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

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.”

Pains in my Fifth Point of Contact

Z-Pack! Arrgh!

Those of you who have suffered along, reading my scribblings (uh, I mean…) been frequent visitors to this blog, likely know that, in addition to spending years in The Sick People Business, I am, well, conservative. This works out both politically, as well as with regard to my life choices. I have heard that everybody is conservative about things that they know best. Firefighting is renowned with the deliberate pace of accepting new innovations, probably due to the fact that if the innovation tanks, firefighters (and civilians) die. The military once was very conservative, for similar reasons.

So, TINS, TIW, driving my happy, fuzzy, disease fighting ass home after another fun filled, exciting day of Beating Back The Scourge of Zithropenia (Azithromycin+/penia=Zithropenia. (n) The state or condition of having a pathologically low blood level of azithromycin. (fictional malady)). I was listening to a talk radio host, and this worthy declaimed that they “Know my own body. I get this same bronchitis every year about this time of year, and I always get the Z Pack!”.

Let’s pause, and “bookmark” that statement. There are three things that I want to address therein. Once I unclench my teeth, that is.

This soul continued: “So, I went to a doctor, just like last year, because I had this bronchitis, just like last year. I mentioned that I wanted the Z Pack, just like last year, because I got better after taking it. I guess that was the wrong thing to say, because he prescribed something else, which took longer, and didn’t work as well”.

Another bookmark, please. Generally, this commentator makes sense, and I agree with their perspectives. They typically make valid points, in my view, and their analysis of events makes sense: they appear generally internally consistent. HOWEVER, I need to contemplate whether there becomes a variety of what I will call a “reverse Halo effect”, for lack of the precise term. That means, if this commentator can so badly err in this regard, perhaps I ought to view their perspectives with greater skepticism.

Now, about those “bookmarks”. Let us begin with (1) “I know my body”. Let us agree, “know my my own body”, and “know whereof I speak in matters medical” is not a circle in the Venn diagram of facts. Generally, the soul with whom I am interacting (placing myself in this person’s clinician’s place), is not a physician of any stripe, commonly not an RN, and likely does not know the manner in which antibiotics (for azithromycin-The Z Pack-is an antibiotic, of the macrolide class thereof) function. In some regards, this is similar to presenting to your mechanic, and asserting, “I know my car, and I need a new framistan!”

Perhaps, should your mechanic pull the OBE codes he/she might have some insight into the, oh, I dunno, correct analysis of why your vehicle is making that funny noise, that, just maybe, you ought to listen to.

On that same topic, the imp in my head often suggests that, in response to that conversational gambit, that I ask, “Indeed? What is your opinion of the role your amygdala is playing in your illness?”, or, “Are you certain the the Z Pack will be strong enough? Shouldn’t you take imiprimine for your cough-worse-at-night, or sniffles?”

I rarely listen to the imp’s advice.

Secondly, “I get this same bronchitis every year around this time”. While I am by no means a microbiologist, nor do I play one on TV, and the last Holiday Inn Express that I stayed in was in 2016,

in my Nursing studies, and in my midlevel studies, I do not recall a single instance of our instructors informing us that microbes possessed awareness of the seasons, let alone calendars. My assessment, assuming that my examination does not provide contrary evidence, is that the seasonal nature of the malady likely reflects seasonal changes in the environment. Here, in The Un-Named Northern Fly Over State, that likely means, in the fall, that you finally became cold enough to turn on your furnace, and, generally, that means a forced air furnace. Said furnace has been dormant for 4-7 months, allowing all the dreck suspended in the air to settle out in your heating ducts, and, once you get chilly again, and the furnace is activated, which means the the blower is energized, air begins to move through your ductwork, and all that dreck, quiescent for lo, these many months, is aerosolized once again, and you again breathe it all in.

Since, in the interval, your mucosa has grown UNACCUSTOMED to these irritants, you, once again, have irritated sinuses, which swell (“my head is plugged” and/or “I cannot breathe….through my nose”), and, in the manner in which your mucous membranes respond to irritation, they pour out mucous. Since it takes a while for you immune system to again achieve equilibrium, the delay until you go to the clinic + the delay before you fill your prescription + the delay until you complete the course of azithromycin of which you speak so highly, roughly equals the time frame required for your immune system (read: mucous membranes) to adapt to the new, dust laden, environment your autumnal activation of your heating system elicits.

Rinse, repeat, for spring “bronchitis”, likely elicited by mold finally being unburied from the snow that we enjoy months at a time. Ibid, spring pollen release, similarly, summer lawn clippings, or whatever.

Finally, “I always get prescribed the Z-Pack” (implied is “and it always fixes me”.) Please contemplate the logical fallacy of “post hoc, ergo propter hoc” (“this follows that, therefore that caused this”). To illustrate, I purchased a new pickup truck in the summer of 2020. Therefore, absent my truck purchase, Mr. Biden would not presently be in The White House. Right? See above regarding seasonal irritants to your sinuses, and their effects, along with the timeline described two paragraphs above.

There is an additional factor, segueing into the next point, wherein azithromycin interacts with other medications (betcha they didn’t know THAT, eh?), as well as particular medical conditions (go internet search “black box warning”. I’ll wait here while you do so.) To translate the medicalese into english, “QT prolongation” refers to an alteration of the heart conduction system, which, occasionally, can produce alterations of the heart rhythm that can be lethal.

We generally consider that to be a bad thing.

So, these are prominent among the reasons that I am considered “the Z-Pack Nazi” by my co workers.

With reference to the assertion that “…he prescribed something else, which took longer and did not work as well”. Please refer to the timeline outlined above, consider the drug-drug interactions, as well as drug-medical history interactions cited above. Now consider the possibility that Doxycycline, over ten days, was every bit as effective as azithromycin (which is to say, not), and perhaps the speaker went to the clinic earlier in their course than historically.

All that is with absolutely no knowledge of this radio person’s medication list, allergy list, past medical history, review of systems at the time of the office visit, nor of the physical exam findings. Simply, it elicits teeth grinding, and reminiscences of actual patient encounters that I personally have had.

Thanks for riding along.

Duty · Fun And Games · guns · Pains in my Fifth Point of Contact

SNIPPETS

So, TINS, TIWFDASL, and one of the registrars walked back, and informed us, “They say that there is a man out there with a gun!”

My response was to ask, “Is there any reason that you are NOT telling the police this, rather than telling me?”

“Oh, should I call the police?”

“Ah-yep! Right freaking now would be very nice!”

@@@

If you have COPD (emphysema), it is likely not so very helpful to smoke marijuana.

@@@

Me: “So, you’re here for your cough. When is your cough worse?”

Them: “When I cough.”

@@@

Please, after I have explained my plan of care for your cough, which is caused by the irritation caused to your throat by the mucus in your throat, mucus originating in your sinuses, Please do not correct me with the observation that “My mucus is in my throat”.

It is very likely that, when I illuminated and inspected your throat, I DID notice, and, indeed, did comment upon, the tsunami of snot therein. Further, it is likely that every child of Ghawd that I have seen today has, also, snot streams running down their posterior pharynx: their throat.

So, when I explained to you that that mucus is irritating to your throat, since your throat is not well designed to tolerate that event, and that irritation manifests as a sore throat, or a tickle and a cough, or both, did you consider the possibility that the mucus originated, oh, gosh, I don’t know, IN YOUR SINUSES, AS I, INDEED, MENTIONED IN MY DETAILED EXPLANATION OF YOUR MALADY AND MY PLAN TO MANAGE SAME?

So, the nasal steroid that I recommended to you, over the counter, will suppress the inflammation (that I mentioned was the root cause of your woe), and thereby suppress the outpouring of snot which is the proximate cause of your cough, and, therefore, end (or really, really suppress) your cough, which was the ostensible purpose of your visit in the first place.

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

“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!”

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.

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

Cross Country Adventure

So, TINS, I was NOT FDASL. Rather, youngest brother and I were driving a rental truck full of my mother’s earthly possessions back to The Un-Named Maternal State. She had died, and we were consolidating her possessions so as to end paying rental on a storage locker, once we had each kept a few items as keep sakes.

In any event, we had departed early in the afternoon, and therefore were NOT going to make the trip in one go. Gotta admit, the allure of driving through the night, well, had faded with the years. Neither of us were thirty, anymore.

As it started to get to about midnight, Youngest Brother had searched for, found, and reserved a room at a hotel something on the order of 1/3 of our way There. This hotel was described as “near the airport of (fairly large city)”. Now, I have flown a time or several, and have some expectation, expectation that I feel is not unreasonable, that there would be, ya know, SIGNS, announcing the presence of something as large as, oh, gosh, I don’t know, AN AIRPORT. Signs, no less, on the adjacent interstate highway.

Notwithstanding my expectations, I managed to drive a considerable distance past (fairly large city), and began to wonder out loud where the freaking airport, and, with it, our hotel, might be. Youngest Brother did a bit of internet searching, as well as phone map application searching, before he announced that I had managed to drive past it.

Score, ME!

So, we reversed course, and drove back, finally observing a sign announcing the airport, set way, way, way back off the side of the highway, obscured by shrubbery. We only saw it, because, unlighted, another vehicle’s headlights momentarily illuminated it.

I guess that these folks believe that if you do not know how to get tyhere, already, you don’t belong there in the first place!

Once we arrived, Youngest Brother entered, and registered us, obtaining a pair of key cards. We trundled our crap up the elevator, and found the room. This hotel used proximity key cards, and (I supposed) placing the key adjacent to the door locking mechanism would trigger the door to unlock, and we would stumble into sleepy time bliss.

Or not. The lock blinked a persistent red, and there was no whirring as of, say, unlocking, to be heard.

Youngest brother returned to the desk, there to explain the problem to the clerk and elicit a replacement, functioning, key card. He returned to report the following.

He told the clerk that the cards did not function at our lock.

The clerk asked him, deadpan, “Did the light turn green?”

Brother’s answer: “Nope!” (while thinking, ‘Of course it turned green, you idiot. The door popped open, and right now my brother and I are sitting on the sofa, eating our dinner!’)

I suggested an alternative answer. “Yeah, it turned green. And I looked all around, and never did see the butler who is supposed to open the door, turn down my sheets, and unpack my luggage! What sort of low rent establishment are you running here, anyhow?”

We did, in fact, receive a new set of keys, which worked.

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.”