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?”

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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!”

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.

Duty · Having A Good Partner Is Very Important!

WARN-A-BRUTHAH!

I was on vacation, early last year, and saw a t shirt, with the Warner Brother’s logo, and the script, above and below the shield, admonishing the reader, “If ya see da poleece, WARN-A-BRUTHA!”

https://www.topseasonshirtz.com/view/114/if-you-see-the-police-warn-a-brother–t-shirt

(this will be relevant soon. Be patient.)

The other day, I was watching our grease board, where the registrars enter each patient’s name, and a summary of their complaint. I was (unpleasantly) surprised to note one fresh entry, asserting that the named patient, an infant, had “difficulty breathing”.

I directed my MA to go see that patient, and assess this complaint.

He promptly entered one of the exam rooms with this child, obtaining vital signs, and telling me, “Reltney, I think you want to see this kid, next!”

I entered to see an infant, with audible rhonchi (coarse breath sounds). The heartrate wasn’t awful, the respiratory rate was sort of elevated, and the oxygen was 94 %. Not perfect, but OK. This child was retracting wherein the skin beneath the lower margin of the ribs was being drawn in, a little, with each inspiration. We administered a breathing treatment, in hopes of resolution of the rhonchi, and less effort of breathing.

After the treatment, the rhonchi had improved, just a little, and the retractions might have maybe, sort of, kinda improved. I asked the parents to hold on a while, to see how the child progressed.

I rechecked in another ten minutes, and the retractions had definitely gotten worse. Vitals were still not awful, but one of the principles of treating children is that they generally tend to do OK when ill, until, abruptly, they do not. I was concerned that this child was running out of steam, and approaching a crash. So, I called ED, gave report, and sent the child over.

Subsequently, I was talking to the registrar supervisor, and told the story with which I started this story. I amended it to read, “If you or the mother think that the child is sick, warn a brotha!”

And, in this scenario, my pale ass is the “Brutha” in question.

Duty · Gratitude · Protect and Serve

WHY?

TDW-Mark II and I are amateur radio operators. A couple of weeks ago, we heard one of our small town’s EMS units dispatched to a “woman fell and injured her face” call.

We listen to Fire/EMS dispatch, because it provides an insight into the events of our town, and perhaps distant early warning of spicy times.

In any event, the crew called on the scene, and, very (VERY!) shortly later, got back on the radio, requesting police.

Dispatch inquired, “On the double?”, and the medic replied, “Yes, on the double”.

They next called for another ambulance, and the fire department for manpower. Soon, we heard fire crews negotiating an entry, and one of the medic units transporting one to The Local Trauma Center, as a priority.

That assemblage of folks, all volunteers except the police (the medics get paid so little, that they might as well be volunteers!) led me to contemplate Duty, and the mindset of those who run toward the sound of trouble.

May I present a rerun? Here is the original post from 2019, and a link to the website entry that inspired me.

http://counterjockey.blogspot.com/2019/09/weapons-wednesday-service-smiths.html#comment-form

Why do MEN (and, nowadays, more and frequently, WOMEN) willingly go in harm’s way?

Why do folks bunker up, suit up, gun up, whatever, and run toward the sounds of trouble?

Counter Jockey has gunned up, and sought out the source of those sounds. As have thousands and thousands of others.

Yesterday was The Eleventh of September in the Year of Our lord 2019. Eighteen years ago,  343 members of the FDNY died, doing their duty. 60 police officers lost their lives. 8 EMS personnel died, not employees of the City of New York.

They died attempting to save some of the 2977 people who would wind up dying that day.

“Duty” is the simple answer, and we all are, or ought to be, thankful for our neighbors who see their duty, accept their duty, and pursue their duty.

But what makes someone see such a thing as “My duty”?

What makes someone say, “So help me God.” ? Those who have so sworn, know. Someone has to stare down predators, and say, in effect, “You stop, right here, right now.” Someone has to stand, and hold that line. Otherwise, the dependents behind those stalwarts will lie vulnerable to the heartless. And, those who have selected Duty, will not allow that.

343 members of the FDNY died, that beautiful autumn day, doing their duty. What sort of folks run into a burning building, a building which had already been sized up be one of their own with the prediction, “Some of us are gonna die, today”?

Read the “Never Yet Melted” blog, about Rick Rescorla. Brit born, naturalized US citizen, Director of Security at Dean Witter/Morgan Stanley (https://neveryetmelted.com/2019/09/11/colonel-cyril-richard-rick-rescorla-may-27-1939-september-11-2001-3/) He is credited with saving 2794 of the 3000 employees working that day. He, his deputy, and three other of his security staff were among the exceptions.

So, here’s what I leave you all with. Look for your duty. Do your duty. try not to flinch, try not to step back. Because, you, and I, all of us, are standing in the shadows of Great People. Imagine, if you will, that they are cheering us on, looking over our shoulders, and expecting that we will not falter. Because, they have left us a legacy of honor, of Duty, of doing their jobs, that make it possible for all of us to be here, today, to have the opportunities that we enjoy. Let us not let them down.

Regarding that day an entire generation ago, let us tell of the Heroes who raced into a building, knowing it was to collapse. Let us tell our children of the Heroes, civilians all, who sacrificed their own lives, that others would not die at the hands of the heartless. Let us tell each other of the Heroes who dwell among us, unknown to us, perhaps unknown to themselves, who will rise up to the demands they face, and risk all to save another. Let us measure ourselves against them, and be grateful they dwell among us. Let us hope we can measure up, should our time come. God Bless those who stand in harm’s way, on our behalf.

Duty · Pre Planning Your Scene · Protect and Serve

Another post, from another website

Bad Dancer (commenting at Gun Free Zone blog) says:

October 21, 2022 at 9:50 am

Thank you for the article and links Reltney McFee I’ve read it several times and will go through it again to make notes soon. I appreciate you sharing your experience and advice.

I’m building a few kits as Christmas presents this year. Are there any supplies you recommend added for a family that has a 1-2 year old?

Thank you for reading. Outstanding question! With regard to families that have toddlers (or infants), my first pass suggestions would sound very much like, “What did you want on your last camping trip, that you did not have?” along with, “what sort of comfort item does your child love?”

If I were to add to that, I would look to my own “Grand Kids Are Here: What Might I Need RFN?” (GKAHWMINRFN) supplies. Now, remember, I’ve been a paramedic, paramedic instructor, ED Registered Nurse, and mid level provider since Jimmeh Cahteh was the HMFIC (OK: President).

On the top of my “GKAHWMINRFN” bag is a pediatric BVM (Bag-Valve-Mask: commonly referred to as if they were all branded as Ambu Bags). You might be happy with a pediatric sized rescue breathing mask of some sort, or, easier to pack, mastery of mouth-to-mouth resuscitation.

Near the top would be comfort items, so as to both distract the child, as well as help the child “buy in” to the procedures to be performed. Blankets, pacifiers, stuffed animals: whatever floats the child’s boat.

Remember that children, particularly infants and toddlers, are NOT simply pint sized adults. Due to differences in body surface area, kidney function, maturity of their livers and other factors, they may metabolize medications quite differently from adults. So, just slapping some QuikClot on Little Johnnie’s wound may be a problem. OTOH, here is what I did find in a reference that I use, myself, clinically every day:

“Compared with standard sponges, the use of the kaolin-impregnated sponges in 31 infants undergoing the Norwood procedure had a significantly lower intraoperative use of blood products and lower incidence of perioperative bleeding requiring return to operating room for hemostasis (0 versus 41 percent) [44].” (source: https://www.uptodate.com/contents/overview-of-topical-hemostatic-agents-and-tissue-adhesives?search=quick%20clot&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H2249912903

That means, better bleeding control. THAT suggests that a kaolin-impregnated sponge (QuikClot), at least, is not inappropriate for use on bleeding in children that is not otherwise controllable by dressing, direct pressure, and (in extremis) tourniquet-ting. So, small (2×2, 3×3) dressings impregnated with QuikClot appear to be reasonable.

Splinting materials for fingers, limbs, or whatever, are going to be a challenge, both because children do not, as a rule, comprehend the entire “lay still while I splint you” thing, nor the bit about “do not wiggle about, you will work you way out of this splint, and your injured (whatever) will hurt, and be injured further.” So, however much tape or gauze you THINK that you will need, you are wrong, and will require considerably more than you guessed. Unless, of course, you have made it a habit to secure IV armboards to infants and toddlers, several times a day, for the past several years. If you have done so, and done so successfully, please tell me when/where your classes will be, and save me a seat.

Another tangent from adult IFAK/Jump Bag/Holy Fertilizer kits, and child directed emergency care, is that children will both dehydrate, as well as become hypothermic way, way more rapidly than adults, and, once they have burned through their reserves, will crash and burn, often irretrievably. The axiom is that children generally do OK with their injuries, until they don’t. And, when they don’t, they crash biggly. Adults generally slowly decline, until they die. Therefore, measures to protect a child from heat loss are important. That means blankets and knit caps in appropriate sizes. The foil “emergency blankets” are a mixed bag: they are not going to get saturated in whatever bodily fluid is present (good thing), but they are not going to trap heat in a maze of air pockets formed by a Mark 1, Mod Ø fuzzy/fleece/wool blanket. (and you will notice the difference). Select thoughtfully.

Another feature of kid injuries, particularly infants and toddlers, is that they are top heavy. Their heads are a greater proportion of their body weight than adults, and that means that their initial point of impact may be more likely to be their heads, than their hands/wrists/forearms. Therefore, when you are in the hot seat, you need to be suspicious of the possibility of a head injury, when children fall. You have learned to spine board/cervical collar/secure for transport, head (and that is often spelled N-E-C-K) injured patients, right?

Right?

Another needful skill, that you pray is never needed.

That is it for my off the cuff, just got home from work and warmed up my laptop, answer to your question.

Thank you for the stimulating inquiry. Gonna be food for more rumination!

Reltney McFee

Duty · Humility · Sometimes You Get to Think That You Have Accomplished Something!

Revelations, and Pride In My Child

A couple of months ago, I was chatting with my daughter, Brenda. She somehow revealed that, years ago, when she was a single mother, working part time and going to school, money was tight.

I had kinda known that.

Just HOW tight, I evidently had not appreciated. She revealed that several times, she had gone to bed without supper, in order that her child could eat.

Let’s consider that, for a moment. It certainly elicits mixed feelings in me.

Foremost, pride. My daughter is professional, committed, and decisive. Her revelation reveals outstanding triage skills, as well as monumental commitment to her child.

Secondly, frustration. It is not as if I could not/would not remedy her pantry problems. Hell, I have been an overtime working fool nearly all my life, and another day of OT, in order to feed my child and grandchild, well, I suspect “BFD!” communicates my feelings adequately. (that is “big freaking deal”, although the second word generally refers to certain ancient and generally highly regarded fertility rites…).

Thirdly, frustration. (again). It is not as if I do not buy groceries, to this day, just as if I were still feeding four hungry adolescents. That both provides me with plentiful left-overs for my meals at work, as well as abundant food-in-waiting. The only thing stopping me from a pantry filling visit to my child, is her failing to tell me such might be useful.

Finally, it reinforces my appraisal of my child, that she is A WOMAN, and, like her mother, knows not of this “back down”, you might speak of, with regard to her children. Formidable, competent, decisive.

Duty · Having A Good Partner Is Very Important!

The Heinlein Rule

Perhaps, I ought to initiate another tag, “The Heinlein Rule”. 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 have spoken of Eloise in another post, as well as one particularly heads-up MA and how each of them, professional in their bones, acted on their own initiative and decisively to protect patients.

So, one day, TINS©, TIWFDASL©, when the registrar meandered back to the nurses’ station.

She opened her conversation, “Just checking. This woman reports that she is bleeding, and 3 days out from her delivery. You *DO* want her to go to emergency, right?”

Before I could contribute anything, my MA asked, “Does she look dizzy, or pale? Did she walk straight? Anything else going on?”

The registrar replied, “She looks pink, not sweaty, walked straight, no other complaints when I asked about any.”

My MA stated, “Please direct her to emergency.”

The registrar looked at me. I stated, “What she said. Does she have transport?”

“Yep, She is here with some family member.”

“Outstanding. She should be on her way, please.”

The Lord blesses me with partners who play “Heads UP!” ball.

Duty · Gratitude · Humility

Sometimes, I am Humbled

Last week, I got back into my “groove”. I have had the reputation of sending folks to ED with greater frequency than my colleagues. So, this one gentleman arrived, in pretty remarkable abdominal pain. His exam was NOT reassuring, and I wondered if he had a hot gall bladder, or some other variety of intra-abdominal catastrophe-in-waiting.

Now, to be honest, I am not particularly young, nor am I particularly spry. Indeed, for the past several weeks I have been gimping about the clinic, as my one knee is undecided whether it will ache, give out, let my kneecap spin freely about my mid leg, or some unpleasant combination of the three. So, it is apparent to any observer who cares to notice, that my one leg is not making me happy.

Yeah, I know: STBM. (Sucks To Be Me), after a fashion.

So, this gentleman, in no small pain his own self, as a parting conversational gambit on his way to ED, and maybe surgery, wished, “I hope your leg feels better!”

Jeez! Some people! With all the setting good examples of compassion, and empathy!

Makes it difficult, sometimes, to be as cynical as I tend to be.