Fun And Games · Gratitude · Life in Da City! · Pains in my Fifth Point of Contact

Random Thoughts Part VI

Assessment of the elderly, sounding confused.

When I am assessing a patient, and ask, in my interview, ref location/day of month/day of week/name/etcetera, when you are not the patient, and YOU answer, talking over the patient, please realize that IDGAF about YOUR mentation, and when you coach the patient, it really, really interferes with my assessment. Plus, it is entirely likely that I myself KNOW the place/day/date/season/etcetera, because, you can bet your ass that if it were NOT Tuesday March the 41st, I would certainly be somewhere else, doing something else, other than attempting to struggle my way through your interruptions of my evaluation of your parent.

In a similar vein, when I ask Jim-Bob where he hurts, probably, when you coach Jim-Bob, admonishing him to “Tell the doctor where you hurt”, you are not really contributing any value whatsoever to the interview. If Jim-Bob indeed comprehends my question, you are only adding noise and distraction and likely, that is NOT helpful. If, on the other hand, Jim-Bob does not understand my query, your repeating it IN THE VERY SAME FREAKING WORDS, neither adds to the information that I require, so that I may care for Jim-Bob properly, nor facilitates timely implementation of that care. So, unless Jim-Bob does NOT speak Engrish, himself, please STFU, and allow me to interview the patient. Or, perhaps, go boil some water, gather a fresh newspaper and some clean shoelaces, right now, please.

Which will, of course, require you depart the exam room and allow me to complete my interview and examination.

Thank you.

Thoughts about Cost vs Price:

Lowe’s “bargain bin” AA battery powered cell phone charger: $10

Having several in your Bag-O’-Tricks at work, so you can hand one to a patient you’re sending to ED via ambulance, whose phone is dead: Kharma.

Having that guy get my cheap-o, bought-on-a-whim charger back to me, with a thank you: PRICELESS!

EMS LAW OF ALTITUDE: Patient’s weight divided by number of floors above street level equals a constant, “K”. Therefore, a 300 pound inert patient on the first floor is roughly equivalent to a 1200 pound patient on the 4th floor. With no functional elevator. And the first due engine company out on a working fire.

(redacted)’s Law: (I don’t have permission to use his name, but it’s not *MY* formulation) When responding to an EMS call, and you are pretty sure that you are on the correct block, but, for some reason, folks in this neighborhood do NOT have any house numbers, seek out the most tumbledown anonymous house on that block, and knock, Your patient awaits inside.

(redacted’s partner)’s Corollary Number One: The one house on the block with ghetto gates (bars on the doors and windows), is your call.

Corollary Number Two: Occupants of the house with the gates KNOW who is performing all the neighborhood B & Es.

Corollary Number Three: There is nothing inside the grilled house worth stealing. The decor is milk crates, cast offs, soiled mattresses on the floor. Even odds that the smell makes the place a haz mat scene.

Final Thought”

Please, please, please! If your physician has ALREADY prescribed a medication for your affliction, take the freaking med, BEFORE your come to my clinic stating that you require treatment for that selfsame affliction! Because, it could happen that my self control may lapse, and I may, indeed, ask you just how exactly I may help you, when you not only were prescribed, but physically picked up, the very medication that I would have prescribed (and, indeed, wound up prescribing) for your problem.

But, OF COURSE, you weren’t here to get a work note! Totally!

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

Paying Attention Is Important

So, TINS (c), TIWFDASL (c), and working in Da Corridor. This was Da City’s, well, let us say, in paraphrase of the immortal words of Old Ben Kenobi, “Da Corridor: You will never find a more wretched hive of scum and villainy!” So, not the nice part of Da City.

I was working “The Corridor”, and an academy classmate, let us call him Gordon Lightfoot, was detailed in that day from another house. At this point of time, TBTCIDC was closed, as they were in the midst of moving kit and caboodle to the shiny, new, and in-the-medical-center hospital they had just opened. (Well, it had not been opened, just yet, and that little detail will figure prominently in this tale!) The hospital that was TBTCIDC’s “stand-in” was NOT generally the trauma center, but was in the medical center.

We caught call after call, transported sick (and a lot of not-so-sick) people, and generally saved lives. Our next run was on an asthma patient, and off we went. In fact, this particular address was only a block from the medical center.

We arrived, announced ourselves, and acquainted ourselves with this person’s malady. I brought the stair chair, and we wheeled this soul out to the ambulance, and settled them onto the cot. I had JUST entered the cab, preparatory to a leisurely trip to The Stand In Hospital, when Gordon stuck his head through the window connecting the cab with the patient compartment, and bellowed, “Reltney! He’s arrested!”

I hopped around to the back, and helped Gordon get set up for a spot of in transit CPR. Once he was set, I re entered the cab, and called dispatch: “Medic One, Code One, Stand In Hospital. Cardiac arrest, witnessed. Eta One Minute!”

Dispatch acknowledged. I tuned in the hospital alert frequency, and called: “Stand In Hospital, come in for Priority One traffic!”

They acknowledged, and I started my turn out into traffic, lights flashing, and siren wailing. “Witnessed cardiac arrest! CPR in progress! ETA one minute!”

The nurse on the radio was not clear on the message. “Say your ETA?”

“Open the doors! We’re here!”

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

Whenever I Start to Think That I am The Smartest Guy in The Room, I am in the Wrong Room!

Another time, I was fighting disease and saving lives as the afternoon nursing house supervisor. Start of shift stuff had been done, I had made some rounds, and arranged for staff to get off the unit to eat. I was piddling around with some paperwork of some sort, and heard an overhead page of “Code Red: 1 East!”

At that time, in this facility, 1 East was our psych unit. I phoned the switchboard, and she told me that there had been a pull station activated on the unit, and I needed to go verify it before she could call the fire department.

Uh, excuse me? WTAF??!! I directed her to call 911 right freaking now, and communicate the alarm at once. “But, our policy is to wait until the supervisor verifies the fire!”

I told her that, employing the telepathy that had stood me in such good stead in years on the Fire Department’s EMS division, I had just this second confirmed the alarm, and she needed to stop dicking around, and call the fucking firefighters.

I hung up, and took off at a trot for the nursing unit, and unlocked the door.

Immediately, I was happy that the alarm had NOT been delayed. The unit was quite smoky, and the smoke was starting to bank down to about shoulder height. I found the charge nurse, and asked her for report. She reported that every patient had been accounted for, and every one was presently in the day room, with two sets of smoke doors between them and the fire room. One of the patients had, somehow, ignited his mattress, and then things got exciting.

The security supervisor and I did another sweep of each room, double checking that nobody was on a floor, or draped over some furniture. Happily, nobody but the two of us was there. Oh, yes: the two of us and the first due engine company.

The firefighters trundled the smoking mattress out of the unit and into our alley, whereupon they performed a sort of urban baptism ceremony, pouring The Healing Waters Of Engine 56 upon the Sinning Mattress.

The next morning I had a stern chat with my boss, and the phrases “NFPA standards” and “fire code for health care facilities” were flung about. Along with the observation that the reported SOP was ABSOLUTELY inconsistent with the prevailing standard of care.

Duty · Having A Good Partner Is Very Important! · Life in Da City! · Pains in my Fifth Point of Contact

Phone calls that make you go”WTAF??!!”

So, TINS, TIWFDASL as a nursing supervisor in a small hospital in Da City. I had checked our afternoon staffing, and accounted for all the staff. I had wandered around, meeting and greeting my staff, and made arrangements such that everybody could eat. I checked in with security, and, as usual, there was nothing happening.

I was back in the nursing office, completing some paperwork or other, and received a call from the switchboard. The operator informed me that Channel 69 news was calling, asking about some patient who had fallen out of a window at our facility. I told the operator to send the call to me, and stat call the security supervisor to meet me in my office, RFN.

The call was odd. (Now THAT is a surprise, idn’t it?) The caller identified herself as a reporter for one of the local stations, and that they had received a report that a patient had fallen from a window, and landed on a roof of part of our building. I responded that this was inaccurate. I knew this to be inaccurate because, in the event that such a thing had occurred, the staff would call me immediately, no such call had been placed, therefore no such thing had happened.

We concluded our conversation, and I turned to my friend the security supervisor. I asked him to immediately inspect our roofs, either in person or with one of his officers doing so in person, and ascertain the absence of anybody (or, any body) on any of our roofs. He hopped right to it.

Next I called each of my charge nurses, and ordered them to immediately, with no delay, personally lay their eyes on each and every one of their patients. They were ordered to immediately call the switchboard to report that they had indeed personally laid eyes on every one of their patients, or stat page me overhead in the event that any patient was not physically on their unit.

One charge nurse protested that she was too busy to perform this task. I noted that this was what we termed “a work order” in our employee handbook, and her options were to get to it, right now, or prepare their soliloquy for 0900 the following morning, wherein they would have the opportunity to convince the director of nursing that they should, indeed, continue their employment at our hospital. Because ANY other response other than “Let me go, so I can get to this”, would result in their being clocked out and escorted from the building, right about now.

Surprisingly, that elicited compliance.

The security supervisor paged me, requesting that I meet him in the cafeteria, that being about the center of the hospital. I arrived and he briefed me: his officers had inspected the roofs, and noticed nothing awry. A couple of his officers had shanghaied the maintenance man, and secured a ladder. They were going to climb up and re-inspect the accessible roofs, to verify what their preliminary survey had suggested. And, nobody/no body had been found.

I physically went to each nursing unit, spoke with each charge nurse, and had them show me their census, along with a report of their actions to inspect each patient. No missing persons. Hallelujah!

I phoned my immediate supervisor, and gave her the short form report. Of course, the long report, in five part harmony, with full orchestration, with circles and arrows and illustrations to fully communicate the entirety of the affair, was waiting on her desk for the morning.

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

The Reveal!

You may not be surprised to learn that I spend considerable time meeting folks, and some of those folks do not bowl me over with the force of their intellect.

Occasionally, somebody who does not otherwise impress me as being particularly dull witted, appears to decide that The Reveal is needful, NOW!, and therefore proceeds to impress me that they are, in fact, an idiot.

So, TINS, TIWFDASL, and I was interviewing some soul about his particular malady. As is my usual practice, I inquired about what symptoms had precipitated today’s office visit, duration of symptoms, what had been done prior to visiting me to address the symptoms, simply as a beginning.

So, this soul related that his symptoms had been treated on a couple of previous occasions, in the past month, and had transiently improved, and then returned. He had, so he told me, been treated with “an antibiotic”.

“What antibiotic?”

He did not know. “The antibiotic that they prescribed for me.” (as helpful as THAT is….)

“How long did the doctor have you taking that antibiotic?”

“Until it ran out.” (Certainly. Of course.)

I attempted to discern how long it had taken before the antibiotic had run out, since treating Malady “A” might call for a 5 day run of The Z Pak (boo! Hiss!), whereas Malady “B” might be addressed by 28 days of Doxycycline, for example. Ya know, just as if I cared what had elicited this gentleman’s symptoms, with an eye toward, oh, gosh, I don’t know, maybe TREATING HIM EFFECTIVELY, or something.

At this point, he felt it relevant to review some of the high points of his resume. For some reason.

“I’m college educated! I’m not an idiot!” (uh, sir? First, college educated maps poorly onto “not an idiot”. Not a very high correlation. Secondly, in circumstances where you wonder if it might be appropriate to reassure somebody that you are NOT an idiot, it is very likely that you are about to reinforce the impression, that you ARE an idiot. That certainly has been my experience in my own life, you may want to consider if there might be some parallels in your own.)

I somehow got back on track, and began my review of systems. At this point, he revealed that, in his estimation, “You are being dismissive of my concerns!”

HUH? Inquiries about your allergies, medications, and medical history are not “my attitude”. That’s how I attempt to avoid prescribing something to you that you either are allergic to (and you did not mention to my nurse….), or that might interact malignantly with your regular medications. For example, I dislike eliciting a GI bleed (stomach bleed: think bleeding ulcer) simply because you did not think that it was relevant that you take coumadin (a blood thinner), now that you are here for your orthopedic injury. Should I prescribe ibuprofen (popularly known as Motrin), that in combination with your coumadin might lead to a life threatening GI bleed, and I feel that to be a bad thing. Occasionally, that review of systems elicits something kind of important, like chest pain or difficulty breathing, that you forgot to mention, because your ankle pain is the only thing that (for some reason) you are concerned about.

But you are paying me to be concerned about that other, life threatening, stuff, and have the wit to not miss it.

Duty · Life in Da City!

“This is no shit….”

Occasionally, I receive a comment to the effect that my acronyms are confusing, and my correspondent has been unable to divine their meaning. (which would be why I have a tab captioned “Abbreviations, Acronyms, Jargon and Terms of Art”). Perhaps it might be entertaining (well, I might be entertained!) should I review how that particular preamble arose.

Something on the order of 40 years ago, the magazine Soldier of Fortune had an article about “War Stories”. Near as I can recall, from the mists of time, there were three essential elements of any good war story.

First, the Obligatory Disclaimer: “This is no shit!”

Second Required Element, The Required Preamble: “There I was, fighting disease and saving lives….” (In the SOF formulation, it was more along the lines of “fighting communists and defending Freedom…”)

Third Required Element, The Compulsory Thematic Element, wherein The Narrator is a HERO, of Olympian proportions, overcoming impossible adversity.

So, there I was, seated on the bench (yes, reminiscent of “The Group ‘W’ Bench” of Arlo Guthrie/Alice’s Restaurant fame) outside the Department Doctor’s office. The preceding evening, while carrying some soul out of their house on West Boulevard, the gusts had lofted some speck of debris into my eye, and I had reported same to my supervisor, who had sent me to ED and those worthies had sent me home for the evening. In order to return to duty, I had to be cleared by the Department Doctor.

I was seated among a batch of firefighters, and we all were swapping stories of how we had come to receive orders to report here. This fellow slipped on wet pavement and had wrenched his back, another had injured his knee, and was only awaiting clearance from the department to return to duty, since his orthopedic surgeon had released him post operatively.

The next guy to tell his tale clearly had been schooled in The Grand Tradition of Firehouse Stories, and rolled right into his story. “Yeah, we caught an alarm, and the first floor was pretty well involved. We knocked it down with the deck gun, and started an interior attack. So, there I was, fighting fires and saving lives, and the floor fell in! Dumped my ass into the basement! Everybody was pretty excited, until they dragged me out, and found I was only banged and bruised up. The chief sent me to the hospital, they sent me home, and now, here I am!”

My turn. “I was on a run on The Boulevard, and some dust got blown into my eye…” (“….and they all moved away from me on The Group ‘W’ bench…”) “…and the lieutenant ordered me to go to ER, and they put me off for the night. I thought that it was overkill, but, what are you gonna do?”

They all moved back, and one offered, helpfully, “Kill a morning outside the department doctor?”

Yep, pretty much.

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

Parenting Skills

I was interviewing a soul, who had brought their spawn along with them (because, why WOULDN’T you bring your 5 year old to your urgent care visit?). Said spawn (of course) had no self entertainment skills, likely due to the screen the named patient/parent placed into his hands immediately upon his whining that he wanted the phone, right now! While I was endeavoring to elicit nature of present illness (eg: what are your symptoms, and why did you determine that coming to urgent care was the thing to do?), duration of present illness (and, please Ghawd, please, say something more specific than “a good little while!” Pleasepleaseplease!), and provocative or palliative factors affecting this illness, said sprat was entertaining himself with the phone, and, it developed, felt the burning need to experience the sound track in his very marrow. In order to accomplish this task, he set the volume at eleven. Of course, in the confined space of the examination room, it was deafening.

I stifled my initial impulse to wrest the device from his hands, dash it to the floor, and grind it beneath my heel, all the while shrieking “Kill! Kill! Kill! Kill!…”, and then, settle upon my seat, and, calmly, ask, “Now, where were we?”

Instead, I continued to ply my patient with the appropriate questions, in a normal, soft, tone of voice. Of course, the named patient could not hear a damned thing I was saying. I smiled, and repeated my queries in the same, soft, calm tone of voice.

Still, the cacophony drowned out my every word. I smiled, and paused. The light began to dawn in my patient’s eyes. She turned to Little Jimmy (or whatever this child’s given name was), and directed him to silence the device.

He whined that he could not hear, should that happen. She repeated herself, and he again whined.

Then, in a feat of effective parenting nearly unsurpassed in my clinical experience, she retrieved the phone, silenced it, and pocketed it. Little Jimmy whined and groused, but his mother turned to him, directed him to quiet down, lest they “have a chat” in the vehicle, and turned her gaze, again, in my direction.

Miraculously, Little Jimmy settled down. I completed my examination and interview, and everybody went their separate ways.

Duty · Fun And Games · Having A Good Partner Is Very Important! · Life in Da City! · Pains in my Fifth Point of Contact

Vehicular Extrication

Long ago and far away, I spent my salad days as a street medic in Da City’s EMS. I know, right? Startlement abounds, amirite? Anyhow, this one time, we caught a run. We arrived to find an intoxicated gentleman seated in the rear seat of a four door sedan. Interestingly enough, he was seated upon the floor thereof, with his legs extended beneath the front seat.

We figured that extricating him from the vehicle would facilitate assessment (eg, WTF was his primary malfunction, and what, if any, would be our role in addressing it?). Therefore we started to attempt to move his legs so that he could return to being seated upon the rear seat, and exit the vehicle from there. No joy.

It tuns out that highly intoxicated folks, like our friend here, were not so very good at listening to and following directions. Our entreaties that he fold one leg, and remove it from beneath the seat, seemed overly complex, as he did not successfully implement step one of our process.

So, we tried to move the seat forward, thinking that this would afford our patient enough maneuvering room so as to fold leg “A”, move it laterally, extend it, and repeat the process with leg “B”, and thereby achieve freedom.

Nope. As the seat moved, he shrieked as if we were removing the leg, likely anticipating reattachment on the sidewalk. So, that avenue of approach was foreclosed.

Doug and I consulted with the vehicle’s owner, who had been pacing about, intent that we not damage his baby. Or the patient, I suppose. Doug and I were fresh out of ideas, and figured that our friends in the firefighting division, with halligan bars, K-12 gasoline powered saws with metal cutting blades, hydraulic extrication tools, and similar toys for fun and games, likely could devise several new plans to remove this gentleman from the floor of the back seat.

I shared this thought with dispatch, noting that our patient appeared in no immediate life threat, and perhaps a “Code Three” (aka “Priority Three”, or no red lights no siren) response might be appropriate.

Dispatch acknowledged our request, told us that a squad would be on the way, and “Firefighters never respond ‘Code Three’, always ‘Code One’”.

Alrighty, then.

The vehicle owner overheard all this, and appeared to become considerably more excited. “You called the mother-f*@$ing firemen! They will f*@$ up my car!”

Doug and I agreed with him, that likely there would be some damage once the firefighters had extricated Mr. Drunk And Boneless from his car.

Mr. Drunk And Boneless thereupon became the recipient of a loud, profane, creative, and enthusiastic exhortation that he remove himself from the vehicle so as to greet the firefighters while sanding upon his own two feet, on the sidewalk, rather than seated upon the floor of the exhortor’s car. (Paraphrased). This was accompanied by pulling, pushing, tugging and bending, as the narrator demonstrated the contortions that he believed would facilitate the exit of the drunk and boneless fellow from the narrator’s vehicle.

And it came to pass that, once the squad had arrived on our scene, Mr. Drunk And Boneless was seated, relatively happily and nearly uninjured, upon somebody’s lawn, rather than enmeshed in the seat of the vehicle that had held him securely within it’s embrace.

The squad looked the scene over, returned to service, and our patient told us to bugger off, as he simply wanted to sleep.

Well, bye!

Having A Good Partner Is Very Important! · Life in Da City! · Sometimes You Get to Think That You Have Accomplished Something!

Serendipity

One evening, I was eagerly anticipating the prospect of departing work on time. We had not turned a metaphorical wheel for something like 45 minutes, and the clock on “the clubhouse wall” promised us only 20 more minutes until we recreated a LeMans start, jetting off into the night.

So, of course, somebody wandered in. She got registered, and my MA roomed her, interviewed her, vitaled her, and got some pee to analyze for indicators of a urinary tract infection, as such were her reported symptoms.

I reviewed the vitals, allergies, meds, and past medical history, as the urinalysis machine deliberated, finally printing out it’s findings. Surprisingly, given Miss Lady’s report of frequent, urgent, uncomfortable urination, there were no white blood cells nor nitrate (indicators of bacterial source of her discomfort). What there was, was an abundance of glucose (sugar). Indeed, the machine indicated something like 1,000 mg of glucose per decaliter (100 ml, or 1/10 of a liter). That’s a lot of glucose. I requested a finger stick blood glucose test.

That read “High”, as in, too much glucose in the drop of blood tested, for the machine to measure it. The machine will register blood sugar levels as high as 600 mg/dl.

I entered the room, introduced myself, and asked, what prompted her visit tonight.

She recounted the urgency, frequency, and discomfort with urination. “I feel like I have a bladder infection!”, she declared.

“Well, ma’am, there are no indications of infection in your urine. There is, however, an abundance of sugar in your urine. This is present, as well, in your blood. Are you a diabetic?”

“No.”

“Well, ma’am, you have more sugar per ml of your blood, than is present in a similar volume of sugary soda pop. You are, indeed, a diabetic. You need to go to emergency right now, so that they can get you started on managing your diabetes. Give me a minute, and I will print out your chart so you can show the folks in ER what I have found.”

Fun And Games · guns · Having A Good Partner Is Very Important! · Life in Da City! · Pains in my Fifth Point of Contact

Retail Pharmacy, So To Speak

A long, long time ago, in an ER very far away, I was a night shift ER nurse.

Surprise!

So, TINS, TIWFDASL, well, uh, not so much. I and the other nurses were capitalizing upon a slow moment and gabbing away at the nursing station, when one of our security officers ran in (literally!) and announced that “We got a shooting in the driveway!”

Having heard no loud noises, I was puzzled, but, these officers were not prone to overstatement, so I asked a couple of the other nurses to grab a cart, I grabbed some gloves, and off we went to the ambulance entrance.

Now, by way of background, this was in the early days of the crack cocaine epidemic (although, how one contracted “crack cocaine” from another person without active, willful action on one’s own part is unclear to me). A couple of blocks away was what might be considered to be an open air drug market. Folks (commonly suburbanites) would drive up, engage a soul in conversation and arrange a transaction, another confederate would be summoned and the exchange would take place, money from the buyer, drugs from the vendor.

We were told that in this particular transaction, the named patient, seated in the back seat of this two door vehicle, appeared to believe that he was the designated quality control inspector. Indeed, the tale appeared to paint this fellow as believing that he ought to remonstrate with the vendor regarding the unsatisfactory nature of the product that had been delivered.

As the History Of Present Illness unraveled, the vendor did not seem to have fully committed to a “Zero Product Defect”, nor a “Every Customer Fully Satisfied, Every-time” merchandising philosophy, as, when the shootee indicated that he, the shootee, intended to enforce his product quality complaint by with holding payment, he, the vendor, is reported to have produced a handgun, and shot the shootee.

Bad times ensued. The driver, unsurprisingly, panicked, and sped away. A few blocks later, he, the driver, noticed our bright “Emergency” sign, and pulled in, bellowing an incomprehensible narrative.

So, security cleared the car of the terrorized goslings, and I (and security, and my nursing partners) tried to extricate Mr. Beenshot’s inert form out of the rear seat of a coupe, indeed, a compact coupe.

It only closely resembled a cluster fuck. For a while.

We maneuvered Mr. Beenshot into our code room, and commenced to resuscitating. Before things had progressed very far, our doc had determined that this guy had a “STAT!” transfer in his very near future, and so the nursing supervisor, who had come at a run upon our paging a Code Blue overhead, peeled off to arrange with our transfer ambulance service that they produce a crew and truck RFQ (Right F*%king Quick), and then phoned TBTCIDC to provide them a heads up.

We eventually got him stabilized (kind of, sort of), and the physician had a detailed chat with TBTCIDC senior physician. Off Mr. Beenshot went, and we sought out the entourage, intending to elicit more history, more circumstances leading up to the shooting, more pretty nearly anything, so we could provide that information to TBTCIDC, as well as, well, notify next of kin.

Alas, the posse had unassed our waiting room sometime while we were distracted, trying to save the life of their friend, I mean, co conspirator.