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I did take a look at the injury photos, and I was rather shaken. I've seen just about every injury that a human being can suffer at one point or another. I've even had bilateral above the knee amputation victims, but this was something else. But the worst of it, by far, was the reports of the children's injuries, in addition to the death. Pediatrics and traumatic amputations are two terms that should never go together. I'm speculating, but with what's come out about the crudeness of the devices, flash powder, pressure cookers, and timers, anyone could have built this, and I mean anyone. In the end, this could have been the handiwork of nothing more than a stupid teenager who watched one too many Youtube videos. It would explain why there was no 'chatter' before the event and, most interestingly, no one came forward afterward, I can completely see it being some 16 year old with problems at home who didn't grasp what this actually was going to do. Sure, it could be real international or domestic political terrorism, but, I'm just saying this wasn't C4 or even HMTD or something even rigged to a cell phone. This was less than amateur. Anyone, and I mean anyone, could have pulled this off.

Seeing the pictures made me really cringe. I wish I could have been there to help. From an EMS response standpoint, here are my thoughts: - The prevalence of lower limb injuries is interesting. This could just be by placement, but it may have been by design as well. - I'd really like to see the PTT/INR stats on some of the victims. Bad guys have been known to pack the shrapnel with warfarin containing pesticide to increase mortality rates. - Hats off to Boston EMS. Wow. Great job. The response will become required MCI reading in the future. - This is the MCI eventuality that a lot of us have trained for and hope would never happen. I hope that it will reinforce the importance of training, preparedness, and preplanning.

I never buy the "its the hidden agenda" line. This "hidden agenda" nonsense is something that right-wing pundits made up so people will vote for them and buy the products their sponsors are selling. I've never seen paranoia like this creep into mainstream political ideology, but its scary. Really scary. That guy in Alabama was a prime example of it. Years ago, a heavily armed guy who built a bunker in his backyard and patrolled his land at night would have been a red flag. But that way of thinking has become so mainstream that it didn't even register. We need to end this crap before more people get killed.

Explain to me this one. The DEA clamps down on certain chemicals and lab equipment that can be used to manufacture illicit drugs. Its not that its impossible to acquire it, its just that it takes a lot of paperwork and accountability to do so. These chemicals and pieces of equipment have a myriad of uses, far more uses than high capacity semi automatic rifles do. Why is it such a big deal to apply the same rules to certain firearms than we do to certain pieces of glassware?

I'm sorry, but I came to the consensus that the only time its acceptable for a man to wear a pink shirt is on the French Riviera. I'll do my part by dangling a bully over the side of a highway overpass like I do every year.

Maybe those brave men who go play paintball on the weekends could tolerate living in caves for a little while, chbare. But as soon as the power gets shut off and they lose wi-fi, they'll find their popular support among their constiuents dropping rather quickly. I'm still waiting to hear how these scenarios would play out. The last time there was a show down with the feds was probably Little Rock, Arkansas. The National Guard was federalized and that was the end of the story. I assure you the civil rights movement was far more divisive then the current debate on firearms, and all that came out of that showdown was a General having to ask a governor politely to step aside. You had the Freemen. They lost. You had those F.E.A.R. guys. They lost. You had all those fun leftist groups back in the 60's and 70's. They either lost or became yuppies. No grassroots or separatist effort in the history of the United States has been able to resist the federal government by force to anything even close to an appreciable level outside of the Civil War, which was actually kind of a blow out. The only problem was that the modernized weapons caused a staggering amount of casualties. You can stockpile .223 ammo and make all the venison jerky you want. The Army Rangers have more rounds, better training, and probably more jerky, too. Its a delusion.

But Dwayne, even the really dubious argument that "I need this much firepower to prevent government tyranny" is ineffectual. You would need a lot more than a Bushmaster to have any chance against a modern government. Things like Javelin missile launchers and anti-satellite missiles would need to be legalized. I've tried to picture in my mind what this doomsday scenario would look like, and really, it had better be over something than whether you can 5 or 10 rounds in your ammo magazine at any given time. What would be the breaking point? Suspension of habeas corpus? Already happened during the Civil War. How about government takeover of manufacturing? That happened too. World War II. How about a president elected in a highly contested election that had to be brought in front of the Supreme Court? That was the year 2000. Martial law? Hurricane Katrina. Well, technically that wasn't really martial law, but a state where laws were suspended and evacuations were ordered. I think that happened during Sandy, too. I just want to know Dwayne, what is the eventuality that's being considered? How plausible is that scenario? And if that scenario unraveled, how long do you think your average armed citizen would last in that modern battlefield scenario? Do you harbor the illusion that they could hide in the woods like the Viet Cong or something?

The point I'm trying to make is that in a lot of cases the thing that defends people from corrupt governments is the federal government. The federal government ended slavery. They put Al Capone in jail when Chicago and Illinois couldn't, or rather wouldn't. Its not the federal government scooping up American citizens and throwing them in jail because they look brown, that's Joe Arpaio. The federal government tries to stop things like that. Read up on the New Orleans Police Department. Would you want them being in charge without the DOJ stepping in? What about the financial sector? What happened when the SEC blinked briefly back in the early 00's? Do you have any idea what Wall Street bankers would do to you, your family, and perhaps your sister if the federal government wasn't watching them like a hawk? I don't want to come off like I'm championing the feds, who believe me, have their share of cock ups. But I just want to clue you in on something I've learned. The people who complain about the federal government are usually these big fishes in their little ponds of their local areas, who want to abuse their power and get away with it. Also, on its face value answering the question "Why do you need an assault rifle" with "so I can shoot government officials if I need to" does not particularly put me at ease or invoke my trust.

Dwayne, I understand your opinion, and Waco was a clusterfuck, but then again, you did have a cult leader inside keeping people prisoner and marrying underage girls. Its not like Janet Reno drove a tank through a church pot-luck. This is the way I look at it. The federal government has had very little to do with my life. Pretty much the only thing they've asked of me is to register for selective service when I turned 18, pay my taxes, and use proper postage. The Federal Government has never cut me off in traffic. The Federal Government has never kept me up at night with their loud parties. I've never seen the Federal Government instigate a fist fight at a ball game. I've never seen them trample someone at Wal-Mart. Law abiding citizens, on the other hand, I've seen much of that. Those people are the ones that have the most influence in my life. Those are the ones that pose the biggest threat to my safety. People complain about the government, but its my firm belief that the most plentiful and worst abuses of governmental authority don't come at the federal level, they come at the local level. How much corruption has to exist in a police force for the federal government to actually step in? The answer is quite an astounding level, because the Department of Justice is limited into what they can investigate, and in my experience you are far more likely to have your rights abused by some redneck sheriff than you are by a member of the FBI.

Let me get this straight about volunteer billing. You provide a service... the organization gets paid for the service... and the people doing the service don't get paid. Heck, the people in China assembling the iPhones at least get a couple of cents an hour.

Here, use your imagination about what this does to an arm, leg, head, lung, hollow, or solid organ: I know any gun shot wound on a child is catastrophic. But again, if 18 of those children weren't transported, it means the wounds were beyond catastrophic.

Here I'll clarify on the .223 round. Relatively speaking, the round itself is not particularly large, but the powder charge is designed to propel it at supersonic speeds. You see, right around the Vietnam war, they realized that a bunch of small bullets flying at high speed presents the best chance of scoring a lethal or neurogenicaly incapacitating wound. In other words, this gun was designed to shoot at something that is shooting back at you. That is there purpose. That is why they were built. That's why they are so deadly. Of those 20 children killed, 18 were pronounced on scene. What type of wounds do you think they suffered? What type of wounds would child have to have for EMS providers not even to bother attempting resuscitation? Even in an MCI situation, from what you know about yourself and your colleagues, what type of injury would a 6 year old have to have so that you don't work them? That type of wound? That's what a .223 round does. That's what they were made for. Inflicting catastrophic wounds on human beings.

Chbare, I'm talking about you in particular. I don't know you very well. You're probably a level headed individual who can be trusted with a gun of any sort. I have no doubt about that. But the problem is that a lot of people who have access to firearms aren just like the people I described. Gun owners can't put their blinders on and say those people don't exist, and in significant numbers. They do. Trust me, they do.

Chbare, I've heard all of them for just about every piece of equipment that you could possible strap on to a firearm of any sort. Except for folding stocks, that is. I have yet to hear a practical use for folding stocks except for concealing a large capacity, high power weapon, and the only reason you need to that is if you plan on ambushing someone, which is only appropriate in a combat situation. There is no situation in the civilian realm that a normal, level headed person would need something like that. You know what also cuts down on the noise made by firearms? Earplugs. They're cheaper and you can't screw them onto the end of a Ingram Model-10 and go tooling around the neighborhood. You know, once upon a time, even before Greenpeace existed, people noticed that a lot species of game were getting wiped off the map by poaching and over-hunting. So hunters came together and helped create laws to protect wildlife and habitats so that they could enjoy their sport responsibly, and thus the conservation movement was born. I think its time that hunters, sports shooters, and others who want to own firearms come back to the same point. If you want to protect what you have, come up with your own plans to regulate, enforce, and keep the people who shouldn't be in your area of expertise out of it. You can either say "look, there's a difference between a break open shotgun and a military grade high capacity rifle" or you can say NO NO NO WE WANT IT ALL, and then one day you'll wake up and have lost it all. You don't think amendments can be changed, enacted, or repealed? I assure you they can. Prohibition was enacted by constitutional amendment 18, and then repealed by amendment 21. 54% of the population is for gun control right this very minute, and unless this nonsense stops, its only going to get higher.

Here's my take on this. I grew up on a farm in the country, around various forms of firearms. Part of my medical training is the effects of various firearms and the injuries they cause. Part of my operational training deals with the aftermath of sudden catastrophic events. I have personally dealt with more gunshot wounds than I can remember. So any argument that I'm some sort of limp wristed gun grabbing liberal do-gooder is pretty well null and void. I am not against private firearm ownership. I am against the private ownership of military type firearms, namely, semi-automatic large capacity rifles, and accessories like folding stocks and suppressors, which have no legitimate application. No where in the constitution does it guarantee unrestricted access to any style firearm that is in production. These weapons contribute not only to the amount of casualties per incident but also in the lethality of the wound. The .223 round and the AR-15 style rifle was specifically designed to produce the best chance of achieving a lethal wound against an armed opponent at medium range. There is no place other than a battlefield that such a weapon is appropriate. The fact that a good proportion of these weapons in private circulation are owned by people who harbor anti-government and by into paranoid ideologies should be a cause for great concern. I have no great use for the term "law abiding citizen" because not only have I seen what supposed "law abiding citizens" are capable of; fist fights, road rage, bar brawls, domestic violence, virulent racist sentiment, just because you've never been convicted of a crime doesn't mean you are any person who should be allowed to own a weapon capable of taking out an armored fire team. I'm not sure which Wal-Marts you've been to, but the people at the Wal-Marts I've been to, the ones getting in pushing matches over the next generation iPad, those are the people who shouldn't be allowed to have access to sporks, let alone a gun. I don't care if they've never been convicted of a crime or not. Nancy Lanza was a law abiding citizen. So was Jared Lee Loughner. So was Charles Whitman. So was Seung-Hui Cho. So was Eric Harris and Dylan Klebold. What I think though, what needs to change more than gun laws is gun attitudes. I am so sick of pseudo-macho, jingoistic wannabes and their stupid sayings. I know why guys like that have guns. Its not so they can respond with deadly force if necessary. That's not why they want to bring their concealed weapons to Starbucks or Wal-mart or even on an ambulance. No, they want it for when someone cuts them off in traffic, or calls them an asshole, or spits on them. That's when they want to know they have a gun on them, and they are disgusting people. I am also sick of the NRA. The NRA was once an organization for sportsmen and other firearm enthusiasts. Now it is a haven for domestic extremists and their paranoid, hateful views. If you're a hunter, I suggest joining Ducks Unlimited instead. They're about hunter's rights, wildlife conservation, and you won't find many mentions of the United Nation's invasion plans or who the media's really run by, or where the president was born. The NRA needs to go. What if you substituted flamethrowers for the type of weapons I'm talking about? Flamethrowers are perfectly legal. Flamethrowers have uses other than killing, like clearing brush or doing controlled burns on fields and stuff, and you know, I'm willing to bet they make pretty effective self-defense tools, too. But no one demands they be allowed to walk into Starbucks or Wal-mart with a flamethrower. No one shows up at political rallies with a flamethrower holding up a sign about tyrants. We'd recognize that as really dangerous behaviour. No one says "You can have my flamethrower when you pry it from my cold, dead fingers," and if the guy in front of you in the checkout line was muttering about his concerns of the government taking away his flamethrower, you'd be probably pretty concerned. Well, that's my view on guns, I consider them to be like flamethrowers.

The UN is in the United States. New York, to be exact.

If the IAFF continues to insist to put together five paramedics on an engine all who have intubated once in the past 3 years, intubation success rates will continue to suffer. That's about all I can say on the matter.

My $0.02... If the paramedic doesn't want to do 12 leads on people who are less than 3 minutes away from a hospital, well, that's on him. Maybe he has a reason for it. Maybe that center is a PCI center. I don't know your system and I don't know him. But that's his decision. There is no excuse for belittling others in front of family members. You should address that directly with him. Many times people don't even realize they are being belittling and will apologize and change their ways. I get the sense though, that you, much like other people who are a lower level provider assigned to work with a paramedic, just doesn't like to take orders. You don't like people telling you what to do. That's fine. It's an understandable sentiment. Unfortunately, the paramedic is in charge, it is his unit, and you are the new guy. Your opinion should be valued and considered, but it doesn't mean that because you disagree, you're right. You had to fight to get this spot. Well, just because you won doesn't mean it should be ideal for you. Make the best of it, and if serious issues come up, address them then and there.

I'm not sure what this all about. My guess is your AG has been smoking out with that federal judge who said that Obama is going to use UN troops to invade and steal your barbecues.

It's entirely possible to do. First of all, not all paramedics do 24 hour shifts. I myself do 12 hour shifts. 24 hour shifts means you'll be away from your family for two to three days. Compare that with the five days a week people are usually away and you see its not that bad. My wife doesn't have a problem with it, then again, my wife has a super-human ability to put up with the amount of shit that I inadvertently track into her life. So long as you don't become an asshole and believe its okay to bang person X because of the "stresses" of your job, you can make a family life work just fine. But once you start believing that because what you do gives you license to act like an asshole, i.e. drink, fool around, basically act like a total douchebag, then you will lose the people you love or at least once love. I know many firefighters like that. But I know even more of their ex-s.

You know twist, I had this entire response ready to go, ready to explain the difference between hypoxemia in COPD and high flow oxygen in the presence of tissue schema, but I'm giving myself a break, so let me just say, you're really, really wrong. You're so wrong I'm not even going to bother going into detail telling you how wrong you are.

Actually, Richard, Black Talon and "Cop Killer" bullets are at opposite ends of the ballistics spectrum. Black Talons are designed to transfer maximum energy to the target, they do this by mushrooming in a way that creates six or so small, razor sharp points to cut into flesh and bone. The more mushrooming capacity a bullet has, the less likely it is to penetrate body armour. It transmits the bulk of the energy to the first thing it hits. Teflon coated bullets, on the other hand, like military-grade jacketed ammunition is designed to pierce armour. It is designed to keep its ballistic energy and trajectory despite having encountered resistance.

Study.

I nearly had my arm broken by a guy on PCP. I didn't file charges, because he was on PCP. This reminds me of a patient I had way back in the dark days when I first started working, doing an inter facility transport for a 16 year old with seizures. They called 911, the police responded first. When they arrived, he was post-ictal and kicked one of them. You could say the officers used more force than necessary in restraining him. You could also say they beat the living shit of him. If you can't manage an AMS patient, find another job.

Hi novice, as an American who moved to Vancouver, I think I can tell you a bit about it. First of all its tough to get permanent resident status in Canada. You can either get it through a family or a skilled worker application. I'm married to a Canadian citizen and it took me about two and a half years from the date of my marriage to get my status in Canada. Unfortunately, the news recently said that Canada was so backed up with skilled worker visas that they basically returned everyone's application and have to start over. If you can get a student visa to study at JIBC, that's really awesome, and if you can afford to, go for it. There is a demand for PCPs in BC, to be sure, but like anything in EMS, getting the spot you want sometimes means having to be patient and work a job in a position you don't want. My biggest pieces of advice are: Don't try to do immigration through Quebec. Quebec is an island unto itself and has separate immigration rules. Secondly, don't think about working in Washington State in EMS while you wait on your Canada immigration. Washington State not only has a very insular, protected EMS system that requires a system to sign off on you before you are certified i.e. you have to find an organization to first hire you, then put in your papers for certification, making it very difficult to get a job, in addition, Washington State's economy which relied heavily on timber production was decimated when people stopped building new houses. On the other hand,one interesting thing I found out was that that the BC EMR level is equivalent to a WA EMT-B level, and there is some reciprocity agreements there. Lastly, do not get fooled by anyone or any business that tells you they can streamline your immigration process. They can't. Its not in the province of BC's hands, its in the federal government of Canada's hands, and unless you have some contacts at the highest levels of government, nothing can really be done to speed up an application. So, if you can get a student visa to study at the JI, go for it, that sounds really awesome. On the other hand, it will be extremely tough to be able to work in Canada, even if you do get the full PCP license, and then even if you get the PCP license and the work, which will be a real feat in itself, you'd still have to work on getting hired, and intakes to various organizations sometimes only happen a couple of times a year. It isn't something that isn't worth working for, but it is very difficult and make take a long time to complete. But remember, people go to college for four to six years to get the job they want. You might have to as well.