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.

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Going Solo

There I was, Fighting Disease And Saving Lives, one weekend day, and I was soloing. Generally, our agency’s practice is to have two providers on duty at a time. On this particular day, I was “It!”, with no partner. The floor staff was sympathetic. I was all “Meh?” about things.

I was reminded of an old joke. It seems this fellow had had his fill of driving a lengthy distance, and elected to stop for the night. He stopped at one hotel, and was told that there were no vacancies.

He stopped at another, and yet another, only to be told, again and again, that there were no vacancies.

Finally, in response, he asked, “If the president of The United States was standing here, telling you that he needed a room for the night, are you telling me that you would turn him away?”

The desk clerk declaimed, “Of course not! Of course, we would make accommodations for The President!”

The traveler squinted at the clerk. “Well, I just read in The Daily Tattler that The President is in Bagwanistan this week. Since he will not be arriving, I’ll take his room!”

The application to my situation was to ask administration if there was anybody else working with me on that day. Of course, as reflected in the fact that there was, you know, nobody else there with me to fight disease and save lives, they would tell me that, no, there was nobody else to work with me that day.

In this imaginary conversation, I would next ask, “Suppose I got hit by a bus on the way in to work today? What would you do, then?”

The reply likely would be that “In that event, we would do (xyz)!”

Which, of course, would elicit the response, “Surprise! I did NOT get hit by a bus! Hey, howzabout (do xyz), and get me some freaking help, eh?”

Partners. Or, Not.

So, TINS, TIWFDASL, and it was approaching the end of my shift. The other midlevel was a locum (think: rent-a-clinician), and since I was busy with my side, I wasn’t paying a lot of attention to her.

One of my patients was pretty sick. As in, “Where is my ambulance”, sick. I also had a couple of other folks, who had to wait while I dealt with Mr.-or-Mrs.-pretty-sick.

Once the ambulance had departed, I tended to my other patients, and noted that the floor staff appeared pretty, well, relaxed. I asked them, “Doesn’t Little Mary Sunshine have any patients left?”

They looked at me. “Uh, no. She beat feet out the door while you were in with your emergency. Oh, and one of her patients did not get their antibiotic. The pharmacy called, and would like you to fix that.”

I did a literal double take. “Say what?”

The MA repeated herself. There was still 10 minutes in the shift.

They tell me, several months later, that I got very, very quiet at that. Concerningly quiet.

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.”

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.

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.

“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!)