Should I Stay, Or Should I GO?

Aesop, of The Raconteur Report, recently had an exchange with “B”, the proprietor of the “In The Middle Of The Right” blog

“B” had opined that the advice provided by Sumdood, a “Newspaper Doctor”, quoted in The Daily Mail, was wrong. He then elaborated upon his perspective why, in his area, waiting for their version of EMS was more likely wrong, than not (outside of specific outlier circumstances).

Aesop, who has been an ED RN for many years, presented a contrary appraisal, suggesting an action plan wherein in nearly every single case, calling EMS, and awaiting their arrival was more likely to be a superior plan, than any “snatch ’em up and boogie to the hospital” alternative plan of action. He then enumerates his concerns with that get-up-and-go course of action.

“B” responded, citing his rural setting and the assertion that he, “B”, a civilian, could make the trip in his personal vehicle in an estimated 16 minute trip, compared to his estimate of EMS responding in around 15 minutes, and an estimate time-to-ER adding up to something like 35 minutes. He opines that contrary views seem ”..let us say, city-centric”.

I responded as follows, edited for typos:

“You do make some good points. OTOH, having lived in a rural county (our hospital was the only one in two counties this away, or three counties, thataway), I, as a former medic, can authoritatively state that having your partner drive the ambulance, is orders of magnitude better, from a patient care perspective, than you barreling yonder to your local hospital. There are, of course, exceptions. If you have the expertise to differentiate A from B, or G, then feel free to make that determination. As I told my daughter ref her wheezing child, do you know CPR? Can you perform same in a moving automobile? What’s your notification plan, to warn the hospital that you’re coming in hot with a critical child?

One Weird Trick? Your local medics, at whatever level of licensure, CAN do those things, DO have those capabilities. Yes you likely can phone whoever, WHILE driving essentially “Code 1”, AND wondering how you’re gonna provide care, while simultaneously driving, navigating, communicating, and assessing your patient.

Reflect on the deleterious effects of task stacking, on each one of those mission critical tasks, while under stress that most of us will never have experienced in our lives.

Which one of those tasks are you willing to compromise?

So, yeah, there will be occasions wherein scoop-and-go is reasonable and prudent. In my experience on thousands of EMS runs, and decades as ER RN those are uncommon.

Like, use-a-tourniquet-as-a-civilian uncommon. “

Mr. “B” replied, citing his assessment that his local EMS “was only a transport service”. He asserted that “...even heart attack victims...” received this level of care. Again I responded. 

“TBH, field care of an MI or an ischemic/hemorrhagic stroke is, at best, ongoing assessment, supplemental oxygen. Again, every fraction of a second you are watching traffic is another fraction of a second you are NOT assessing your patient. Conversely, every fraction of a second you glance at your patient, is a fraction of a second for some kid to run into traffic/some granny to bust a red light/other trip stopping additional calamity.

But, you are correct. Aesop’s years in ER, my 2+ GENERATIONS of EMS and ED experience mean nothing, because “city”. Or something.

You indeed DO know your AO better than I do. You, indeed, know the risks you are willing to undertake, better than I do. And, finally (in both senses of that word), you know the risks that you are willing for your loved ones to assume, in this hypothetical situation.

My 2 cents worth of advice, is worth exactly what you paid me for it.

I’ll E-mail you, your change.

I genuinely hope that you never need to field trial your plans. Just as I pray that I never again have to field trial my own plans.”

Another exchange, with my response:

(“B” observes:) “THEN a 16-18 minute drive to the ER (close to 35 minutes) is better than a 16-18 (or even less, yeah, I am that good of a driver with the equipment to match, even under the stress you refer to…I’ve done it once before) minute trip to the ER for a real medical professional to treat is the better option? ”

(Reltney McFee responds) Well a coupla things: in my experience, folks who are in arrest, generally have measurably better outcomes (even if any outcome from an arrest trends toward “dismal”), should they receive, say “16-18 minutes…” of, say, cardiopulmonary resuscitation. Hell, taking your numbers, even 45 minutes of CPR is more likely to produce a “good” outcome (for whatever value of “good” you select) than 16 minutes of anoxic cardiac arrest.

Again, your circus, and you ought to organize your monkees in the manner that you think is best.

Aesop and I are presenting alternate viewpoints, that’s all. In my case, since around 1988, I have been in rural areas as EMT, ER RN, and midlevel provider. Again, in my case, I have carried a pager for my local fire department exactly so that SOMEBODY would show up at someone’s house, who was having the worst day of their lives, in order to attempt to mitigate same.

My opinion derives from 2 generations in the sick people business, in rural areas. No, not Four-Corners-Of Arizona rural, but Upper-Midwest rural.

Should a summary be worthwhile, my baseline is to encourage everybody to become an EMT, at least at the basic level. It’s around a semester at Lansing Community College (to select a venue near to my “neighbor”, Eaton Rapids Joe, aka ERJ), and should you find yourself in hard circumstances, you will NEVER EVER think, “Gosh, I sure wish I had known less about that problem!”

If you have read ERJ’s thought experiments formulated as tales, you have narratives of scenarios wherein basic EMT skills might be life saving. Hell, if you listen to “B” from In The Middle Of The Right, you will hear him describe living in an area where, should YOU! Have basic EMT skills, your family will for a fact be measurably safer than if you do not.

As with anything I tell y’all, (hell, for that matter, with anything I tell my patients!), none of you are in my chain of command. You are, however, in my “chain of nag”, so, consider yourselves nagged to train up. Hard times are looming, and whatever form that they take, you will not ever think “Dammit! I wish I had not known how to respond to that!”, when “that” threatens your child, or spouse, or neighbor.

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“The overdose is over there!”

So, TINS (“This Is NO Shit”), TIWFDASL (“There I Was, Fighting Disease And Saving Lives”), one lovely autumn evening in Da City, and my partner, Doug, and I caught a run for an overdose.

Now, at this point in time heroin was very, very “popular”. We had considerable experience with identifying narcotic overdoses, and managing them. (at least, “managing” them as much as we were going to, in a basic life support ambulance, in Da City with all the attendant financial constraints, and in circa 1980) The unbreathing/microscopic pupils/diaphoresis (wringing wet sweat) presentation is difficult to forget, once you have seen it a few…hundred times.

So, we arrived on the scene, and knocked, Our knock was answered by this huge guy, wringing wet (remember: autumn night in the northern tier of states, temp running around 60 degrees in the daytime) and, as I played my Mag Light over his face, I could not see any pupils. I remember thinking, “Jackpot! Only, how come he’s standing yet?”

That was answered when he gestured over his shouolder, as if to direct us, and announced, “The overdose is over there!”

Al-righty, then! We went as directed, promptly digging out the bag-valve-mask resuscitator. THIS fellow was not only wringing wet as well as having microscopic pupils, he was, into the bargain, not breathing at all!

We wrestled him onto our cot, wheeled him out to the ambulance, and coded our way to TSBTCIDAC. (The Second Best Trauma Center In Da City). There, after a brief ceremony featuring the Ghawd Narcan, he arose, figuratively picked up his pallet, and walked (well, ok: more like stumbled) out of the door.

SOMETIMES, I AM ON THE RECEIVING END OF BLESSINGS

So, TINS, TIWFDASL…..Ok, well, not so much. I had taken a break from FDASL (Fighting Disease And Saving Lives), that which the majority of humanity would call “a vacation”, and was on a cruise. In a breach of my usual practice of formulating pseudonyms to protect the privacy of otherwise uninvolved parties, I will call out this particular cruise company, Carnival Cruises, for EXEMPLARY! Customer service.

TDD (The Darling Daughter, Brenda), of whom I have spoken, had four children, we might denominate them as Ariel, Beatrice, Charlie, and Danielle. She had married a man of whom I vigorously approved, and they (the parents) had forged a partnership of the first rank.

So, Beatrice had been ill last year with a periorbital cellulitis (an infection of the tissues surrounding one’s eye). She had recovered, after a bout of IV antibiotics (which intervention she had NOT approved of) and an inpatient hospital stay.

Something on the order of a month ago (as I write this), it appeared that she had developed a recurrence, and so her mother took her off to ED. These folks treated her with IV antibiotics, but, when things did not promptly resolve, further investigation followed. It appeared that she had an inflammation of her one optic nerve, and this being very (very) uncommon, well, eventually she was transferred from The Mothership Hospital, to The House Of Ghawd. THESE worthies treated her for a variant migraine, (since, she had been on high dose steroids for several days), and sent her home.

About the time TDW-Mark II and I were depart on our vacation, she (Beatrice) returned to ED, since her headaches had not improved. My daughter reassured us, stating that there was nothing I/we could add to things, and it seemed foolish to her for us to forfeit the payments made for this vacation, and that she (Brenda) had things as under control as they were going to get, in the near future.

Since my daughter has a spine of ordnance steel (just as does her mother, The Plaintiff), is smart and has a finely calibrated “This sounds like bullshit” detector, we reluctantly set out. TDW had internet on her phone in this trip, so that updates, if required, could be communicated.

This is where the “Carnival has my business until the heat death of the Universe” part comes in. TDW received a message, relating that another ED visit had resulted in (another) spinal tap, and that this had revealed increased CSF (cerebrospinal fluid) pressure. They (the ED doc) had drained a small amount of CSF, which dropped the pressure, and improved Beatrice’s headache. That was unexpected.

So, the question becomes (a) why does Beatrice have this increase in CSF pressure? (b) Why does she have a headache mitigated by reducing this pressure? (c ) what treatment implications arise from the preceding two answers? And (d) who are the “pros from Dover” to ascertain the above answers?

So, here I am, afloat in the Caribbean, my vehicle no less than 1,000 miles from my grandchild, and no phone service. How might I back up my daughter?

I went to the Guest Services on this ship, and asked if there was some way I could pass along a 24 hour shoreline ships operations number, that my daughter could call in the event that she needed to contact me Right Freaking Now!?

Yep.

The Guest Services rep handed me a phone, told me the “make a phone call to CONUS” code, and invited me to phone my daughter. He stated, “The phone number that will show up on her caller ID, will get her straight to this desk, which is manned 24/7. If she calls, we can find you and get done whatever is needed.” He continued, “There will be a charge, but we will reverse it. Simply tell us once it shows up, we will make it disappear.” He offered us internet, under the same terms, so that we could e-mail back and forth as needed. I thanked him, and told him that presently, we had communications in other than urgent settings, addressed adequately.

Chapter Two, in why “Carnival Cruises Will Have My Business Until The Heat Death Of The Universe”: So, two days later, Beatrice is going home, Brenda has ‘lebenty thousand referrals and followup appointments, and it appears, presently, that things are improving. This Is No Shit, There I Was, lolling around our cabin and contemplating a nap (such is MY exciting life!), when the stateroom phone rang. I picked up, and there was Guest Services on the line, asking how we were doing, how was my grand daughter, did I require any other assistance.

Very, very rarely am I on the receiving end of this sort of care. I am a cynical bastard, and generally am calm in any sort of dilemma. This, well, I teared up and developed a catch in my voice.

And, present reports (as of this writing) Beatrice is improved (sort of), and we have hopes of unraveling this conundrum.

POSTSCRIPT: I just now went downstairs to talk to the supervisor of Guest Services, to give the personnel there an “Attaboy”. The line supervisor requested I (hand!) write a note summarizing my observations. I have three thoughts in this regard: firstly, asking ME to hand write anything is soon to be an exercise in cryptology, requiring skills similar to those employed in deciphering the Rosetta Stone. Secondly, regarding the concept of “summary”: y’all have read my blog: does anybody really think that the phrase “summarize”, and my long winded bloviations, belong on the same page at all? Thirdly, it occurred to me that I have cried, perhaps, 4 times in the past 20 years. This being number 4.

Dressing For Success

One time, my family gathered at a restaurant in Greektown, celebrating one occasion or another. This was in Downtown Da City, and, at this time, there had developed the phenomenon of flash mobs, wherein high spirited youths would apparently spontaneously congregate at one location or another, and in the course of the festivities, civilians, otherwise uninvolved with the group, would be assaulted and robbed.

TDW-Mark II and I spoke of such an event, and the potential for same to develop when our children, and grandchildren were at hand, and decided that this Would Be A Very Bad Thing. We selected our wardrobes accordingly.

It turns out that my son in law, my daughter, and my brother, all feel similarly about this sort of thing, for, when I counseled my sister in law, a very nice (and very naive) soul that, “If a group of folks all enter this restaurant all at once, I will tell you to take the children into the kitchen of the restaurant, and keep them there. Under no circumstances are you, or any of the children, to re enter the dining room, unless one of us physically arrives to escort you out!”

She protested, “But, we aren’t allowed into the kitchen!”

I showed her my wolf grin. “If I tell you to do so, I guarantee that nobody will say a word about you and the children being in the kitchen. The noise will be way, way too loud for you to hear them, if they were to do so!”

She looked puzzled. My son in law explained. “Mary, if Brenda grabs the kids and beelines to the kitchen, two things: do not be left behind, and do NOT get between her and the kitchen door!”

“Why is that?”

“If you are between Brenda and the kitchen door, and one of the ‘celebrants’ starts into the kitchen, he will be shot. Do not be in the way.”

Mary turned back to me. “Why would they try to go into the kitchen?”

I wolf grinned her way, again. “Because I had failed to kill them.”

My son in law chimed in, “I will have missed them, too!”

TDW-Mark II joined in. “Me, most likely I will have run out of ammunition. I do not plan to miss!”

My brother observed, “And, I will police up the stragglers, if any!”

Looking aghast, Mary declaimed, “You cannot believe that anybody would try to hurt somebody at random! I just do not believe such a thing could happen!”

TDW responded, “You just keep on believing that. In the meantime, if The Stretcher Ape tells you to get into the kitchen with the kids, do so right fucking now, pretty please?”

Abandonment, and Trust Issues…

A while ago I had an MA assigned to me. She was (is) capable, focused, intelligent, and engaged; she maintained awareness of what else was occurring in the department, and reacted promptly and appropriately. (She was the protagonist of the tale of the early morning floppy child)

As things developed, she had an opportunity to transition to a day shift, Monday to Friday, 9 am to 5 pm, work-no-weekends-or-holidays job (in contrast to our present work-til-9-pm, every other weekend, every other holiday scenario). And! Get a raise in pay!

Naw, I cannot see why she would entertain such an opportunity for a single second, either.

So, of course, I teased her. “Oh, I see how you are! You would rather spend time with your husband, with your children! Oh, yes, I suppose all that is just fine for you, but what about ME?”

As you might expect, she started her new job, and, occasionally, took some overtime, working with me from time to time. Of course, each time I would tease her. “Oh, I see! Now that you are dead to me, NOW you come back, just as I was resolving my grief at your cruel abandonment of me!”

My partner joined in, observing, “You know, if you came back to work in this department again, you could never break up with him ever again! He has been an embittered husk of a man, since you left!”

(This is the same partner who observed, when I once wore a fleece prominently displaying the fact that it was an item from the National Rifle Association, by means of the 2 inch tall initials “NRA” over the left breast, let me know, “You know, they spelled your name wrong on your coat!”)(My name is “Tom”)

We reached a lull one overtime night, and I renewed my teasing. “You know, I taught you everything I know, while I was standing on one foot, and you abandon me! Oh, yes, you have a ‘HUSBAND’, and you have your ‘CHILDREN’, you have dreams, and plans for your life, but, what about MEE?!?”

She chuckled.

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?”

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 21^st 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.

“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!”

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.

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.