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.

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

Two More Tales

Once upon a time, Da City was “The Arsenal of Democracy”, heavily industrialized, and a place where a reasonably hard working high school graduate could graduate, and, within a year, have a solidly middle class lifestyle working in a factory. One auto company had established an industrial complex just outside Da City, and on an island in this complex, had established forges, stamping plants, and coking ovens. Even across the river, the smell had to be experienced to be believed.

I worked with one guy, back on EMS, who had worked, pre-fire department, for one of the private ambulance services. They had caught a run for some emergency or another on this island, and, this being the days of 24 hour shifts, my friend fell asleep, letting his partner, who was driving, take care of things.

He related, “I was awakened when the ambulance stopped. I looked out, at the gas flaring off, and the chemical smell of sulfur heavy in the air. The area aroiund us looked like a hellish war torn moonscape, and I thought, “Oh my f@@king Ghawd! He’s wrecked the ambulance, I’ve died, and this is Hell!”

Another story, from a slightly later time, had me working with Doug and Rob, at a house in the far western area of Da City. We were dispatched to an assault, and met the cops on the scene. Upon entering the house, a gentleman (looking to be something like 6 feet and some change tall, probably running probably 220 pounds) reported that the woman of the house, who, herself, looked to be like 5 feet 2 inches, maybe 120 pounds, had assaulted him, striking him with her fists. He reported that he needed to be “checked out” due to his (non evident) injuries. She interjected that she had not assaulted him, he had, rather, assaulted her (and inflicting no perceptible injury in that process). He responded, loudly, and it was on. The Great West Side Debating Society Quarterly Meeting began.

While “the adults” were yelling etc, I noticed, in corner of the next room a perhaps 5-7 yo little girl, crouched in corner, mouth open, fists clenched as in a silent scream. While cops refereed “the adults”, I crouched down in front of child, attempting to verbally soothe her. One female officer noticed, and came over. I introduced the officer to the child, “This is my friend, Officer Evans. She would like to talk to you for a while. Is that OK? She, and the rest of her friends will keep you safe.”

We disengaged, everybody signed no transport forms, we went in service. As Rob finished the trip sheets, he paused, and commented, “You know, I think we may have just witnessed a watershed moment in that little girl’s life.”

Bastard. I fear that he was right.

Fun And Games · Having A Good Partner Is Very Important! · Life in Da City! · Pre Planning Your Scene · Sometimes You Get to Think That You Have Accomplished Something!

First noc I wore fire boots at work: freeway run, on a snowy night.

TINS©, TIWFDASL©, and going to paramedic school in my off time (this was many, many years ago). In the course of this schooling, I spent some time in clinicals, variously in the local ED in a wretched hive of scum and villainy not so very far from Da City, or with one of the advanced life support crews running calls in the self same wretched hive.

It’s generally educational to spend time with other medics, as their organization’s culture, and lore, is likely to be kind of at a tangent to your home outfit. The education may run both ways. In any event, There I was, (studying) Fighting Disease, and Saving Lives in The Wretched Hive, and one of the host medics came on duty, ferrying his “load out” into the ambulance. I noticed that he tucked a pair of fire boots behind his seat, and asked him about them.

It being winter in The Northern Un-Named State, well, we were susceptible to receiving considerable amounts of snow from time to time. I believe the professional meteorological term is “ass loads”. My host noted that this could result in snowy shoes, and therefore wet feet, and that there were few things so miserable as cold, wet feet, in Da Nawth, in winter. Waterproof boots, that reached nigh up to one’s crotch, served admirably to avert this sort of undesirable outcome. I took notes.

Soon, I acquired my very own pair of “Storm King” (old standard) NFPA complaint boots. So, it happened that I wore them to work one snowy evening, and, early in the shift, Doug and I caught a run for “one down” on the expressway.

We pulled up behind the state police cruiser, and saw a figure prone in the snow and slush. The trooper told us that the patient had been struck by an overtaking vehicle, when the overtaking vehicle did not notice that our patient was bent over the lip of the trunk of his STOPPED vehicle, ON THE SHOULDER OF THE DAMNED EXPRESSWAY!

Our patient did not fare well in this exchange. I pulled up my bunker style boots, so that they reached nearly to my crotch, and knelt in the slush. Doug logrolled the man, and I slid the backboard beneath him, and logrolled him my way, so Doug and I could then center him on our spine splint. We buckled him in, collared him, schlepped him into our rig, and beat feet to TSBTCIDC, which happened to be one exit and a coupla turns away.

I remained dry and warm. If I had never worn those boots another day, that night, in that slush, they paid for themselves!

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.