Fun And Games

Tales From The Nightshift

So, TINS©, TIWFDASL© one night in The Maternal State, years and years and years ago. My father had taken ill, and of the three of us boys (the attorney, the contractor, and me, the nurse), it seemed that I was the best fit for the job of helping Mom take care of our Dad.

Well, that, and I was the one who did not have a family.

So, in order to keep my house and my vehicle, my creditors agreed that it would be nice if I were to continue receiving a paycheck, while I was 800 miles from home, and taking a voluntary leave of absence from my employment. So, I became a travel nurse!

This one night, I was working midnights at Some Suburban Megalopolis Hospital’s ED. It was way, way late, and we had cleared all the souls from our beds, and were engaging in my favorite slack time occupation, Story Hour.

So, one nurse was recounting how her boyfriend was failing to meet performance/behavioral expectations in one way or another. The other nurses (all women) responded, in a sort of choir, with murmurs of affirmation for the reporter. Except for one particular nurse.

This woman’s speech was rich with the cadence and harmonies of Da Islands, with a Caribbean note permeating her pronouncements.

“Aw, naw, ghurl! Ya no haveta put up with dem shenanigans! He gotta go, out de doah!”

The chorus affirmed this pronouncement.

The protagonist in our little Greek tragedy continued with her lamentations of Mr. Unworthy’s misdeeds, and our Caribbean Correspondent again provided her assessment: “Out de doah!”

Again, the call of more misdeeds, again the response from the congregation: “Oh, naw! Out De Doah!”

It devolved into a documentary of The Misdeeds Of Men, and along about that time, I found something I ought to be doing. At the other end of the department.

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cats · Duty · Pains in my Fifth Point of Contact

Two more snippets

FICKLE CATS::

When I am in bed, they snuggle up against me: likely due to the warmth from my electric blanket. I can pet them, and they do not beat feet, alarmed, at my approach. They purr, and roll into my petting. On the table in the cat room, similarly, I can pet them, and they purr like miniature motorcycles.

Elsewhere in the house, I approach them, and they elope as if I were the Cat Attacking Golem, or something. Of course, when they are on the counter, or the dining room table while we are eating, I do chastise them: “Are you on MY counter? Bad Cat!” accompanied with a sort of interpretive dance, which most closely resembles an effort to shoo away angry, invisible, hornets.

ANOTHE STORY FROM THE STREET

So, TINS, TIWFDASL….well, no. I was at home, long ago and far away, when The Plaintiff (aka TDW-Mark 1) and I were still in wedded bliss. In the very rural county in which we lived, EMS was provided by a sort of tiered response: in the event of an emergency, dispatch would alert the sheriff’s deputies on patrol, and tone out the nearest fire department to send their rescue. The ambulance would depart from the hospital in The County Seat, and the crew would make their way to the scene. There, the three agencies would address the problem, and then, response complete, resume whatever they had been previously been doing.

I volunteered for the local rescue, since, I figured, I would want SOMEONE to respond when/if we had our own emergency, therefore it seemed reasonable to carry a pager and respond when some neighbor had THEIR emergency.

Let me interject that I had a scanner at home, and so I (and TDW-Mark 1) could monitor the goings on in the Fire/Police/EMS world. Or, our corner thereof.

So, one evening I was home. The pager went off, and I responded to the fire hall. Another firefighter arrived, and we were off.

We arrived to find a sedan crumpled amongst the trees lining the side of County Road Whatever. The deputies had already triaged the scene, and pointed out one soul who was not making much sense. As I approached, my differential diagnosis expanded from head injury, to head injury, or intoxicated, or combinations of the above. This was elicited by the prominent odors of ethanol emanating from my subject.

Well, when you have a soul who was involved in a collision, as this guy had been, who is not able to navigate or articulate, as this fellow was not, one must wonder if the collision had cracked his coconut (not, strictly speaking, a medical term, you know…), and that was why he had his articulation and locomotion difficulties, or was he intoxicated into dystaxia/dyarthria, or (perhaps worst of all potential scenarios) was the intoxication obscuring his intracranial bleed, or something similarly dire?

I, paramedic and RN that I was at the time, was elected to ride in the back as Mr. Ethanol Odor was transported to hospital assessment and management. Of course, he was spine boarded. Of course, he disapproved. Of course, he protested, loudly and profanely, about our handling of him, as well as the fact that he desired to depart our company and be on about his business (not an exact quote).

I recall providing report by radio, his soliloquy in the background. He was describing my character flaws, and errors in my upbringing, at volume. As an exact quote, he suggested the my shortcomings included, “Assholes! M@74erf&25ers! Dickheads!” (I suppose he included my partners in this assessment, come to think about it.)

I unkeyed for a moment, prior to concluding my report, and, rekeying the radio, observed, as he renewed his Short Course On Character Disorders, “As you can tell, patient in no evident respiratory distress!”

I arrived home to find TDW-Mark 1, chuckling. “No distress, huh? Have you told your mother hello for him?”

Fun And Games Off Duty

Material From “An Away Game”

From Eaton Rapids Joe’s eponymous blog, a thought for all of us sick folks out and about:

Sunday, January 8, 2023

Strep Throat

Anecdotal evidence suggests that there is a lot of Strep Throat locally right now.

Strep Throat often follows colds and other viral infections. It is primarily an opportunistic infection that takes advantage of the fact that frequent coughing and throat clearing irritates the throat and removes some of the protective layer of mucous.

If you read “symptoms” on the internet you will find countless repetitions of the words “…the back of the throat looks beefy…” While this may be totally clear to medical students it was not clear to me. I am made of meat. All of my inside parts look “beefy”.

After way too much digging, what they mean is that the normal, whitish, filmy covering over the back of your tongue, upper mouth and throat is gone. The Strep bacteria displaced it.

Strep is nothing to screw around with if it doesn’t clear up in a day or two. It can infect your heart valves and/or kidneys.

Posted by Eaton Rapids Joe at 8:12 AM

MY COMMENT:

Simply to make things more interesting, technically, the strep does not, itself, “infect” kidneys or heart. Some varieties of strep B produce a toxin that elicits a sort of autoimmune response, “rheumatic fever”, which is readily prevented by antibiotics. Take note! The abx really do NOTHING for the sore throat (which, of course, is why we all see our doctors in the first place), rather, they protect us against a potential consequence of infection with certain varieties of Strep B which may trigger that response.

Should one develop rheumatic fever, (which itself may be life changing), that may be followed by rheumatic heart disease, which can be a BFD (Big Freaking Deal), with scarring of the valves, leading to narrowing thereof, and requiring increased effort from your heart to force blood through them, leading to heart failure. This, also, is generally prevented by antibiotics (abx).

Life in Da City! · Pains in my Fifth Point of Contact

Snippets VI

The following is a collection of tangents. Please, be tolerant.

I was talking with the midlevel student taking a rotation with me, and, it being her first rotation (…unfortunate soul, to be stuck with The Stretcher Ape as your first clinical!), and was waxing poetic about gestalt, quickie patient assessment, and binary EMS assessment.

I observed that a writer for JEMS magazine, decades ago, observed that there were stages to EMS patient assessment: initially, is the named patient “Big Sick”, or “Little Sick”?

If “Big Sick, particularly in the setting of basic life support services, probably you desired to load that patient, and go.

If “Little Sick”, you likely had time to assess the patient in greater detail, and either rethink your initial assessment that this soul was “Little Sick”, or reinforce that assessment, and then transport in a leisurely and deliberate manner as appropriate.

The application to our walk in clinic, is that should your, or your MA’s snap assessment be along the lines of “That dude don’t look right!” (immortalized as “DDLR”), perhaps you ought to look into expediting that soul’s transport to ED, perhaps via EMS. I told her that “DDLR” is probably The Primary Vital Sign.

Another Story

One night, we had cleaned out the ED, and done all our housework. This was long, long ago, and far, far away, back in my halcyon days in Da City. I was a staff nurse in our ED, and we had “story hour”, many a night when there were no patients, and nothing to clean or restock.

Somehow, the conversation turned to threatening patients. One nurse volunteered, “You know, I have something in my purse that might be a conversation starter with such a soul, with the conversation trending towards, “How do I get my ass out of here, before this crazy nurse kills my ass?”

Another offered, “Hmm. Such a sad sack might, or might not, find himself in a cross fire, not that I would know anything about that sort of thing, myself!”

Another thought out loud, “I wonder why it is that I always place my bookbag in the med room? Could it be that there might be something there that would trigger a reconsideration of life choices, in some bad actor?”

One of my buddies, still on the road, laughed when I told him that story. “Really? Don’t you realize we all on the street know your ED is the most heavily armed ED in Da City?”

A Thought Experiment

If you were married to Nancy Pelosi, and was faced with the choice of having sex with her, or finding a homeless psychotic gay guy, what would You do?

Recounted conversation:

Patient: “I don’t believe in covid!”

Me, responding to my partner who had just quoted said patient (faux-Russian accent) “Da, tovarisch, but, covid believe in YOU! (stifle your cough, and wear your damned mask!)

Bob Marley Tribute Band

Cletus and Jane-Bob came in the other day, accompanied by their spawn. The nominal adults smelled as if they had just sat in with a Bob Marley Tribute band. The children were clean and inquisitive, and engaged readily with me as I inquired about their symptoms.

The childrens’ ear infections were readily identified, instructions provided, and they were off and on their merry way.

With these poor life choices as their life exemplars, I wonder how long the children will remain clean, or inquisitive, or engaged with the world?

Another opportunity to bask in the wonderfulness of legalized, recreational, marijuana.

oops!

Apology

For those who have (for whatever reason) grown accustomed to reading my material on an every-Friday-Afternoon basis, I apologize. Between work, family, and general laziness (er, I mean, other distractions!), I have not committed any thoughts to metaphorical paper this past week. But, I have an installment tee’d up for this coming Friday!

Duty · Gratitude · Humility · Protect and Serve

DUTY: A RETROSPECTIVE

It is the eve of Christmas Eve as I sit here. The roads were TFA (Too Freaking Awful) today for me to drive the lebenty some miles in to work, so I had called off.

TDW-Mark II had commented that today would be a good day to NOT be taking road calls, and I agreed.

I remembered a Christmas at home, 2 years ago.

So, TINS©, I was lolling around the house on Christmas Day. TDW-Mark II and I were casually surfing the web. I had my handheld amateur radio on, monitoring our county’s fire dispatch. Because, well, I can.

In our county, emergency personnel are generally volunteers. The EMS is paid/full time (such as THAT pay is!), Sheriff and local PD are paid/full time (but often respond from home, off duty, so to speak), but the firefighters and rescue are volunteers, dispatched by pager. The tones dropped for a cardiac arrest, CPR in progress, in the outskirts of the county. Now my county is rural, primarily (by surface area) farmland. The ambulance was called out, as well as the County Seat Volunteer Fire Department (Hereinafter, CSFD).

I heard EMS acknowledge, and the duty fire chief as well. He (the chief) directed that the firefighters respond without him, as he was a couple of miles from the scene and would respond directly.

Dispatch then filled in the dispatch information, beyond the address. A 70-something male had collapsed. CPR was in progress. He was vomiting, and the family was clearing his mouth as best they could. A couple of minutes later (likely that seemed like days, to the folks on the scene, performing CPR on one of their family!), the fire chief called out on the scene “Chief on scene with one firefighter. Sheriff on scene. Dispatch, roll one engine for manpower.”

So, let’s “dolly back”, and consider this. With the possible exception of the deputy (who might also have responded, off duty, from home in his patrol car), all these folks were snug in their own homes, fat, dumb and happy, savoring the anniversary of The Birth of Our Saviour, as well as immersing themselves in the excitement of the children at All! The! Presents! they had received.

They carry pagers because, well, that’s what they do. More likely than not, they do not see themselves as heroic, or making sacrifices, because, after all, in most of America (hell, I suspect in most of the world), the men and women performing these jobs simply see themselves as doing what needs to be done, because they are able to do so.

And therefore, when the pager alerted them, they grabbed their coats, put on their boots, and left their warm and happy homes, heading to somebody else’s home, someplace where, as Chief Dennis Compton of Mesa, AZ Fire once described it, “We are responding to somebody’s worst day of their life”.

So, as I imagine it, the duty chief was enjoying a Christmas with his family, the tones dropped, and off he went. Before he could get out of the door, one of his sons, or maybe a son in law, (or daughter or daughter in law, here in the 21st century) said something like, “Hey, Dad! Hold up a second! I’m taking that call with you!”

These folks voluntarily immersed themselves in another family’s tragedy. Strove to hold the line, to reverse the evident course. Went to work on Christmas.

When the firefighter came on the radio requesting the sheriff department’s (volunteer!) Victim Support Team, I could call that play. I do not know if I teared up at the family’s terror, at their loss, at the fact that forever more Christmas would not hold happy childhood memories, but, rather, would be “the day grandpa died”, or if I teared up thinking of the folks who, simply “doing their jobs”, had left their warm homes in response to some stranger’s plea for help.

But, I wept.

Please, give a thought to those who respond to those calls, today and every day of the year, all over the world.

And offer a prayer on behalf of those they go to rescue.

Duty · Having A Good Partner Is Very Important! · Sometimes You Get to Think That You Have Accomplished Something!

“Warn-A-Brutha”, in action.

So, TINS©, TIWFDASL©, and my MA, let us call her Maryann, exited the room that she had entered, shortly before, to assess and obtain vitals on a child.

“Reltney, this child here is working kind of hard to breathe, and he is coughing a lot: it seems to interfere with his taking a breath!”

I entered the room, and noted a child coughing approx every 10 seconds (and I mean a full throated cough, not some modest little “harrumph!” kind of thing), and, as I observed his breathing, noted a rate of around 60 breaths a minute.

Not so good.

We administered a breathing treatment, and he had kind of, sort of, maybe improved just a little bit.

I finished my assessment, and went to chart, intending to return and re assess him once my (generally 4-7 minute) charting was completed.

I did so, and noted that his breathing had dis-improved (is that really a word?). I invited the physician with whom I was working to lay eyes upon him, briefing her upon my observations and actions thus far.

Once she had assessed him, she was not favorably impressed. She, also, thought he was working kind of hard to breath. She, also, wondered if this was fixing to run him out beyond the end of his reserves, whereupon he would crash, likely biggly, and become a no shit emergency. She wondered if sending him to emergency, prior to that happening, might not be more wise than waiting until he did, indeed, crash.

I agreed.

I wrapped up my charting, once the child was safely on the way, and hunted up Maryann. I congratulated her. “You did good. Your prompt assessment that this child was not breathing right, set in motion events necessary to get him to the appropriate level of care, in a timely manner. Well done!”

Fun And Games Off Duty · Gratitude · Humility

Everyday Folks, Everyday Gracefulness

Sometimes in my walkabout daily life, I encounter folks, simply being nice. So, TINS©, I Was NOT Fighting Disease And Saving Lives, rather, simply grocery shopping. I happened to get in line behind an elderly woman (Pot, meet kettle. You ought to talk amongst yourselves, since you have so much in common…) who appeared to not have altogether figured out the entire “One of these is a credit card, the other is your membership card.” thing, as she attempted to pay with her membership card.

The cashier was patient, and collected. She explained that, no, THAT is your card with which you get your discounts and points, and THAT is your bank card, with which you pay for your groceries. They are different cards, for different things.

It took a couple of attempts, but the customer got her points, and successfully paid for her groceries, and wheeled her way out of the store.

The cashier apologized to me for the hold up. I responded, “Ma’am, some things are problems, some things are inconveniences. If this wait is as bad as my inconveniences get, I am in pretty good shape. Oh, by the way: way to be patient and graceful with that elderly lady. Good on ya!”

Duty · Life in Da City! · Pains in my Fifth Point of Contact

Once Upon A Time….

So, TINS©, TIWFDASL©…Let me take a tangent, here, for a brief moment. (Yep. “Ooh! Shiny!”) The Darling Wife-Mark II and I were visiting my son and his wife, My Darling Daughter In Law, let us call her Esmeralda, and he (the son) had asked me how work was going. I (of course) replied, “Thing of beauty! Why, I spend my days Fighting Disease, Saving Lives, and Beating Back The Scourge Of Zithropenia!”

Esmeralda did not appear to comprehend the level of sarcasm that is my baseline, because she responded, “So, writing scripts for Zithromax is pretty much your entire workday?”

Sigh.

So, back to my story: there was this soul, once upon a time, in a clinic far, far away, who was on Medicaid (since my agency’s mission statement is pretty much, provide healthcare access to those who otherwise are underserved), and was diabetic. But! Wait!

This soul also had a burn on their extremity, attributed to spilling some boiling water thereon. This had occurred a day or two previously, and looked rather gnarley. (No, that is not, strictly speaking, a medical term.)

For those of us who are not In The Sick People Business, extremity burns generally are considered a reasonable referral to a burn center, because if contractions or scar tissue limit the utility of that extremity, life changing disability can result.

The local wound center could not accept him for the serial assessments, dressing changes, and suchlike that treating his wound would require. (don’t recall the rationale for this clinical decision).

I called the burn center at Tremendous State Megaversity, seeking care for this soul. They responded that they did not participate with his flavor of Medicaid. Therefore, I was told, my patient (remember: on Medicaid, which generally maps pretty accurately onto relatively impoverished) would have to pay kilobucks, out of pocket, for their care.

Of course.

So, please remember that the Venn Diagram of “folks on Medicaid” and “impoverished folks” results in a bulls eye of sorts, wherein the “impoverished” circle, encompasses the “Medicaid” circle.

Therefore, my patient did NOT have, nor have access to, kilobucks. So, did I send him to the local wound clinic, which for whatever reason had already told me that they could not accommodate him?

Nope.

Did I send him to Megaversity Burn Center, who had subject matter expertise in, oh, gosh, er, umm, BURNS?

Nope.

Of course, he returned to our walk in clinic, The World Renowned Center Of Excellence, In All Matters That The Subject Matter Actual Experts For Whatever Reason Cannot Handle, for his wound care and his serial assessments.

Because, I’m not bitter. Nor burned out. Nor sarcastic.

Not a bit.

Housekeeping · Pre Planning Your Scene

BATTERY MONTH

It has been said that amateurs study tactics, professionals study logistics. I have attempted to put things aside for rainy days, and, with Mr. Biden at the helm, and Mr. Buttigieg as Secretary of Transportation, well, my achy knees tell me that rainy days are a’coming.

This being November, it is Battery! Month! Semi annually, I inspect my batteries, and assess their charge. I inspect for signs of leakage, I test the strength (using a voltage meter: Radio Shack used to sell them for $10-$20, once upon a time), and contemplate whether I have enough of each size. Unlike ammunition, “MOAR!” is not always the correct answer, for, ammunition keeps nearly forever if kept cool, dry and in the dark. Batteries have a self discharge phenomenon, and both rechargeable as well as alkaline (and carbon-zinc), or “primary”, batteries, will lose their charge over time. (“Primary batteries” are single use, and their charge derives from the chemicals with which they are made. “secondary”, or rechargeable, batteries can be brought backup to charge, after discharge, although after a sufficient number of charge/discharge cycles, they gradually lose their ability to accept and hold a charge.) Therefore, in an ideal bunker, I would have just enough that I would have fully charged batteries in service, and enough fully charged replacements to cycle back and forth, so that no battery would die a lonely, unused, death, way back in the back of my battery shelf.

I am still striving for that level of efficiency.

When I checked this month, to my disappointment, I found that most of my rechargeable batteries had discharged. Once I see if they will accept and hold a charge, I will know if they are in need of replacement, or simply every 3 month assessment.

I have some primary cells, for items that are frequently used. I have an LED penlight fueled by AAA batteries, and another identical penlight, except that this LED emits in near UV. That is handy for illuminating rashes, sometimes revealing luminescence typical of certain strains of dermatophytes. You might recognize the rashes caused, such as “ringworm”, or dandruff, or athlete’s foot, among others. Not all the dermatophytes glow under UV, but when it does, it is an “AHA!” moment.

My SureFire and ITP flashlights ride in holsters on my belt. They are bright, “Light-up-the-yard” lights. There are two, because should one fail, it is likely that the other will function. There are two, because should one fail, it is likely that the other will function. I have spare batteries in my “Bag Of Tricks” (h/t to Felix The Cat)

Our vehicles each have a “torch”, to differentiate the hand held lights, from the headlamp, the light-up-the-interior-of-the-vehicle lanterns, or the LED warning flashers. One is powered by CR-123 batteries, two are powered by C primary cells (the torch, and one handheld flashlight)

The LED flashers are powered by AAA batteries, and are intended to allow oncoming traffic to see that there is something (Me!) in the roadway, in the event of a breakdown, collision, or other night time deviation from normal. It turns out, when you buy “budget” rechargeable batteries, they have fewer charge/discharge cycles in their make up, than quality cells. Guess which will replace the unsatisfactory batteries? Yep: buy once, cry once. Or cheap out, and cry. In the dark.

Each month has it’s own focus, such that I do not spend every single day off in any one month in my subterranean lair, checking off stores against a checklist. If all goes smoothly, I might get my inventory done in an afternoon. As a starting point for those who might be interested, I have included a representative sample of my battery-and-lights checklist.

BATTERIES

EDC: UV Penlight AA x 2

Penlight AA x 2

Surefire CR-123 x 2

ITP CR 123 x 2

Proton Light

Keyring LR 41 x 4

Badge LR 41 x 4

Bedside

Surefire G-2 CR 123 x 2

Ultrafire 18650 x 1

Camper: Lantern Box

Coleman Quad Lantern #1 D x8

Coleman Quad Lantern #2 D x 8

Siege Light #1 D x 3

Siege Light #2 D x 3

Siege Light AA AA x 3

CAR LIGHTS

TDW Car

Torch C x 2

Headlamp AA x 2

LED Beacons AAA x 3 each (6 beacons)

My Vehicle

Torch C x 2

Headlamp AA x 2

LED Beacons AAA x 3 each (12 beacons)

Small Handheld light CR 123 x 2

Large Handheld Light C x 4

Medic Bag Surefire CR 123 x 2

Field Phones

Set #1 (2 phones x 2 D cells each) D x 4

Set #2 (2 phones x 2 D cells each) D x 4

Night Vision

AA x 4

Red Flashlight Toolbox

Mini Mag Lights x 2 (2 AA ea) AA x 4

Ray o Vac x 1 (2 AA) AA x 2

Mini Mag 3 cell AA x 3

Sure Fire Hurricane Light (weak CR 123, holds 12)

CUMULATIVE TOTALS, FOR EACH TYPE OF BATTERY

AA x 24 in service at any one time

AAA x 64

CR 123 x 8

18650 x 1

LR 41 x 8

C x 8

D x 30