Sometimes You Get to Think That You Have Accomplished Something! · Uncategorized

DELAYED GRATIFICATION

 

I entered the PA world somewhat late in life. I had spent nearly 30 years toiling as a RN, in ER, as nursing supervisor and in ICU, when I decided that a change was in order.

For most of my nursing practice, I had counseled my patients that stopping smoking was in their best interests. Those that seemed receptive, got the entire “treatment”, recounting how my (now) ex wife, mother of my children, and an RN herself, smoked. I observed that, aside from marrying me (and subsequently divorcing me), she was pretty smart. In addition, she displayed a backbone formulated not from calcium salts, but rather from ordnance steel. As Mom, I am entirely in favor. (As the Plaintiff, I’m not such a fan) In either case, even in light of her own ICU experience, she persists in smoking. I shared that this illustrated that the difficulty of ceasing smoking was often understated. Worthwhile, but underestimated.

I regaled patients with this tale time after time, as each seemed receptive. I never received any feedback for these efforts. Yet, following the role of nurse as teacher, and later of Physician Assistant as teacher, as well as clinician, I persisted.

My first PA job out of school capitalized upon my years as paramedic, ER RN as well as ICU RN, and placed me in a rural hospital ER. I continued to insert smoking cessation teaching into my discharge instructions, even if I did not see it elicit any change in behavior. My nursing colleagues even observed that my time was not effectively employed, because, in their appraisal, folks would not stop smoking due to my efforts. I persisted.

One attraction of a rural community is that everybody is, indeed, your neighbor. You get the opportunity to practice community medicine, even as an ER clinician. The child whose sprain you treated last weekend, likely will be playing on the local school team alongside your own child the next. You are not anonymous, and neither are your patients.

That was brought home to me one evening, as I took my family out for dinner in our small town. It was some surprise to me, in spite of the foregoing, that our waitress approached us with the greeting, “I bet you don’t remember me, do you?” I admitted the truth, and asked how she was.

“My ankle is all better,” she prompted, and continued. “I bet you don’t remember telling me I had to quit smoking, do you?”

Again, the truth was told. She again prompted me, “You told about how smart your wife is, and how she is a nurse, but still smokes.” (THAT earned me a glare from the Loyal Opposition!) I allowed that I frequently offered such counsel, while attempting to non-verbally make nice with the mother of my children.

“Well”, she continued, “I really thought about what you told me, about emphysema, and leather skin, and throat cancers and all that stuff I was risking. I decided that I did not want to drag an oxygen tank around like my mother did. I quit smoking last week, and it is all because of you taking the time to tell me how bad it was for me!”

I responded with something encouraging, and in recognition of her own investment of energy, decisiveness, and determination, and she thanked me again and walked away to serve other customers.

I think about that woman from time to time. I realized that people will stop smoking, when they are ready to do so, for the reasons that matter to them. The only thing I can do is encourage the decision, and attempt to nudge it along.

Occasionally, I can nudge a decision. Then I must wait for the patient to make that decision, on their timetable, and for reasons that matter to them.

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guns · Having A Good Partner Is Very Important! · Life in Da City! · Pre Planning Your Scene

Medic 5 Heart Attack

 

So, this one time, at band camp…..no, wait. That’s not quite right.

So TINS©. There I was FDASL©, detailed out to Medic Five from my home house. It appeared that I had offended the Patron Saint Of EMS and Street Medics, grievously, because I arrived to find Cletus, grinning widely, awaiting me. Shit.

I asserted The Prerogative of Seniority, and drove, leaving Cletus to medic. (Remember that. File under “Things That Come Back To Bite Me in The Ass”) The day passed pretty uneventfully, runs came in, patients got transported, and we, of course, fought disease and saved lives.

Now, at that time, nearly 40 years ago, Medic 5 was out toward the western margins of Da City. The firehouse called home was on Bliss Road, close by to the Western Expressway. Western suburbs included Gardenia and Westworld. Our hospital choices included a couple of small hospitals of the plethora that (at that time) dotted the city, or a couple of respectably sized facilities in those selfsame suburbs.

So, somewhat later in the afternoon dispatch invited us to respond to a “heart attack”. This took us nearly to the city limits. As we pulled up, there was a figure hopping around on the porch, arms a-waving, feet a-tapping, directing us to that dwelling. (Uh, you mean to tell me that every other house, lacking front porch frenetic interpretive dance performances, are NOT the scenes to which we were called? This is my shocked face!)

So, of course, Cletus bought into the pandemonium, whole hog. He leapt from the rig, just about as soon as I brought it to a stop, and beat feet into the house, leaving me, the handheld radio, and every other thing (except the medic bag) behind. I placed the ambulance in park, shut off the beacons, and radioed in to dispatch that we were on the scene.

I turned on the handheld radio, and followed him into the house. As the occupants opened the door, I was struck (nearly literally) by the pall of gunsmoke that wafted out into my face. Asking about my partner, I was directed into the rear of the house.

I reached the end of the hall, and, in the bedroom to my right noted my partner bending over a supine soul. I announced myself, and CLETUS TURNED ON ME, SNUB BARRELLED REVOLVER IN HAND. Of course, he was pointing the barrel at my belt buckle. I swept his hand over my head, removed the handgun from his hand, and asked him what the…er, fenomenon he thought he was doing.

“She had it in her hand, as I entered the room.”

“Uh huh. What else is up?”

“I dunno.”

“Howzabout you find out?”

As he turned to assess this lady, I figured that having a loaded gun, on my scene, and not in my control, was A BAD THING. I wasn’t about to remove it from the scene: that seemed to me to be very like tampering with evidence, so, instead, I opened the dresser next to me, opened the cylinder and dumped the bullets into one drawer, slammed that drawer shut, and tossed the revolver into another drawer, which I also shut.

I turned back to Cletus, and saw him reaching for the BVM (bag-valve-mask), as he evidently had determined that this soul was arrested. Hmmm. Trauma code. Kinda expecting a malign outcome.

I handed him the prep (handheld radio), asked what else he thought he would need, and ran to the truck for the cot. We wrestled the patient onto the cot, trotted from the house, and set Cletus up for a restful episode of solo CPR in the back of a moving ambulance. Yeah, totally.

I called to dispatch, asking the location of and directions to the nearest trauma center (it wasn’t my house, wasn’t my district.) I reported , “Medic Five, Code One, Westworld Hospital. GSW Chest, cardiac arrest. Notify police, no scout at scene.”

Sometimes, you can hear the double take over the radio. “Medic 5, did you say GSW?”

“Affirmative. GSW chest, cardiac arrest.”

“Medic 5, are you sure?”

“Yeah, dispatch, kinda sure. My partner retrieved the pistol from the victim’s hands, I tossed it into the dresser drawer next to her.”

“Very good, Medic 5. We’re calling the hospital now.”

So, I navigated the Tie Fighter that is an ambulance running code, through the suburban traffic. I was (pleasantly) surprised to see traffic moving aside, as if I were Moses at the Red Sea, as the siren and beacons made known our intent.

We arrived at Westworld Hospital, and turned our patient over to the ED crew who, unsurprisingly, called the code after a brief attempt at resuscitation. Cletus and I cleaned up the truck, and completed the trip sheet.

We were just about to head out, when dispatch called us, directing us to phone them.

Once I had done so, I was directed to phone another number, because the detective wanted to talk to me. Once I had identified myself, he launched into his inquiry.

“You the medic on the scene?”

“Yeah, me and Cletus.”

“So, this was a shooting, right?”

“Yep, gunsmoke and all.”

“So, where is the pistol?”

“I dumped the cartridges into the dresser drawer, and tossed the gun itself into the top drawer.”

There was a pause. “You know, you have messed up my scene, and tainted my chain of custody.”

I contemplated this for a moment. “Well, sir, there was no officer on the scene I could turn the gun over to, and I was reluctant to leave a loaded, unsecured, firearm floating about on my scene. I did not think it would be clever to (a) remove a gun from a likely crime scene, (b) have in my possession a firearm that had been implicated in a likely crime scene, or (c) carry said firearm into a hospital with me. So, I did not identify any better option, at that time and on that scene.”

Life Lesson Number One: Sometimes, you have to extemporize.

Life Lesson Number Two: to quote John Farnam: “You may be killed when you take decisive action. You may likewise be killed when you do nothing. Either way, dithering is toxic. Indecision and delay will prove fatal. So, size-up the situation quickly. Hit the “go” button. Don’t look back.”

http://defense-training.com/2018/who-dare/ (datelined 14 May 2018)

Fun With Suits! · Pains in my Fifth Point of Contact

Erehwon ER Day Shift Call Off

So, a long, long time ago, in a county far, far away, I was the overnight ER nurse in Erehwon Memorial Hospital (“Both nowhere, AND backwards!”). I’d clock in at 1900, and until 0200, there’d be two of us working the 6 bed cubbyhole that passed for the Emergency Room out here in the suburbs of nowhere. Once 0200 came along, it was me and the Physician Assistant, all to our lonesome.

So, TINS ©, there I was, Fighting Disease and Saving Lives ©, and, long about 0500, I received a phone call from our director of nursing, Beelzebub. She reported that (a) the day shift nurse had called off, and (b) I was going to have to work over.

Now, at this time, we had four children at home, two of whom were toddlers. In addition, Erewhon Memorial Hospital had awful insurance, and expensive into the bargain. Therefore, since my wife made more money than I, and had cheaper and superior insurance, she carried us all as covered family members. That made HER the primary breadwinner, in my book. Our routine was I’d boogie home, and she’d meet me at the door, and traipse off to her Monday through Friday, 9-to-5 office job. I would then watch our children, until she came home, and nap away for a couple of hours until I got to do it all again. Working 12 hours meant a couple of things. First, it made for long, long duty days with that sort of plan. Second, working every other weekend, well, on work weekends I got to sleep the day away. Third, there were 2 days every week where I had to enter the parental “Iron Man” contest, and the rest of the time I was not more challenged than was my baseline.

So, departing from work late was not going to work for me, inasmuch as that would either make my wife late for work (a non starter), or leave the toddlers alone at home while the older kids went to school (another non starter). Alternatively, I could boogie on home, and be the Dad. That was my Plan “A”, and I was reluctant to deviate from it.

Surprisingly, when I presented my reluctance to Beelzebub, she was unimpressed. “You will simply have to work late, until I can find someone to cover for you.”

As was I. “Uh, no. Your problem is NOT covering for ME. I am here, and will be here until the end of my shift at 0730. Your problem is covering for the employee who called off. I am unable to do so.”

“Well, you simply cannot leave. I do not have anybody to cover.”

She did not appear to be listening. “Well, I likely can stay until 0800, but not one minute later. I will not have my wife be late for her job, simply due to your inability to perform yours. Similarly, my children will have a parent at hand this morning, and that parent will be me. I can inconvenience myself a bit on your behalf, but I did not call in, I am not responsible to write, enforce, or amend the sick or tardy policy, and I will not accept that responsibility.”

Still with the not listening. “You can not leave. I will prevent you from leaving!”

That was interesting. “Uh-huh. How, exactly, do you plan to stop me? Simply so you know, I’m an ex-Da City street medic, and I have been threatened by honest-to-God, no shit felons. It will be interesting to see what you bring to the conversation, that they did not. And, if you’re later than 0730, you will miss your chance.”

She was not giving up. “You cannot leave the narcotics unsecured.”

I had thought this through, just a bit. “I understand that. My plan is to secure the narcotics, and count off with whatever nurse you send to relieve me. If you have not done so by 0730, well, then I will secure the narcotics keys someplace I personally know to be safe, and bring them back with me when I return to work next week.”

“If you take them home, then I’ll send the sheriff out to retrieve them.”

This, as well, had been part of my ruminations. “That works for me. Once that deputy has provided me with documentation that he or she is a legitimate recipient, I will provide them to that officer, and require a written receipt.”

She delivered what she evidently thought was her trump card. “If you walk out that door, I’ll bring you up with the Board of Nursing on charges of patient abandonment.”

Me, I had a figurative Ace of Trumps. “That ought to be interesting. Just so you are aware, in that event I’ll bring charges against you, before the Board of Nursing, regarding your neglect of duty. You know folks will call off: you provide sick time. Yet, evidently, your ‘plan’ is to have somebody work as long as 36 hours, because you do not have any sort of real plan. I’m confident that I can argue that any reasonable and prudent administrator, of your background and training would know, or ought to know, that somebody might call off. With that knowledge, comes an affirmative duty to have a real plan to address the dislocations that this sick call will predictably produce. A plan that, evidently, you do not have.”

She did not seem to have a counter. “You cannot bring me before the Board of Nursing!”

I was unconcerned. “I’ll be certain to mention that. In my written complaint. To the Board of Nursing.”

The call terminated at about that point. I called home, and brought my wife up to speed on the entertaining soap opera that was my workplace. She was concerned about the youngest kids, and we game-planned a couple of alternative measures to manage things. We ended the call with a plan of action.

So, long about 0735, one Mark 1, Mod Ø Very Pissed Off Floor Nurse arrived to “take report”. Inasmuch as there was no soul there at all, not on the payroll, that part was quick. Narc count went smoothly, and I danced my happy ass out of the door. I met my wife on the road, part way to her job in the next town, we handed off the kids, and she continued to her job, and we went home.

The Moral Of The Story: Nurses are very, very good at passive aggressive behavior. I had been a nurse at that point for nigh onto 20 years. I would put my passive aggressive against anybody’s.

And, planning for things that are readily foreseeable, might be A Good Thing.

Tee-hee.

Fun And Games Off Duty · Uncategorized

Motorcycle PI on the way to the State Park

One sunny summer day,  The Darling Wife and I were on the way to a state park one of our friends had spoken fondly of. We were motoring along on one of the divided highways, and noticed that traffic had stopped.

Indeed, it had JUST stopped. We halted next to a fellow pulling a large house trailer with his station wagon (yep, true story!). He had managed to stop, likely a near-panic-stop, without leaving his lane, and well short of the supine figure on the pavement maybe 20 meters in front of him. The spilled motorcycle nearby suggested how he came to be there. Suddenly, I was VERRRY impressed with Mr. Station Wagon’s motoring skills.

Once we had stopped, and I had parked the vehicle, I noticed other motorists creeping past us, on the shoulder or between the lanes of parked cars. TDW and I were puzzled by this, thinking that, occasionally, events happened that were more important than somebody getting to their destination without delay, and some poor schmuck supine in the roadway might qualify.

I exited the vehicle, and retrieved my medic bag. I suggested to TDW that she pay attention to traffic, and phone it in to the local sheriff/fire department/EMS/Etcetera, while I sorted out the scene. She interrupted her tirade about “stupid mother flatterers”, or something that sounded kinda like that, to acknowledge my comment, and took up the CB microphone when a trucker asked what was happening.

Once I had walked up on the scene, one individual was kneeling at the supine person’s head, immobilizing him, and announced, “I’m an off duty firefighter!”

I replied, “I’m a physician assistant, an ED nurse, and former paramedic.”, and began to size up the situation.

Another person presented herself, and announced she was an ER nurse. I suggested that vitals would be really nice, and handed her my stethoscope and BP cuff.

Yet another person arrived, asking, “Can I help?” I suggested a pen and paper would be good, to write down the vitals for the responding medics, and this soul took off, returning with a notebook and pen.

Yet ANOTHER person arrived, announced that he was a National Guard medic, and everybody introduced themselves. Again. He was detailed to arrange for scene security, so that no impatient retard could creep/blow through the scene and sweep us all up like last week’s dust. He grabbed a couple of other bystanders, and made it so.

I started a secondary survey, looking for unseen bleeding or fractures. I found none, and about that time the first firefighter/Medical First Responder arrived. The nurse and note taker provided him with vitals, and I provided my summary of the survey.

I gathered my stet and cuff, and retreated to the car, where TDW awaited. She had news for me, relating to the 18 wheeler behind us, that I now noted to be jack-knifed across all lanes of traffic. It seems that he was the trucker asking about what was happening. She told him about the “special” souls intruding into the accident scene with their cars. She quoted him as observing, “So, ya know, I can fix that!”. The next thing she beheld was this truck turning from the extreme right lane of traffic, until his cab was nosed against the median rail, and his trailer was into the right hand shoulder.

Sure slowed down the jackwagons. Nicely done!

Once the medics had packed up Mr. Dumpedhisbike, and moved along, and the fire department had moved the motorcycle, we were free to resume our journey. TDW observed, once we were mobile, “Ya know, I see again why you pack all that stuff into your trunk! Sure comes in handy, from time to time!”

Having A Good Partner Is Very Important! · Life in Da City! · Uncategorized

History Lessons

Long ago, and far away, I was FDASL © in Da City. On EMS, when I was partnered with Doug, things were generally smooth, as he was a great partner, had his head in the game, and we worked well together. In addition, he was a genuinely nice guy.

We took turns medic-ing, and driving. One night, Doug was driving, and I was doing patient care. Well, TINS ©, Doug and I were out on a scene, with a gentleman who was some variety of sick. For some reason, now lost in antiquity, this soul felt compelled to deliver an oration on the subject of The History Of Oppression Of People Of Color (such as himself), By The Blue Eyed Devil (that would be me).

He had pretty much completed the review of Prehistory, The Roman Empire and Oppression, and was beginning the preliminary discussion of Black Folks Being Oppressed In The Middle Ages, when he stopped for a breath. Turning to my partner, himself of The African Persuasion, our patient invited him to participate in my education. “Ain’t that right, Bro?”

Doug looked at this person, as if he had just discovered a new species of insect, and responded. “Sir, ya know, if I were you, I’d speak a little more nicely to my partner, here. Me, I think you’re an asshole, and just as soon as my partner has had enough of your shit, well, we’re out of here.”

My tutor turned to me, goggle eyed. I smiled, and (just as if I really meant it) I said, “Uh, sir? Weren’t you just about to tell us what sort of sick you were, and whether you wanted us to take you to the hospital?”

Uncategorized

Lawdog nails it.

https://thelawdogfiles.blogspot.com/2018/03/meditations-on-death.html

READ THIS.

Mr. Dog understands Duty, and Honorable actions. A week or two ago, I heard a police officer interviewed on the radio, talking about law enforcement response to active shooters.  It went something like this: You hear bad noises.  Go to where the noises are coming from, and make it all stop. Period.

After Sandy Hook, within my family we discussed What Should We DO? I looked at my wife, she looked at me, and we agreed:  armed hall monitors, like in Israel.  I was asked, “How are the schools supposed to afford that?”

We answered, “Well, for 4 days a week, when she and I are not at work, my grandchildrens’ school will not have to worry about that expense. ”

“Do you think you will kill an armed intruder, intent on shooting students?”

My answer, “I sure as hell hope so! In any event, said intruder will have something to worry about, other than which is the next helpless victim.  I am confident I’ll fuck up his attack plan.”

I was told, “You’ll simply get yourself killed.”

My reply:  “That is possible, may be likely.  Can I not measure up to the courage of the teacher who died, sheltering other people’s children, with her own body? If I fix him in place long enough for the responding officers to END HIM, will my death have been in vain?”

Could it be, that my wife and I are the only parents/grandparents/neighbors who would volunteer for such duty?

I cannot believe that.

Mrs. Clinton’s child was protected, in school, by men with guns.

Mr. and Mrs. Obama’s children were protected, in school, by men with guns.

They are not alone.  Politicians’ children are protected by men with guns. (d)s, as well as (r)s.

Are not your children, your grandchildren, as worthy of protection as theirs? As anyone’s?

 

 

Pains in my Fifth Point of Contact

Pain Scales Are Tools of The Devil!

“Pain level of 15/10”

For those who did not know, sometime in the eighties, The Powers That Be ([T]PTB), in their unlimited wisdom, determined that Pain Was Undertreated!, and, of course, Something Must Be Done! This, as is usual in these initiatives,  meant that the untermenschen must be thrown beneath the proverbial bus, and, not surprisingly, we were.

We Peons were instructed that “Pain is the fifth vital sign”, and that “Pain must be adequately treated!” And so, “Pain Scales” were inflicted upon us. (I leave as an exercise for the student, what the connection between the foregoing and the present PANDEMIC! ZOMG! Of DEATH! BY! OPOIDS! Happens to be.) (Of course, it is the EVIL! Drug companies, and EVIL! Physicians who are at fault. Therefore, let the Benevolent PTB ride to our collective rescue with The Answer, right?)

So, TINS©, there I was, in the emergency department at this time in my life, Nursing away, FDASL©. I was in triage one shift, and, of course, interviewing and vital signing and pain assessing the teeming millions seeking cures (and work notes) (and narcotic scripts).

Pain assessment involves asking the patient how severe his/her pain is, with zero being no pain at all, and 10 being “the worst pain in the world”. Folks are asked to scale their pain against this imaginary yardstick. Mostly, people try to be fairly straightforward, and generally rate their, say, sprained ankle, at the time of assessment as something like a “4/10”. or maybe a “7/10”. Then, there are those creative souls who try to game the system. This is my shocked face.

One night, one soul arrived, reporting back pain, or some other malarkey. Strolling into the triage room, said soul sat, and I cataloged allergies, medications, medical history, pulse, blood pressure, respiratory rate, temperature. I asked about pain, with my usual spiel.

Sir/Madam, if zero is no pain, and 10 is the worst pain in the entire world, what is your pain level at right now?”

This person, appearing for all the world to completely nondistressed, looked me steadily in the eye, and replied “15”.

I blinked. “So, if zero is no pain whatsoever, and 10 is the worst pain ever, your pain is 15 on that scale?”

My correspondent paused to take a handful of chips from the bag on his/her lap, chewed thoughtfully for a moment, and responded, “Yep.”

Again, I blinked. “And, 10, T-E-N, is the worst pain in the enitre world, right?”

Yep.”

And, your pain is 15, F-I-F-T-E-E-N, correct?”

Again, with the chips. “Yep.”

So, you’re telling me that your pain is one-and-a-half times as severe, as the worst pain ever, anywhere, in the whole world, right?”

Yep.”

So, that would make your (chip eating, non screaming, non writhing, non weeping, non wringing-wet-sweating) pain, the worst pain in the world, am I hearing you correctly?”

Rumination, in both senses of the word. “Yep.”

So, if ’10’ is the worst pain in the world, and you, right now, have the worst pain in the world, and your pain is ’15’ out of ’10’, then you’re telling me that your pain, right now, is half again as severe, as the pain that you are having right now, am I hearing you right?”

More cud chewing. “Yep”.

What could I say? “I’ll make certain that the doctor learns all of this. Please have a seat in the waiting room, we’ll call you as soon as we can.”