is a scheme that attempts to boost the price of a stock through recommendations based on false, misleading or greatly exaggerated statements. The perpetrators of this scheme, who already have an established position in the company's stock, sell their positions after the hype has led to a higher share price. This practice is illegal based on securities law and can lead to heavy fines."
Pump & Dump specifically refers to a scam in the stock market, and in that context it is illegal. However, Bitcoin is not a stock and is not subject to the same protections. If you are receiving panicked emails from Bitcoin related companies and newsletter's urging you to get into Bitcoin before it's too late, you are being pumped. Fear is a known tactic used by marketers to whip up emotions and encourage consumers to buy products. Examples of fear in this context are currency collapse, nationalization of retirement accounts, and stock market crashes. Although these are legitimate concerns everyone should address in their investment portfolio, it is not wise to allow simple concerns to grow into full blown fear which then becomes the all encompassing basis for making panicked, phobia based investing decisions. Investments made emotionally generally turn out to be money losers.

If my last paragraph enrages you to the point that you are scrolling to the bottom of the page to leave a nasty comment about how ignorant I am, then you have fallen prey to another predatory pump & dump tactic: brand tribalism. If you feel compelled to vociferously defend the honor of your chosen product (e.g. Bitcoin and the honor of your fellow Bitcoin owners), congratulations... you have joined a tribe. As a soldier of that tribe you have a duty to defend the rest of the tribe from foreign invaders who threaten the integrity of your tribe.

The Speculative Bubble:
"Tulip mania... was a period in the Dutch Golden Age during which contract prices for some bulbs of the recently introduced and fashionable tulip reached extraordinarily high levels and then dramatically collapsed in February 1637... At the peak of tulip mania, in February 1637, some single tulip bulbs sold for more than 10 times the annual income of a skilled craftsworker."
Bitcoins smell a lot like tulips. In this 17th century speculative bubble, panic buying drove the price of the insignificant tulip bulb to insane levels, right before panic then caused the price to reset back to normal... which is something far less than 10 times the income of a skilled craftsman.

Any time something increases in price by 1,500% within one year, you should be alert to the possibility of a speculative bubble. Similar to tulip bulbs, there is nothing more tangible apparently behind this recent rise in the price of Bitcoin than social panic. There hasn't been a sudden decline in the quantity of bitcoins, a sudden increase in the utility of bitcoins, or sudden increase in the intrinsic value of Bitcoin (because there isnt any... it's just as much a fiat currency as US dollars). Panic buying is driving up demand, which is causing the price to shoot through the roof. Its price is in fact now approaching the annual income of a low wage earner in the US, and certainly far exceeding the annual income of workers in some less developed countries.

“And if they insist on trying to time their participation in equities, they should try to be fearful when others are greedy and greedy only when others are fearful” 
 Warren Buffett, 2004 Annual Shareholder Letter.
Warren Buffett made his billions being greedy when others are fearful, and fearful when others are greedy. The current ferver surrounding Bitcoin ownership mirrors the behavior of people buying Powerball tickets whenever the jackpot reaches $100 million, and should frighten away any responsible investor. This is a distinctly different fear from that used by marketers to sell their products, since it is disconnected from the groupthinking, irrational fear associated with tribalism. As I have previously explored, people lose the capability for critical thought in large groups. Buffett, and another major player - JP Morgan Chase CEO Jamie Dimon - have both spoken out about the dangers of investing in Bitcoin and other cryptocurrencies. When incredibly successful and wealthy investors deign themselves to offer advice to the rest of us, it is wise to listen. 

In 1929 a wealthy investor named Joe Kennedy dumped his stock portfolio just prior to the Black Tuesday market crash after a shoeshine boy gave him a hot stock tip. Kennedy figured that if shoeshine boys were giving investment advice, then the market was overbought and the bubble was about to pop. Several days ago, a CNA at the hospital give me a hot tip to buy some Bitcoin. Please, my friends, get out of Bitcoin now before you are dumped!

Thursday, November 9, 2017

Thank you world

This blog has had just shy of 59k page views since I started working on it four and a half years ago. I know probably half of those are bots, but, to the other half, I appreciate your views. I'm especially touched by the people of Germany, Russia (oh no a Russian connection!), Canada, the UK, France, Australia, Ireland, the Netherlands, and India who have contributed the most page views from outside of my home country.

I know that this blog isn't wildly popular or necessarily relevant to the majority of the population, but I do want to say thank you to the tens of thousands of people who have taken the time to stop by my little corner of the internet. Thanks!


I took this photo in Florida while working for FEMA during the aftermath of Hurricane Ivan (2004?). I can't remember exactly where this was, but the name Yankeetown sounds familiar. As hard as we tried, we couldn't get anyone in the area to clarify for us if the sign was an attempt to alert passers by that the handicap chid was slow, or if it was a request for us to drive slow through the area on account of the handicap chid.