Z-Pack! Arrgh!

Those of you who have suffered along, reading my scribblings (uh, I mean…) been frequent visitors to this blog, likely know that, in addition to spending years in The Sick People Business, I am, well, conservative. This works out both politically, as well as with regard to my life choices. I have heard that everybody is conservative about things that they know best. Firefighting is renowned with the deliberate pace of accepting new innovations, probably due to the fact that if the innovation tanks, firefighters (and civilians) die. The military once was very conservative, for similar reasons.

So, TINS, TIW, driving my happy, fuzzy, disease fighting ass home after another fun filled, exciting day of Beating Back The Scourge of Zithropenia (Azithromycin+/penia=Zithropenia. (n) The state or condition of having a pathologically low blood level of azithromycin. (fictional malady)). I was listening to a talk radio host, and this worthy declaimed that they “Know my own body. I get this same bronchitis every year about this time of year, and I always get the Z Pack!”.

Let’s pause, and “bookmark” that statement. There are three things that I want to address therein. Once I unclench my teeth, that is.

This soul continued: “So, I went to a doctor, just like last year, because I had this bronchitis, just like last year. I mentioned that I wanted the Z Pack, just like last year, because I got better after taking it. I guess that was the wrong thing to say, because he prescribed something else, which took longer, and didn’t work as well”.

Another bookmark, please. Generally, this commentator makes sense, and I agree with their perspectives. They typically make valid points, in my view, and their analysis of events makes sense: they appear generally internally consistent. HOWEVER, I need to contemplate whether there becomes a variety of what I will call a “reverse Halo effect”, for lack of the precise term. That means, if this commentator can so badly err in this regard, perhaps I ought to view their perspectives with greater skepticism.

Now, about those “bookmarks”. Let us begin with (1) “I know my body”. Let us agree, “know my my own body”, and “know whereof I speak in matters medical” is not a circle in the Venn diagram of facts. Generally, the soul with whom I am interacting (placing myself in this person’s clinician’s place), is not a physician of any stripe, commonly not an RN, and likely does not know the manner in which antibiotics (for azithromycin-The Z Pack-is an antibiotic, of the macrolide class thereof) function. In some regards, this is similar to presenting to your mechanic, and asserting, “I know my car, and I need a new framistan!”

Perhaps, should your mechanic pull the OBE codes he/she might have some insight into the, oh, I dunno, correct analysis of why your vehicle is making that funny noise, that, just maybe, you ought to listen to.

On that same topic, the imp in my head often suggests that, in response to that conversational gambit, that I ask, “Indeed? What is your opinion of the role your amygdala is playing in your illness?”, or, “Are you certain the the Z Pack will be strong enough? Shouldn’t you take imiprimine for your cough-worse-at-night, or sniffles?”

I rarely listen to the imp’s advice.

Secondly, “I get this same bronchitis every year around this time”. While I am by no means a microbiologist, nor do I play one on TV, and the last Holiday Inn Express that I stayed in was in 2016,

in my Nursing studies, and in my midlevel studies, I do not recall a single instance of our instructors informing us that microbes possessed awareness of the seasons, let alone calendars. My assessment, assuming that my examination does not provide contrary evidence, is that the seasonal nature of the malady likely reflects seasonal changes in the environment. Here, in The Un-Named Northern Fly Over State, that likely means, in the fall, that you finally became cold enough to turn on your furnace, and, generally, that means a forced air furnace. Said furnace has been dormant for 4-7 months, allowing all the dreck suspended in the air to settle out in your heating ducts, and, once you get chilly again, and the furnace is activated, which means the the blower is energized, air begins to move through your ductwork, and all that dreck, quiescent for lo, these many months, is aerosolized once again, and you again breathe it all in.

Since, in the interval, your mucosa has grown UNACCUSTOMED to these irritants, you, once again, have irritated sinuses, which swell (“my head is plugged” and/or “I cannot breathe….through my nose”), and, in the manner in which your mucous membranes respond to irritation, they pour out mucous. Since it takes a while for you immune system to again achieve equilibrium, the delay until you go to the clinic + the delay before you fill your prescription + the delay until you complete the course of azithromycin of which you speak so highly, roughly equals the time frame required for your immune system (read: mucous membranes) to adapt to the new, dust laden, environment your autumnal activation of your heating system elicits.

Rinse, repeat, for spring “bronchitis”, likely elicited by mold finally being unburied from the snow that we enjoy months at a time. Ibid, spring pollen release, similarly, summer lawn clippings, or whatever.

Finally, “I always get prescribed the Z-Pack” (implied is “and it always fixes me”.) Please contemplate the logical fallacy of “post hoc, ergo propter hoc” (“this follows that, therefore that caused this”). To illustrate, I purchased a new pickup truck in the summer of 2020. Therefore, absent my truck purchase, Mr. Biden would not presently be in The White House. Right? See above regarding seasonal irritants to your sinuses, and their effects, along with the timeline described two paragraphs above.

There is an additional factor, segueing into the next point, wherein azithromycin interacts with other medications (betcha they didn’t know THAT, eh?), as well as particular medical conditions (go internet search “black box warning”. I’ll wait here while you do so.) To translate the medicalese into english, “QT prolongation” refers to an alteration of the heart conduction system, which, occasionally, can produce alterations of the heart rhythm that can be lethal.

We generally consider that to be a bad thing.

So, these are prominent among the reasons that I am considered “the Z-Pack Nazi” by my co workers.

With reference to the assertion that “…he prescribed something else, which took longer and did not work as well”. Please refer to the timeline outlined above, consider the drug-drug interactions, as well as drug-medical history interactions cited above. Now consider the possibility that Doxycycline, over ten days, was every bit as effective as azithromycin (which is to say, not), and perhaps the speaker went to the clinic earlier in their course than historically.

All that is with absolutely no knowledge of this radio person’s medication list, allergy list, past medical history, review of systems at the time of the office visit, nor of the physical exam findings. Simply, it elicits teeth grinding, and reminiscences of actual patient encounters that I personally have had.

Thanks for riding along.

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SNIPPETS

So, TINS, TIWFDASL, and one of the registrars walked back, and informed us, “They say that there is a man out there with a gun!”

My response was to ask, “Is there any reason that you are NOT telling the police this, rather than telling me?”

“Oh, should I call the police?”

“Ah-yep! Right freaking now would be very nice!”

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If you have COPD (emphysema), it is likely not so very helpful to smoke marijuana.

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Me: “So, you’re here for your cough. When is your cough worse?”

Them: “When I cough.”

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Please, after I have explained my plan of care for your cough, which is caused by the irritation caused to your throat by the mucus in your throat, mucus originating in your sinuses, Please do not correct me with the observation that “My mucus is in my throat”.

It is very likely that, when I illuminated and inspected your throat, I DID notice, and, indeed, did comment upon, the tsunami of snot therein. Further, it is likely that every child of Ghawd that I have seen today has, also, snot streams running down their posterior pharynx: their throat.

So, when I explained to you that that mucus is irritating to your throat, since your throat is not well designed to tolerate that event, and that irritation manifests as a sore throat, or a tickle and a cough, or both, did you consider the possibility that the mucus originated, oh, gosh, I don’t know, IN YOUR SINUSES, AS I, INDEED, MENTIONED IN MY DETAILED EXPLANATION OF YOUR MALADY AND MY PLAN TO MANAGE SAME?

So, the nasal steroid that I recommended to you, over the counter, will suppress the inflammation (that I mentioned was the root cause of your woe), and thereby suppress the outpouring of snot which is the proximate cause of your cough, and, therefore, end (or really, really suppress) your cough, which was the ostensible purpose of your visit in the first place.

Kitten Tails

So, TINS, TIW, NOT FDASL, at home. As it turns out, I am a cat lover. Indeed, my Darling Daughter has wondered out loud “…Dad? Are we going to have to arrange an intervention?” We had three cats, early in the spring. Then a stray, known around our house as Momma Kitty, decided that our window well would be a nice place to deliver, and nurture, her litter. I learned this as she was in the midst of moving her litter from one window well to another, and appeared to have left one kitten behind.

I came to this realization as I heard plaintive meowing from the window well. I investigated and found one forlorn NOT weaned little kitten, and no mother in evidence. I scooped this furball up, and contacted our vet, he of the “Wrecks” story .

Once Furball had been examined, our vet advised that this kitten, well shy of being weaned, needed to be fostered, and likely our local Humane Society could hook us up.

We contacted them, they accepted the kitten, and promised to let us know once he was weaned and adoptable.

Weeks later, Momma Kitty wandered up on our porch, in company of three other kittens. TDW-Mark II noted that they appeared to hole up beneath our porch, and her observations suggested that they were accessible. She, as well, had observed the kittens eating from the dry food we had been placing for Momma Kitty, suggesting that they were weaned, or nearly so.

After an adventure that I might describe later, TDW-Mark II had retrieved all three kittens, although Momma Kitty escaped our clutches.

We had the kittens vaccinated, and quarantined them for a while, both to he;lp assure that they would not transmit unknown Dread Cat Disease to out three incumbent cats, as well as provide an opportunity to try to socialize them to life as housecats.

As they matured, we arranged for two of them to be neutered, and have their front claws removed. It seems that TDW-Mark II does not like her furniture shredded. Well, to be honest, neither do I.

We brought our two post op cats home, and observed them carefully. A couple of days later, one of the cats appeared to be bleeding. Closer inspection appeared to show that one of her paws had a skin flap, and this appeared to be the source of the sluggish bleeding.

Out came the medic bag, and I attempted to dress and bandage the wound.

It turns out that your average cat is not a fan of the entire wound cleaning/dressing/bandaging thing. Bad News: the entire experience is reminiscent of wrestling with a tiny fur coat full of razor blades. Good News: Olivia The Cat (for it was Olivia who was bleeding post operatively) is a very, very placid cat. Yeah, she let me know that she had hind claws and fangs, but she never once broke my skin. She would occasionally take my hand or fingers in her mouth, teeth resting on me, but hardly any pressure. Her hind feet, claws extended, would contact my other hand, and push me away, but with a gentle pressure, not with a rapid or forceful motion.

With the able assistance of TDW-Mark II, Olivia was dressed and bandaged, and I carried her to our bed, laying on top of the covers, cat cradled beside me, holding the bleeding limb elevated somewhat. She began to purr, and lay with me for nearly 40 minutes before she had Cat! Things! To! Do!, and got up, galumping around the house.

Me? I had work in the morning, and went to bed. TDW-Mark II informed me the next morning that Olivia had untangled her bandage, and slipped the entire mess down her leg, just like a sock balling up around your instep in boots on a wet, cold wintry day. So, TDW-Mark II re dressed the wound, and rebandaged it, this time using veterinary Co-Ban.

This was a much more satisfactory arrangement (well, for us at least….), and lasted until our vet could unravel things and provide some expert analysis of affairs.

A day later, Olivia returned home, and we all lived happily ever after. (well, THAT’S my story, and I’m sticking to it!)

“So, I just have to deal with my pain!”

So, TINS©, TISFDASL©, and was in the midst of winding up my plan of care tutorial for the patient du jour. This soul had been experiencing their pain for several weeks. They had not, of course, contacted their primary care. (To be fair, it is not uncommon for a walk in patient to respond affirmatively to my query regarding attempts to meet with their primary care, and to note that they indeed HAD an appointment, several weeks from our conversation.)

In any event, I had elaborated on management of their problem, featuring rest, ice, elevation, and ibuprofen. I observed that it was likely that their physician would consider things like physical therapy, or maybe a referral to orthopedics. Given how insurance reimbursement works, if I, NOT the primary care, order these things, it is entirely likely that the insurance company will NOT subsidize them, and an initial visit with a specialist, like an orthopedist, can easily run around $500, before the insurance company pays their share.

Personally, I would be happier if the insurance company chipped in.

This soul replied, “Well, I guess that I will just have to deal with my pain!”

I replied, smiling, “Well, that is certainly an option. Alternatively, you might consider the measures that I have just outlined, and those that your doctor might order, which might moderate or eliminate your pain. You could do that, instead!”

Fighting Disease, And Saving Lives

Gather ’round, boys and girls, and let Uncle Stretcher Ape regale you with another tale of FDASL.

So, the other week, I meandered into work, safely early (or so I thought). I was just about to drop my lunch, backpack, and coat, when the overhead page alerted: “Code Alert to walk in!”

Well, that was odd. I grabbed my stethoscope, and walked out of the office, simply to be certain that I was, indeed, in the walk in. Yep, I certainly was.

One of the MAs, looking excited, directed me to the room adjacent to where I was standing.

I entered to find a flaccid child, eyes literally rolled up into her head, as the MA at the bedside was busily obtaining vital signs. She gave me hurried report: child had arrived looking unsteady, reception had twigged, promptly to my FAVORITE “vital sign”: (“Dude Don’t Look Right”), summoned the MA staff, and, well, then things got exciting.

The child, as soon as she had been laid down, had gone unresponsive, per the report I got. I auscultated, verifying presence of air movement and heart beat. Finding a radial pulse, I went to the registrar, and asked, “Where is my bus?”

She smiled, knowing how I think, and replied, “I’ve called the ambulance already”

“Outstanding!” was my reply, and I returned to the room.

As I turned around, I noticed my physician supervisor, as well as my pediatric supervisor. I gave them a brief synopsis of what I knew, and what my plan was (“get her off to ED, as soon as humanly possible”, if I recall correctly).

Soon, EMS arrived. I gave them report, as best I could, and they packed her up and skedaddled (No, that is not strictly speaking a medical term. But, it worked for me!)

I subsequently spoke with the registrar who had first contacted mom and child. She had determined, indeed, that this child very much did not look right, and had promptly summoned assistance.

The first MA to respond, had promptly identified that this was way, Way, WAY beyond our level of care, and had initiated calling EMS, RFN (Right Freaking Now), as well as the “Code Alert”.

Good call.

So, a couple of days later, my physician supervisor, along with the administrator, passed through for a weekly review of our quality indicators. Winding up their pitch, they asked if we had anything to call to their attention. Yep, I did.

I praised the registrar who correctly, and promptly made the triage call. I praised the MA who had responded, and initiated the “Code Alert”, as well as the EMS call, properly, promptly, and effectively. I wound up by stating that they deserved praise for responding appropriately and calmly in a crisis.

This is to illustrate, again, quiet people who, taking pride in what they do, strive to improve, attend to duty, and take care of business. As Heinlein said, “Take a look around you. There never were enough bosses to check up on all that work. From Independence Hall to the Grand Coulee Dam, these things were built level and square by craftsmen who were honest in their bones.” (https://thisibelieve.org/essay/16630/)

I work with these folks. I rely on their intelligence, their judgment, their engagement with what they do. As Eaton Rapids Joe noted, “You get more of what you recognize”.