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

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.

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

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.”

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

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!)

Life in Da City! · Pains in my Fifth Point of Contact · Pre Planning Your Scene

If Only I had Gone to School For This, Or Something!

There has been a spate of RSV going around, lately. RSV, or Respiratory Syncytial Virus, is contagious, via airborne droplets. In small children, it can lead to hospitalize-level-illness, whereas in adults it generally causes “a cold”. The reason younger children can get so ill, is that should the virus elicit swelling of the smaller airways, children, having narrower airways, cannot tolerate as much swelling as adults and older kids, before their ability to move air is compromised. We can test for RSV in the office.

So, from time to time parents bring in their kids, reporting cough, or lack of interest in feeding, or runny nose. Occasionally such a child will test positive for RSV. Occasionally such a child has alarming vital signs. One such child arrived, and the MA truncated her intake, once she noticed retractions and diminished oxygen level in this infant. She trotted out, figuratively grabbed me, and brought me in to see the child.

I saw, myself, the retractions. Retractions occur when the effort of breathing in, is increased to the point that the skin between the ribs, or below the ribs, draws in from that effort. NOT NORMAL!

We administered a nebulizer (“mist”) treatment of a bronchodilator. Subsequently, the retractions had not particularly improved, nor did the oxygenation of this child. I directed the mother that she needed to take her child to the emergency department. She responded that her ride was not present, and there would be a delay as the ride returned.

I recommended EMS at that point. The child appeared to be stable, presently, but I was uninterested in determining how long that would take to go downhill.

The mother responded, “No, I want to wait for my ride.”

It appeared that I had not successfully identified to her the ways that significant delay could make things go horribly wrong. And, waiting for her ride promised to present a significant delay.

Mother was not impressed. Her ride (eventually!) arrived, and everybody went to emergency. Finally.

Duty · Having A Good Partner Is Very Important! · Life in Da City! · Pains in my Fifth Point of Contact · Protect and Serve · Sometimes You Get to Think That You Have Accomplished Something!

Sometimes, The Pucker Could Squeeze Diamonds

So, TINS, TIWFDASL at an urgent care out in Flyover Country. It was a typical afternoon, featuring a parade of sniffles, coughs, and poison ivy. Our clinic was on the south side of the road, east of Middling Sized City, and the Big Time Big Deal Hospital And Trauma Center. In other words, to get the the BTBDHATC, one would exit our driveway, and turn west (that is, LEFT!)

Abruptly, the registrar summoned me. My MA and I walked over, to behold a limp toddler. Very Not Good!

The MA escorted the male carrying the child to an exam room, and began to collect vitals. I examined the child, discovering a heartbeat (Crom be Praised!) and spontaneous respirations. The registrar collected demographic information, and I asked the adult what had happened, prior to arrival.

“Well, he started shaking, and then he stopped. He just wouldn’t wake up, so I brought him here.”

Well, the “wouldn’t wake up” part was still descriptive of the child, and I noted that I would have to call an ambulance immediately, because this could have several causes, none of them good. Indeed, “floppy child” is right up there in my Triage Catalogue Of Very Bad Things.

The adult male paused at this. “I don’t want to send him by ambulance. I’ll take him myself!”

I was surprised. I noted, “So, you *DO* realize that several of the things that caused this, could reappear, and he could stop breathing or his heart could stop. EMS is trained and equipped to deal with those things, should they occur. You, while driving, are not, right?”

He persisted. “I’ll drive him myself”.

We directed him to go there immediately, with no delay nor detour. We explicitly directed him to exit our driveway, TURN FREAKING LEFT (that is, west), and not stop until at the ED.

He stated that he understood, and would do so.

He scooped the child up, and exited the building. I sat down to chart, as well as call BTBDHATC, in order to provide them with forewarning of the sick, sick, sick child coming their way. That is, until my registrar called me, excitedly, to report that this sunovabitch had turned EAST! (exactly away from the hospital) upon exiting our driveway.

WTAF!

I had the clerk print a face sheet, and called emergency dispatch. I related the above information to dispatch, along with my concern that a critically ill child was *NOT* being taken to the ED. I provided the street address we had received, as well as the contact information.

I next called the child protective services emergency number, to report the above. I was assigned a report number, which I charted, and my own name and contact information was taken.

Several hours later I received a telephone call, from a gentleman asserting he was from CPS. I asked him to confirm the report number, the child’s date of birth, name and address of our record. He did confirm all these details.

He queried me about the particulars of the child’s presentation. I supplied the requested information. I asked how the child was. The worker paused, and said, “Well, I am not allowed to provide information regarding an ongoing investigation, particularly one where the child in question has been hospitalized. I’m sorry. “

My response? “Yeah, it’s too bad you couldn’t tell me if the child had been hospitalized or anything. I understand. Thank you.”

Fun And Games · Life in Da City!

RANDOM THOUGHTS, INSTALLMENT NUMBER VIII

@The other day, my MA gave me the typical “thumbnail” report of my next patient. “(sick person of some sort”), (vitals), ….And, you know, he’s older.”

This particular soul was born TEN YEARS after I was!

@ROBOCALLS: I receive telephone calls, from time to time, from unknown numbers. Almost every one is from some computer dialed bullshit. My practice is to say “Hello”, and then begin to count ten seconds. If there is no human being on the line by then, according to my (it’s a robo call: I’m not particularly patient) timer, I hang up.

If there is some human on the line by then, they have, maybe, ten or fifteen seconds to convince me that I have any interest whatsoever in speaking to them.

And, if it’s one of those “we need to speak to you about your computer repair the other day” idiots, it depends: if I’m feeling froggy, I may stay on the line simply to trifle with them and waste their time. If I’m feeling curmudgeonly (which, to be honest, is most of the time), I hang up. In mid word.

OVERHEARD THE OTHER DAY:

Joe-Bob arrives, asking if he could get the work note written for Cletus. The clerk inquired after Cletus’ last name. Joe-Bob did not know Cletus’ last name.

She asked if Joe-Bob knew Cletus’ date of birth? “Nope.”

Cletus’ phone number?

“Nope.”

Cletus’ SSN?

(surprisingly/sarc) “Nope!”

Did Joe-Bob know the date of the visit which elicited Cletus’ work note?

(say it with me, now…) “Nope.”

She wrote down *OUR* phone number, and suggested that, once Joe-Bob rejoined Cletus, perhaps he, Joe-Bob, could invite him, Cletus, to telephone us, and at that point arrangements could be made.

@ Life Lesson: A lesson learned from hard experience: No matter how frequently you look at your watch, in the middle of an awful shift, it is still 3 o’clock!

Life in Da City!

Questions Above My Pay Grade

A long, long time ago, back in Da City, I had left EMS, and was employed as a nursing house supervisor. In the course of my rounds, I stopped by ER. The staff chatted with me, revealed that things appeared to be under control, and they needed for nothing at that time.

One of the staff nurses drew me aside, and murmured, “Check out the ER doc that they sent us!”

I asked, of course, “Why?”, and was told, “Never mind! Once you chat with him, you will know!”

I approached him, introducing myself, and asked how his night was going. I was struck by the fact that he appeared to have several freckles about his face, each with a glint as of metal. Each, in fact, about the size of a pin head. I figured that was odd, concluded my conversation, and moved on.

I subsequently encountered one of the ER nurses in the cafeteria. “What did you make of Dr. Pins?”

“Couldn’t tell you. Never seen anything like it, before!”

So, a little later that night, I cruised through ER, again. (part of my “management by wandering around” strategy). The doc asked me if he could speak to me, in private. That was odd, but, sure, whatev’s.

So, back in the physician’s office, he began to describe a patient. I mean, as in how a resident (or a midlevel) would staff a patient with an attending. He wound up with his query: what did *I* (remember: the NURSING supervisor, with no provider chops whatsoever at this time) think that the patient ought to have done?

I tried not to stutter: I really, really did. I suspect that I failed, but I did manage to observe that other physicians had ordered this, or that test, and not uncommonly had discharged the patient with a prescription for this, that, or the other thing.

The following afternoon, my boss, the afternoon Nursing Director, and I had a chat. A lengthy chat. About Dr. Pins.

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

The Sunshine Rule, Revisited

As you may recall, my go-to principle is that everybody brings sunshine into my life. Sometimes, that is when a soul arrives……

So, TINS©, TIWFDASL© one sunny Saturday morning, and my very first child of Ghawd rolled his eyes when I asked, “do you have any allergies to medication?”, which is part of my Mark I-Mod Ø interview question set.

My inattentive friend responded, “Of course I have allergies! My nose has been stuffy and runny for a week!”

I tried it, once more. “Do you have any MEDICATION allergies?”

“I dunno”

(sigh) “Are you taking any prescription medication?”

“Yeah….”

“Can you tell me what medication you are taking?”

“Nope. Cannot remember.” (eye roll)

I concluded that further interview would waste my time and annoy this gentleman, further. And so, a surly exam followed.

COMMENTARY: Simply so you know, IDGAF what you are allergic to, nor do I care what medication you are/are not taking, despite your physician’s goading, instruction, entreaties, or hectoring.

I *DO* care, very much, that I do *NOT* prescribe prescribe a medication that will cause your immune system to turn you into a fireball. Similarly, I really, really do *NOT* want to prescribe a medication that, in concert with whatever the (expletive) you are, indeed, taking, will perhaps form a binary explosive in your bloodstream. Because you could not/would not tell me whatever else you are, indeed, taking.

So, to me, this sort of thing is kind of important. Please, try to keep up.

Fun And Games · Having A Good Partner Is Very Important! · Life in Da City! · Pre Planning Your Scene

“Reading the Room”, or, Situational Awareness

So, TINS©, TIWFDASL© as an ED RN. At this point in time, the ED employing me (which was Middling Freestanding ED (MFSED) was an entertainment subsidiary of Enormous Hospital System With Delusions Of Grandeur (EHSWDoG).

My subsidiary hospital had the system’s psych ward upstairs, and therefore we appeared to be the psych intake for the three or four county area at which we were the center. So, this one night, an enormous dude, dressed in a three piece suit, perfectly buttoned etc, and BACKWARDS appeared. There were no police accompanying him (so I assume he was not a police psych hold). For some reason, Mr. backwards Suit had decided that he needed to go for a stroll.

As I became aware of the excitement, I noticed a cloud of nurses, as well as several security, negotiating with him to lay back down for assessment, and so forth. Somebody had given him a pen (for Ghawd only knows what reason), and he was appearing to become more excited as time passed. I noticed him only paying attention to the officers, with his (pen holding) hand behind him. He was standing in a doorway from one hallway to another, and I was down the one hall to his right. I strode past him, as if going down that hallway, and, as I passed, I snatched the pen from his hands, and continued down the hallway, as if that were the only reason for my passage.

Mr. Backwards Suit soon de-escalated, was assessed, and (unsurprisingly) admitted for psych evaluation. And, nobody else gave him a pen.

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

Random Thoughts, Part VII

EROTIC STORY SITES ON THE WEB, ARE *NOT* GOOD SOURCES FOR ADVICE ON HOW TO LIVE YOUR LIFE.

A young lady came in to the clinic, and related that her visit today was occasioned by the fact that “My girlfriend’s boyfriend told her that he had (GC/chlamydia/herpes/syphilis/aids/hepatitis/the fuglies), and I slept with him, too.”

I was unclear on the timeline. “*After* you knew?”

She was not. “Yep!”

Sigh. Another round of “test for everything”, and pray that it all comes back negative.

LET’S FOCUS ON THE IMMEDIATE PROBLEM, SHALL WE?

So, TINS© (This Is No Shit), TIWFDASL© (There I Was, Fighting Disease And Saving Lives), and Jim Bob wandered in. In the course of his registration, as well as his rooming, he revealed difficulties voiding. Indeed, my MA related that, once she had requested that he provide a sample of urine so that I might use it to determine what sort of “urine problem” he had, he responded that “I can’t pee”.

In my clinic, there is no catheterization capability. In my not inconsiderable emergency experience, both as RN as well as provider, such a soul requires a catheter, both in order to obtain the urine sample that will guide further care, as well as to decompress the ailing soul’s urinary bladder, as such a condition can become very uncomfortable. Which ignores potential damage to one’s kidneys.

I told my MA that Mr. Cannotpee would have to go to emergency, where, indeed, they had both the ability to place a catheter, as well as labs and imaging to determine what might have caused this problem.

She returned moments later, reporting that he had considered the prospect of a urinary catheter, and thought that he might be maybe able to produce a little bit of urine, perhaps.

His sample was inconsistent with inability to urinate. My appraisal was that IDGAF about this guy’s pharmacologic mis-steps. His stupid life choices that might be revealed by a urine drug screen, a screen that I had no interest in performing let alone contemplating the results of, were his kharma and would impact his life.

And, good luck with that!

LIGHTING UP MY LIFE

Another day, another Child of Ghawd. Soul reports a rash, kinda-sorta itchy, started here, now here, and here, and here. No exposure to suspect plants, no new cosmetics/detergents/soaps/shampoos.

There is a thing, known as a “Wood’s Lamp”, which produces light in the near-UV portion of the spectrum, accompanied by some visible violet (surprising enough!) light. Some itchy rashes will fluoresce (glow, generally a pale yellow-green, occasionally a pale, “coral” red/pink) under illumination from a Wood’s Lamp, and in such cases, it is a dermatophyte that is causing your rash. Treatment is an antifungal, such as clotrimazole (you may recognize the brand as “Lotrimin AF”), or selenium sulfide (the active ingredient in the anti dandruff shampoo, “Selsun Blue”).

This individual described trying multiple creams, lotions, and sprays, none of which effected any improvement. I attempted to elicit a duration of use, and was told, “It just didn’t work!”

Alrighty, then!

For those in the studio audience who do not already know this, dermatophytes are slow growing organisms, and therefore they find themselves in that portion of their growth and reproductive cycle wherein they are vulnerable to treatment, at relative long intervals. For this reason, treatment is relatively prolonged compared with, for example, a boil or other skin infection from a bacterium like staph or strep.

Sigh. I directed my patient to employ Selsun Blue as a body wash, and to continue it for a couple of weeks.

This person looked me dead in the eye, and asked, “Aren’t you going to do anything for my rash? Shouldn’t I use a cream or something?”

Sigh, again. Repeat, verbatim, the care instructions I finished providing, oh, like TWO FREAKING MINUTES AGO. In English. To a native English speaking patient.