SNIPPETS V

STORY THE FIRST

So, TINS, TIWFDASL, just a couple of weeks ago, and, as I entered the room, I was greeted by the younger of the two women seated in the exam room. “There he is! You saved my mother’s life!”

While that certainly was a welcome greeting, I admitted that I was confused. The younger woman, evidently the daughter, filled in the missing pieces. Several weeks previously, she (the narrator) had accompanied her mother (the other soul in the room while we conversed) to a visit to our clinic. She (the mother) had been having a cough of some sort, and I had felt that something in the experience did not sound right. After some assessment in clinic, I had sent the mother to ED, and those worthies had identified a 100% occlusion of one of mom’s coronary arteries (the arteries feeding the heart). Mother had received a stent, and been sent home, and was still among us. Indeed, she was here, today, due to another cough.

Thankfully, today’s cough appeared uncomplicated, and I recommended my usual measures to ameliorate the post nasal drip that seemed to be the source of the cough.

Sometimes I get to think that I really do, from time to time, positively impact people’s lives. That’s nice to think.

STORY, THE SECOND.

Just the other day, I was shopping. Such is the life of a life saving, disease fighting, internet blogging champion (of sorts). As it develops, I am middling tall: 5-7 or so. It turns out that the pasta I was hunting for was on the top shelf, and several other people had purchased some, before me. THAT meant that I could just barely not reach the boxes. I had just realized that I, a tool using animal, could open my knife and extend my reach, tipping over the needed number of boxes, and add same to my cart. That is, I had just realized it, when a gentleman, taller than I, reached up, grabbed a box, and handed it to me, asking me if I needed more.

I requested two more, and thanked him, moving forward with my shopping.

A few aisles over I observed a woman attempting to retrieve an item from a shelf beyond her reach. Before I could respond, another (taller) gentleman stepped up, retrieved the sought item, and handed it to her.

Everyday, plain folks, acts of civility and kindness.

STORY, THE THIRD

We visited my wife’s sister, and her husband, recently. They live in rural Kentucky, and it is rather a change from their previous neighborhood in Metropolis. Indeed, it is a considerable change from my table-flat neighborhood of Un-Named Flyover State.

We arrived, following the directions provided, and noted that the terrain was, well, “hilly” does not really do it justice. As a consequence of that terrain, roadways tend to meander, circling around this hill, or weaving their way up to, over, and down that ridge.

We had spent something like 45 minutes meandering , as the road took us up in elevation, when I noted a sign ahead, announcing “Curves Ahead!”.

I turned to TDW-Mark II, and exclaimed, “Wait, what? THAT was the STRAIGHT part?”

STORY, THE FOURTH: OOPS!

So, TINS, TIWFDASL, and, well, things had come to a slow down. I was working with a physician, on this day at this clinic, and she had never handled an adrenalin autoinjector. We had one handy, and I handed it to her so she could examine it.

I was not quite quick enough, to admonish her to not remove the guard, nor to handle the trigger, on the one end of the device. Therefore, she did, successfully, remove the cap, and then trigger it, sending the needle into one of her fingers, along with some of the adrenalin therein.

The Good News was that, since she was youthful, she promptly withdrew her hand, and therefore only received a fractional dose. The bad news is that adrenalin is a very, very powerful vasoconstrictor, and therefore her affected finger became very, very white, and also burned. Oh, yes, it burned. I cast about, wondering if we had any phentolamine. (an alpha blocker: used to reverse the effects of, among others, adrenalin, when injected into an end capillary bed, Like you would find in your fingers.) Since ours was not an ICU, nor an ED, we did not have phentolamine, nor anything that would serve.

The good news, such as it was, is that due to her youthful age, good health habits (spelled n-o-t s-m-o-k-i-n-g) and the fractional dose of adrenalin she had received, well, after around 20 minutes, her finger regained it’s color, the burning pain faded, and she returned to normal, simply just a bit more shaky than previously.

Subsequently, I obtained, and CONSPICUOUSLY labeled a trainer, specifically intended to harmlessly teach folks how to handle and operate an adrenalin autoinjector. This one has no needle, and no drug.

STORY, THE FIFTH

So, TINS, TIWFDASL….well, okay. I was NOT FDASL, rather, I was off, and, having accomplished all my chores (or, such fraction of “all my chores” as I was going to accomplish that day), my step son (son of TDW-Mark II) called. I had spoken to him about a range day, and he was off work that day, I was off work that day, and it was off to the range we went.

I took my Garand, my .380 pistol, and my 9 mm pistol. Of course, I grabbed the ammo can labeled 30-06 (for the Garand), .380 (surprisingly enough, for the pistol in caliber .380), and the ammo can labeled “9 mm” for, no doubt surprising, the 9 mm pistol.

Now, recall that I have been an RN for, lo, these many yeas. That I have passed uncounted thousands upon thousands of doses of medications, and double checked myself each time, so as to accomplish the “5 rights” of med pass: right patient, right drug, right dose, right route, and at the proper time. This was effected by reading the order, the med container, comparing each with the other, and then, DOING SO AGAIN.

So, we arrived at the range, uncased the Garand, and set up targets. Several dozen rounds later, we placed the rifle in the case, put the ammunition away, and took out the .380 pistol. Fun times.

When it came time to take out, and shoot, the 9 mm pistol, well, I went to the “9 mm” ammo can, opened it, and beheld something like 200 rounds of RIFLE AMMUNITION.

For those in the studio audience who are unfamiliar with Things Firearm, well, 9 mm is a pistol round, and rifle rounds are (a) the wrong size overall, (b) with the wrong projectile (bullet), propelled by (c) an entirely wrong charge of powder, leading to (d) entirely way, way more pressure once the cartridge is set off, for any common pistol to contain, meaning (e) should, somehow, a rifle cartridge be forced into the pistol that I had before me, anyone firing it, should they survive the resulting explosion, would forever after be known as “Lefty”.

Not mentioning the emotional distress I would experience should this pistol, one of my favorites, be reduced to shrapnel.

Sigh. It appears that I had horribly failed the ammunition labeling process, leading to jovial kidding from my step son. Other than that, a good day at the range.

And, the ammunition got re-(and correctly)-labeled.

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SNIPPETS PART IV

I hope that nobody is surprised to learn that, since The Un-Named Fly-Over State is in the northern tier of states, it snows here in the winter (And the fall. And the spring.) That has been the case for certainly the past nearly 70 years that I have been here. Therefore I would hope that my neighbors would have figured that shit out, by now.

On the other hand, there is abundant evidence that my hope in this matter is misplaced.

So, TINS, TIWFDASL…well, OK, I was driving in to work one snowy winter day in order to begin my day of FDASL. I was listening to the amateur radio in my vehicle, and monitoring the county’s fire department dispatch. No ill tidings from that front.

I did notice a car off the road, into the ditch, but I figured that the county deputy already on the scene had things well in hand.

So, there I was, listening to the FM radio, and waiting for any alarming traffic on the HAM radio, when I saw this guy, no shit, skate his compact pickup truck completely across the 3 lanes of expressway traffic, having apparently originated from the on ramp. My guess was that he had entered the ramp at speed that was excessive for the conditions. (did I mention that it had snowed the preceding night? Well, it had. Likely had something to do with the other guy in the ditch.)

Anyhow, once he reached the median shoulder, he started to wifferdill his way along that shoulder, inching his way into the median’s ditch. He did manage to stay upright, so, that was nice…..

The thought crossed my mind, “coefficient of friction: words to live by!”

@@@Snippet The Second@@@

You may recall my tales of cat-herding (Farming? Wrangling?). In any event, one of the cats had a recurring conjunctivitis, such that our local vet voiced concern regarding the potential of a ruptured globe (eyeball breach, with vision-destroying loss of the fluid-vitreous and aqueous humor that is within the eyeball), versus a vision damaging occurrence of scars on the (supposed to be) clear portion of the eyeball.

So, we arranged an appointment with a veterinary ophthalmologist.

Of course, this doctor practiced in an office something like three counties over from our home. Of course, on the appointed day, it was a balmy 33 degrees (f), and could not decide to snow, rain, sleet, or what.

Fun times.

I learned on this trip, that driving Trixie T. Cat anywhere, was very much akin to driving your small, furry, outspoken, elderly, mother-in-law somewhere. I was the recipient of a running series of corrections, spoken (of course) in Cat, that likely would have sounded like “You’re driving too fast!”, “You’re driving too slow!”, “Why can’t you stay in one lane?” (this as I signaled, eased over into the -clear-adjacent lane, and in the course of doing so, ran over the ridge of slush built up between the lanes. So the truck jerked.), “Why aren’t we there yet?”, and the ever popular, “Where the hell are you taking me? I don’t want to go there! Let me out of this damned cat carrier!”

That is, would have sounded like that, if I spoke Cat.

As you might imagine, first off, back seat driving is oh, so very welcome at any time at all. Secondly, such corrections are even more welcome when the driving is, oh, gosh, I dunno, HAZARDOUS! Thirdly, let me take a moment to congratulate TDW-Mark II. She successfully suppressed her baseline impulses to shriek, gasp, or otherwise demonstrate her appreciation of her/our impending DOOM! Probably figured that the cat had that well covered.

Everybody Brings Sunshine Into My Life….

From time to time, I determine that an antibiotic will be helpful in resolving whatever ill is present in my patient. For example, folks with dental infections, and who are not allergic to beta lactam antibiotics (those related to penicillin), get amoxicillin. It is what our dental colleagues have directed me to employ as first line, and pretty nearly always gets the job done.

So, TINS, TIWFDASL, and my patient-du-jour had a dental infection. I presented my spiel, winding up with the observation that I would be sending over a prescription for amoxicillin.

This soul stated that they had received amoxicillin several years ago, and “it didn’t work”.

May I step back for a little bit of dental anatomy? Any surgeon (and, dentists are surgeons of a particular specialty) will tell you that antibiotics are wasted on any abscess, due to the fact that the overwhelming majority of the pathogens are afloat in the pus filling the abscess, and, since no abscess has any sort of circulatory system, any antibiotic will only make it to the periphery of the lesion, and not the the seat. Indeed, surgeons generally are of the opinion (an opinion probably developed during years of residency and 20,000 to 40,000 hours of patient contact) that the foundation of resolving an abscess is to drain the abscess. That will both greatly, greatly reduce the population of germs remaining to cause mischief, but also place those germs in close proximity to tissue that, indeed, has circulation, and therefore provide the antibiotic the ability to access, and damage, the germs.

GUM abscesses are potentially susceptible to intervention by clinicians such as I myself am. TOOTH abscesses, including dental pulp and/or dental root infections, are immune to my attentions.

Therefore, plausibly, this soul’s historic experience with amoxicillin could have been due to the infection remaining inaccessible to the antibiotic.

Back to my story. This child of God requested “something stronger” than amoxicillin.

Two competing thoughts sprang into my mind: First, amoxicillin is the drug of choice. Prescribing something else is akin to purchasing a full ton passenger van to transport your gravel, because “big vans are stronger!”, or something. Really, using the proper tool for the job makes so much more sense.

Secondly, there are several reasons why clinicians do not simply “prescribe something stronger”. One if them is NOT that we are all assholes, who want people to be/stay sick. Rather, for example, gentamicin is used all the time in ICUs for patients who are terribly sick. (wonder if that has anything to do with the reason that they are in ICU to begin with?) These folks get regular blood draws, to be sure that the concentration of drug in the blood is within certain bounds. Too little, and it is less effective than needed. Too much, and deafness and/or kidney failure can result, among other bad things.

So, for certain values of “stronger”, gentamicin is, indeed, “stronger”. On the other hand, deafness as a consequence of your long delayed dental care appears, to me, to be a risk out of proportion to the anticipated benefit. Particularly when I can anticipate the same benefit, with rare risk, from, gosh, er, um, oh, I dunno, AMOXICILLIN.

Back to my story, backing away, a little, from my rant-du-jour: I asked this soul what antibiotic had been beneficial, for past dental infections?

The answer, I swear to Crom, was, “I don’t know. You’re the doctor, don’t you know?”

Words. They fail me.

THE PLAINTIFF AND THE HOUSE.

Long ago, and far, far away, I was sitting in a conference room with my attorney, The Plaintiff, as well as her attorney. We were discussing asset distribution. Her attorney announced that THEIR plan was that we sell the house, split the proceeds, and ride off into the sunset, separately.

Okay, that deserves some context. We had purchased that house something like 8 months prior to this conversation, it was in 2008 (remember those days? Housing values were plummeting like a drunken frat boy off a second floor porch), and we had obtained a “zero down” mortgage. I had kept an eye on housing values, and had noted that this house was worth less than considerably less than owed on the mortgage. We also had, between us, a camper trailer that had been paid off. I suggested, instead, that she take the house (simply so our boys would have their home, in a stable manner), and I would take the camper. I added that she could then, when she deemed it proper, she could sell that house, and keep all the proceeds. Alternately, as I observed, she could consider the market, and realize that the house was worth considerably less that what was owed. In that event, I would accept no responsibility for that shortfall. And, I’d take the camper.

Her attorney was aghast. “You cannot tell me that the house is worth as much as the camper!”

I said, “No, I am not telling you that the camper is worth as much as the house. In my appraisal the camper is worth considerably more than the house, but, it is about what your client wants, after all, isn’t it?”

To make a long story short(er), I kept the house, she got the camper, and no money changed hands in this matter.

Snippets Part III

I have a flexible spending account at work, so as to be able to pay my copays, deductibles, and suchlike with pre tax dollars. Late last year, I noticed that the card by which such expenditures were paid for, was getting declined. I assumed that I had spent all the money and thought no further of it.

Then, I began to get messages from the administrators of the account. Finally rousing myself to speak to them, I learned that the card had been frozen, because, I was informed, they required hard copy receipts for 3 or 4 of my expenditures. This included purchases from my optometrist for, oh, gosh, GLASSES, as well as at the podiatrist, for TDW-Mark II’s ingrown toenail.

It puzzled me, Visa, nor Mastercard never had such issues. I assumed that, just like the commercial banks, that the electronic billing that led to the vendor of, say, my gasoline, getting paid, had all the information required, kind of like a grocery store receipt.

Perhaps I was wrong. Or, perhaps, somewhere in this favoured land, folks go to their podiatrist, or their optometrist, when they feel the need for hookers and blow. (I wouldn’t know, myself, and Hunter Biden was not available to comment on that possibility) So, I guess, I will have to remain puzzled.

@@

Occasionally, I am humbled. Just the other day, I had such an opportunity. The lady bringing the pre school aged children in for whatever their complaint that day, was approximately my age (and, I am by no means of child rearing age. Hell, my youngest grandchild is already in primary school!) She reported, in the course of the conversation, that “My husband and I both got them when they were very, very young.”

Just, matter of fact. No inflection, dry fact.

As I was charting later, I noted that the parent was identified as the grandparent.

So, let’s contemplate that. Some of us are anticipating retirement, with few responsibilities, plenty of free time, and no pressing concerns.

Others, around us, are raising a SECOND family, at our ages, and not flinching.

Some of us are facing demands of duty, and stepping up to those demands, and in doing so are protecting, and nurturing, the most vulnerable among us.

@@

So This Is No Shit (TINS), There I was Fighting Disease And Saving Lives (FDASL), long, long ago and far, far away.

Well, okay. REEEAAALLLLYYYY!, I was shopping in Farmer Jack, in Da City, on one of my off duty from EMS days. I was pushing my shopping cart down one aisle or another, occasionally consulting my shopping list, and a fellow approached me.

He greeted me. “Hey! I know you!”

I did not just recently develop my aversion to Humanity. I spent years perfecting it. “Uh, no, you don’t, sir.”

He, on the other hand, was undeterred. “No, I know you! You work for the fire department!”

“You have the wrong guy!”

“No, really! I remember you  You saved my brother’s life!”

“Yep! That’s me! That’s how I spend my days! How is your brother?”

Snippets, again

@@ Please, do NOT tell me that Bonine is 125 (or 12.5: she was not speaking clearly) milligrams, over the counter. I happen to know that OTC Bonine is Meclizine 25 mg, the same strength anti vertigo medication I prescribe as Antivert, and I know this for reasons. These reasons include (a) I kinda went to school for this stuff, (b) I prescribe Antivert/Meclizine several times a week, (c) TDW and I enjoy taking cruises, and she is somewhat susceptible to seasickness. Therefore, I am familiar with Bonine in it’s seasickness/motion sickness indication. Therefore I purchase it, OTC. Ya know, like last week. (d) When I acquire a medication, I (pay attention now! This one weird trick will help you manage your medicines!) RTFL. (Read The Freaking Label). (e) I have a functioning memory, not blown out by continuous applications of high serum levels of cannabinoids. Therefore I can remember this stuff, along with other stuff I find useful.

Finally, please, Please, PLEASE! Consider the possibility that I, indeed, am trying to both help you, as well as make your life easier.

The above is my internal monologue, which is considerably lengthier than my first pass response, also stifled, of “Hmm. Weird. Ok, then, don’t take it. Good talk. Have a nice day! Buh-bye, now!”

@@ So, TINS, TIWFDASL, as an ED nurse, long ago and far away. It came to pass that my manager invited me to join her in her office, where she told me that several of my colleagues had come to her, concerned with what they esteemed to be my taking overly long to triage patients.

For those in the studio audience who do not know, “triage”, in the ED setting, is the process wherein a nurse interviews the patient to elicit chief complaint (“What motivated you to come to ER tonight?”), history of present illness (“How long have you been ill? What have you done to address it? How did that work for you?”), allergies/medications/history, and vital signs. In the course of that conversation, the goal is to identify unstable folks, and truck them right back to care, and differentiate them from stable folks (like a broken limb with intact downstream circulation), and invite those folks to be patient.

I asked my manager how long I was taking, on average, to triage? This information ought to be readily available from our electronic medical record system.

“I don’t know.” was her reply.

I asked how my triage times compared to the average of my peers.

“I don’t know.”

I asked if the acuity of the patients I triaged was similar, greater, or less than the average of my peers.

“I don’t know.”

I asked if the complexity of the patients I triaged differed in any identifiable way from my peers (think psych requiring lots of redirection).

“I don’t know.”

I contemplated this for a second. “Wouldn’t it be a lot easier for me to improve, if I understood the manner in which I am falling behind my peers? I had thought that one of the advantages of an EMR was the ease with which just this sort of information could be abstracted.”

@@ In my clinic, folks who are currently afflicted with covid, or who fail the screening interview/temperature taking, get seen as “covid + other” patients. They are invited to wait for their turn in their vehicles (or, in nice weather, outside), rather than in our waiting room. Inasmuch as we are a walk in clinic, there are no appointments, and, if you are at the shag end of “The Wave”, well, you face a lengthy wait.

Some of these individuals drive off, thinking (not altogether wrongly) that a lengthy wait=an opportunity to get other stuff done.

The problem with this plan, is that, should a number of the other folks in line ahead of you, either spontaneously cure themselves, or decide, in essence, “F&@k this, I’m not all that sick”, and depart, your turn may arrive earlier than your errands anticipated. So, when the MA calls you on the phone number you provided today at registration, (a) it might be useful if you answered it, as well as (b) if the phone in question was actually in service.

Among the souls who successfully pass these two tests, there are those who respond, when told that their turn was at hand, and we (the MA) had some questions for them preparatory to actually seeing them in the office, “I can be there in 25 minutes!”

Well, that is kind of a fail. The MA will then tell them, “Sorry, we’ll call the next person on the list, who is here now. You will be at the bottom of the list, since leaving the line loses you your place in line.”

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

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

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

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

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

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

SURPRISE!

So, there I was, fighting disease and saving lives, and my MA came to me, regarding somebody who had arrived for a subsequent Covid inoculation. This soul had informed my MA, AFTER THE INJECTION HAD BEEN ADMINISTERED, that she, the patient, had had a reaction to her first inoculation. She described this reaction as swelling, itching, and feeling ill. This had developed in a couple of hours after the injection.

It turned out that, today, this patient had, indeed, developed swelling, runny nose, cough, and whole body itching within FREAKING MINUTES after her injection. (those of my studio audience who have some sick people experience might recognize these indications as harbingers of anaphylaxis)

Weellll, we administered some IM Benadryl, some IM steroids, a breathing treatment, and close attention from my MA. Several repetitions of vital signs and reassessments later, this lady had seen her breathing improve, her itching subside, her swelling tapered, and the cough and runny nose reduced.

So, pro tip: If you swell up after the first dose of whatever the frack you are being injected with, tell a motherfucker, ya know, like, BEFORE you get the next injection. Personally, my geezerly ass will very, very much appreciate it.

Your View, Is *NOT* The Entirety of The World

So, TINS©, TIWFDASL©, alone as my midlevel walk in clinic shift started. We were supposed to have two of us from opening, but, well, some of us are renowned for strolling in something on the order of 30 minutes late. In addition, there was a third provider slated to come in around 2 hours after opening, and work til close.

To start off with, I had a 5 pack of kids. Well behaved kids (Thanks be to Crom!), but, five at a time nonetheless. All in one room, so, of course, it appeared to whoever else had decided to start their day with a visit to the walk in clinic that I was taking something over an hour with one patient.

One such soul opened her exam room door, around 40 minutes after we had opened our doors for the day, and while I was on Number 3 of 5 in the 5 pack, and asked “how much longer?”

I was charting, and replied, “20-30 minutes”.

She asked, “How come?”, and the MA explained “there are 5 in front of you.”

The questioning patient was surprised. “How can that be? There was nobody here when I arrived!”

The MA answered “I had already roomed them when you had arrived”.

“That’s crazy!” observed the impatient patient.

I was kind of busy. My response was “Yep.”

My FAVORITE! Things

My FAVORITE! Things

@ When, as part of my assay of History of Present Illness, I ask you how long you have had your (cough, or whatever other symptom motivated you to march you happy butt into my clinic), please, Please, PLEASE do NOT!!! say “a good little while”, or something similarly non responsive to my question. I will simply repeat my question, using the same words, and the same pleasant, inquiring tone, over and over, until you do, indeed, tell me “2 hours” or “2 days’ or “2 weeks” or “2 months” or “2 years”. Simply so you know, IDGAF how long you have had this symptom, on the other hand, it does have some implications for what plan of care I ought to consider in order to, ya know, actually benefit you.

@ Similarly, for the love of Crom, do NOT tell me, in response to my question, “What have you done for (your symptom)?”, that you have “taken over the counter”. Should any of you in “the studio audience” desire to understand just how unhelpful this is, please spend a few minutes on only one freaking aisle of any drug store you wish, and attempt to catalog the dozens of freaking allergy meds therein. By way of illustration, if you have used a nasal steroid, that would be helpful for me to know, since, should that have been unhelpful, I will be required to up my game.

If OTOH, you simply took The Multi Symptom Dreck You Saw Advertised On The TeeWee Last Night, well, I can then recommend some, oh, gee, I dunno…EFFECTIVE OTC medications, instead.

@ I love it when Joe-Bob goes to (St. Elsewhere) yesterday, does NOT pick up his prescribed medications, and swings by my clinic. Because “I’m not any better”.

@ When I direct you to call your family doctor and arrange followup, and you reply, “They always tell me to go to walk in!”

So, you’re telling me that WALK IN prescribes your blood pressure meds, your psych meds, as well as your diabetic meds?

All this is news to me.

@ When I ask, as my review of symptoms, “Have you felt as if you had a fever?”, and you reply, “I don’t have a thermometer”. (how did folks FEEL feverish, before the invention of the precise thermometer by Farenheit in 1714?) Or, alternately, “your nurse just took my temperature, and said I do not have a fever.” (which, of course [a] I already freaking knew, having reviewed the vitals and nursing notes before I walked in the door, as well as [b] NOT answering my freaking question!)