Gratitude · Having A Good Partner Is Very Important! · Sometimes You Get to Think That You Have Accomplished Something!

Guardian Angel, Working Overtime

So, TINS©, TIWFDASL©, working a weekend gig in a very, very rural corner of The Un-Named Flyover State. I was a mid-level in, completely out of character for me, a very, very rural hospital’s (VVRH) walk in clinic. I was working with an LPN, a woman of sense, alertness, and industry. Sometimes, Blessings are not obvious.

So, mid morning, she gave me report on Our Next Contestant. Late 20’s fellow, had complained of back pain for a week or two, and he attributed this pain to “I pulled my back, working out doors”. So, this was long about February, and in VVRH’s catchment area, it was mighty freaking cold. Snow, long about hip deep, lined the roadways, and the roads, themselves, had been plowed, and, in keeping with Flyover State Rural Road Commission Operating Procedures, had *NOT* been salted. Since everybody got their water from wells, and most of us thought that salting our water was ill advised, the roads had some sand applied, “upstream” of intersections.

I listened to the vitals, and noted her assessment that “this guy doesn’t look right”. I entered the exam room, introducing myself. He told me that he had started to hurt a couple of weeks prior, the pain in his back, described as “Like something tearing”, had increased with time, despite his employing the ever popular intervention of “ignoring it, hoping it would go away”.

Having concluded on this beautiful sunny 8º F day, that is was *NOT* going to get better, he had WALKED three miles into town, by his estimate, seeking help.

He had muscle spasm in his back, true enough, but something about his story sounded several degrees out plumb. I palpated his belly, and felt something therein pulsing away. He also reported that my pushing on his belly, made his back pain worse. I was not certain what it was, but I was pretty sure that this was way, sway above my pay grade.

I phoned the ED physician, spun my tale of oddness, and he accepted my patient. My nurse wheeled him down the hall to Emergency, and we plodded through the rest of our day.

Nearing the end thereof, the ED physician walked in my door, and told me a story, featuring my long walking friend. He, the physician, had also thought that the examination, along with the back pain, was odd, and so he, the physician, had CT’d my patient. That study revealed a honking big, seriously dilated abdominal aortic aneurysm (a dilation of some part of the aorta, in this case in my patient’s abdomen).

For those in the studio audience who are not medically inclined, the aorta is the single largest, highest pressure, artery in your entire body, running about 2 cm in the area just below your diaphragm, about at the level of your renal (kidney) arteries. Those of us who have studied the US Military’s tactical trauma care course, or have had some sort of “care under fire” training”, will have learned that, should the aorta be penetrated, either by projectile or through a rending of it’s wall, the entire blood volume of an adult male (running around 5 quarts) can empty out in something approaching a minute, plus or minus. One thing that places you at risk of experiencing that, besides the projectile-through-your-aorta thing, is having a large aortic aneurysm abruptly rupture.

Of course, in VVRH, there was no abdomino-thoracic surgery service. My friend the ED doc attempted to arrange a transfer for this fellow, only to be SOL (Surenuff Outa Luck). The roads in our corner of the state were being snowed in, and therefore ground transport to pretty nearly anywhere was not going to happen.

Doc cast his net more widely, and more widely. Adjacent State Big Time Medical Center would accept him, but, alas, we would have to figure out how to beam him up transport him there. Middling Outstate Medical Center could not accept him, since they had no vacant ICU beds, which our new friend would certainly require, assuming he survived (a) the trip, (b) the surgery, and (c) the post op period. Any one of which could end him.

Next Up Upstate Medical Center, alas, similarly had no ICU vacancies, and so, finally the physician negotiated a transfer to Downstate Academic Medical Center, who, miraculously, sent a fixed wing aircraft and critical care transport team to our little single runway county airstrip.

A couple of weeks later, I was working a weekend as was the physician in question. He made a point of strolling over , and relating the above to me, both because it was remarkable that the patient had not only survived the trip, as well as the surgery, and the recovery, into the bargain, but was home, and evidently neurologically intact. The doc knew this, because this fellow had come into ED seeking care for a sprain or some such thing, that he had newly acquired, working outdoors!

Gratitude · Sometimes You Get to Think That You Have Accomplished Something!

The “Wrecks” Story (or) How I Met My Vet

A long, long time ago, TDW-Mark I, our children, our dog and I lived basically right down the block from where I type this today. This particular tale is about the dog. The children had been allowed to name him, thinking that we would spell the name the way that they would, as “R-E-X”. However, TDW-Mark I was possessed of a considerable sense of humor (at one time…) (after all, had she not been married to me for nigh onto 20 years?). SHE determined the spelling, “W-R-E-C-K-S”. This was due to the fact that he resided in a household with adolescent males, who were, themselves, high spirited. Therefore the dog was, himself, well, energetic is a kind way of phrasing it.

So, TINS, one morning we awakened, let the dog out on his chain, and settled in for breakfast. After several hours, we noticed that the dog had not barked to be let back in, his usual practice once he had had enough of The Great Outdoors. We looked to see what was up, discovering that the chain had broken, and the dog was not in evidence.

We searched the neighborhood, finding no trace of the dog. We produced “lost dog” flyers, and mounted them at intervals about our corner of our small town. That produced no results.

After a day or two, TDW-Mark I sent me to the local police department, The County Seat Police Department, and I learned that one of their officers had encountered a dog resembling our missing Wrecks, who had been struck by an automobile, and had been transported to a local vet.

I traveled to the vet’s office, and asked after our dog.

This vet confirmed that he did, indeed, have my dog, and that the dog was surprisingly uninjured after his encounter with the car the previous evening. This was determined after x-rays and examination. I asked him how much I owed him for his care. “Nothing. You don’t owe me anything.”

I persisted. “You spent no small amount of your time, and your expertise, on a dog that you had no idea if he would ever be claimed. I get that you do so out of the goodness of your heart, and as a service to the community. On the other hand, I can pay for the care you lavished on my dog. Indeed, if you insist on thinking of it this way, you can imagine that I am paying for the other critter, that goes unclaimed, such that you are not required to pay out of your pocket, for performing a public service, simply because you can do so, and it needs doing.”

I took a deep breath. “It offends me to think that you are going to be leeched off of by some schlub. I am not going to be that schlub. If for no other reason, please take my money because you ought no be penalized simply because you are a nice guy.”

He told me, “Thank you, but, really, you do not owe me anything. Thanks for the thought, but, we are good!”

I smiled and replied, “So, in that case, here is a check for $150. The next time somebody’s dog gets injured, and they cannot pay you for their care, let me help defray the expense you incur.”

And, he has been my family’s vet ever since, going onto 25 years.

Duty · Pre Planning Your Scene · Sometimes You Get to Think That You Have Accomplished Something!

Health Care Stagecraft

So, I see children from time to time. Commonly, they are dubious about the entire “Going to the doctor” thing (yeah, I DO realize that I am not a physician, I am a midlevel. May I observe you explain that distinction, to an anxious child?) With that as a starting point, you can imagine that my approaching said anxious child with a stethoscope, and then with an otoscope (“the ear looking thingy”) might not end well. Yeah, me too.

One of the lessons I learned on Da Street (besides knock from the side of the door, and always have a second way out of any room I enter, and always have a knife, and…well, the important lesson is…..) is misdirection. On the street this manifested itself as changing the topic of conversation, as, on a hostile scene, announcing, “WE have to go and get the stretcher!”, and then both of us doing so, and motoring merrily away from the threatened free fire zone. Returning, if at all, with police.

In a more sedate clinical setting, this manifests itself with my (now) stock spiel for kids.

“This here (hold stethoscope up) is my body tickling thingy. Now, this is really, really tickley, but I only have one, right? That’s not enough to share. So, if you laugh, everybody will know how much fun it is, and they will be sad. ‘Boo-Hoo! (insert child’s name here) got tickled, and I didn’t! That is so unfair! I am so sad!’ Now, we don’t want them to be sad, do we?” (generally, toddler-sober negative head wag) “So, try very hard not to laugh, so that they are not sad! Okay?”

(generally, “ok”)

Once heart and lungs are auscultated, I continue with my misdirection. “You did so very, very well in not laughing, now we move up to the ear tickley thingey! Same rules, try not to laugh so that they do not know how much fun it is, and they are not sad that I cannot share, okay?”

Generally, again, “Okay.” While the child is trying to identify what the heck is so darned tickley about otoscopy, I finish.

One bonus point, is, even if the child screams and kicks and writhes, I can congratulate them. “Wow! You did so very well! I don’t think that they even suspect how much fun that was! You can stop pretending, now! You have successfully finished! Well done!”

Sometimes it is healthcare stagecraft, that lets you complete your job.

Having A Good Partner Is Very Important! · Life in Da City! · Sometimes You Get to Think That You Have Accomplished Something!

Serendipity

One evening, I was eagerly anticipating the prospect of departing work on time. We had not turned a metaphorical wheel for something like 45 minutes, and the clock on “the clubhouse wall” promised us only 20 more minutes until we recreated a LeMans start, jetting off into the night.

So, of course, somebody wandered in. She got registered, and my MA roomed her, interviewed her, vitaled her, and got some pee to analyze for indicators of a urinary tract infection, as such were her reported symptoms.

I reviewed the vitals, allergies, meds, and past medical history, as the urinalysis machine deliberated, finally printing out it’s findings. Surprisingly, given Miss Lady’s report of frequent, urgent, uncomfortable urination, there were no white blood cells nor nitrate (indicators of bacterial source of her discomfort). What there was, was an abundance of glucose (sugar). Indeed, the machine indicated something like 1,000 mg of glucose per decaliter (100 ml, or 1/10 of a liter). That’s a lot of glucose. I requested a finger stick blood glucose test.

That read “High”, as in, too much glucose in the drop of blood tested, for the machine to measure it. The machine will register blood sugar levels as high as 600 mg/dl.

I entered the room, introduced myself, and asked, what prompted her visit tonight.

She recounted the urgency, frequency, and discomfort with urination. “I feel like I have a bladder infection!”, she declared.

“Well, ma’am, there are no indications of infection in your urine. There is, however, an abundance of sugar in your urine. This is present, as well, in your blood. Are you a diabetic?”

“No.”

“Well, ma’am, you have more sugar per ml of your blood, than is present in a similar volume of sugary soda pop. You are, indeed, a diabetic. You need to go to emergency right now, so that they can get you started on managing your diabetes. Give me a minute, and I will print out your chart so you can show the folks in ER what I have found.”

Duty · Gratitude · Sometimes You Get to Think That You Have Accomplished Something!

Maternal Update

Several folks commented, asking how my mother was doing, or wishing her, and my family, well.

Thank you, all. TDW-Mark II and I were both touched by your kindness.

Presently, she is chirpily ensconced in The Maternal State, with my brother, The Accountant. We have chatted, several times (Mom and I), and she is happier where she considers herself to be “home”, than back here in The Un-Named Fly-over State.

She has had her first radiation therapy treatment, and I await an update from my brother/mother.

And, once The Brother Who Is An Accountant has had His Way with several of God’s Children, who are NOT exemplars of “The Healing Arts”, well, THAT will be the topic of a blog post of it’s own.

A very DARK post.

In the meantime, I will attempt to figure out how to give major props to physicians, in the no shit highest traditions of Medicine, who have genuinely Taken Care of Business, to my mother’s benefit, and see if I can do so without blowing op sec.

I will simply say, they are cut from the same bolt of cloth, as the car service guy, who with no drama, no fanfare, simply do their christian best to do the right thing. (see my post of 6-28-19)

Sometimes You Get to Think That You Have Accomplished Something!

Life Happens

So, for the past year or so, my internal goal was to post a new tale roughly every week. Last week, Friday, 27 August, I did not. And, paying attention as I do (for am I not a steely eyed, all knowing, situationally aware gem of readiness?) (or, not so much. Go with that one!), I noted this fact yesterday.

First, the bad news. My mother is elderly. Indeed, she is yet stretching the “elderly curve”. Therefore, she is medically fragile, although you wouldn’t know it from a perusal of her medicine cabinet. Hell, by that metric, she’s healthier than I am!

So, early last week, let us say, she had “a medical issue”. With Brother A being an accountant, and Brother B being a factory worker, well, that leaves Brother C (that would be me!) to be the medical intermediary. Most of us might find that to be, well, distracting. Indeed, I did find myself distracted. So, while we await biopsy results, doctor office visits, in this The Age Of WuFlu, and related malarky, I work, do my household chores, and sleep, when not voyaging to Da City to visit The Maternal Unit.

All of this to say to the hundred or so guests who visit this site every week, thank you for your patronage, sorry about the skipped week thing, and I ought to have more “Sea Stories” coming up in a week or so.

Gratitude · Sometimes You Get to Think That You Have Accomplished Something!

Happy Anniversary To Me!

It was long ago, and far away, this 27 July 2017, when I first took keyboard in hand to begin to record these semi random blatherings, tales of my mis-spent youth.

Several folks have been kind enough to comment, suggesting that they have been kind enough to actually read my Tales Of The Dark Side. Others have actually **followed** my blog.

Thank you, one and all. While I had originally thought to immortalize these things fro my children, thinking that I had mis-remembered or entirely forgotten several of my own father’s stories, I am pleased that folks have found this blog, and appeared to enjoy the stories enough to read them, and, in some cases, come back for more.

WordPress reports that I have had over 11,000 views, and nearly 3600 visitors in 2020, from ten countries.

Thank you.

Fun And Games Off Duty · Gratitude · Life in Da City! · Sometimes You Get to Think That You Have Accomplished Something!

Splinting a Cat, And the Lesson I Learned….(Not What I Had Expected!)

A long, long time ago, in a Blue Hive not so very far from here, I was a street medic for Da City. (Gasp, NO! Say it isn’t so! I…I..never suspected!) I was working nights, attending nursing school days, and attempting ti triage my weekends between school projects, studying, sleep, and having a social life. Oh, yes. AND working.

So, TINS©, TIWFDASL©, and, having concluded a rollicking night of same, I entered my apartment. The building in which I lived had been built circa 1910, and had seen sporadic maintenance since then. This is particularly relevant given that I observed my cat, imaginatively named Mr. Cat, seated at my front window.

It was summer, and I had left my windows cracked. My cats had taken to lounging in the window, both to take in the scenery as well as to bask in an intermittent breeze. This was OK, until in one particular window, in which Mr. Cat had been loafing, the sash cord, which held the window open, failed, sending the window crashing closed.

Mr. Car’s “catlike reflexes” were sufficient to enable him to avoid being entirely trapped by the weight of the closed window, but he wasn’t quick enough to entirely extricate himself. His one front paw was held as if in a bear trap, and he greeted me with a look as if to say, “I say, old man, could you assist me? I appear to be stuck, and it is becoming tiresome.”

The cat-length semicircle of destruction spoke to his efforts to resolve his problem on his own.

I opened the window, and he promptly removed it, and began to clean his paw, as if dust were the only problem. When I observed that he did not appear to want to walk on it, I corralled him, sat down, and began my secondary survey.

I could not palpate any discontinuity in his bones in the affected paw, but he was very reluctant to have me confirm that appraisal with a repeat examination. His breath sounds were clear, and his heart sounds were rapid, but regular with no murmur. (Of course, how much “rapid” was kitty baseline, versus pain versus irritated cat, was difficult to discern.)

He continued to limp, and so I gathered up materiel, and set to fabricating The McFee Cat Splint. I cut out cardboard from a box, wrapped it about the injured limb, and secured it (or so I had thought) with roller gauze.

He, unimpressed, shook his injured limb until the splint went that-away, and he went this-away, and he limped off. Sigh.

I re-corralled him, and we wrestled him into The McFee Cat Splint Mark II. This version featured several wraps about his torso, so as to slow the shake-this-thing-into-next-week response that he demonstrated once I had released him. Good news? It did not head off into a far corner. Bad news? Well, howzabout YOU attempt to explain the concept of “no weight bearing” to a cat, and let me know how well that works?

Sigh.

So, we collaborated (for certain values of “collaborated”, particularly if those include one handedly immobilizing a non-compliant cat, placing a New! Improved! McFee Cat Splint Mark III upon said cat, and then, again, single handedly, securing same upon the same non-compliant cat) in splinting his foreleg, again. This version extended beyond his paw, so that, crutch like, the weight that he would usually place upon this paw was transferred to his chest wall/”armpit”.

Kinda like rodeo, without the clowns. Unless you included me, that is.

I began to put my crap away for the morning, but he persisted in not bearing weight upon the formerly trapped paw, and I soon determined that it was time for an assessment by someone who knew their way around a cat. Against Mr. Cat’s protestations, off we went to the veterinarian.

I had not, in all the excitement, changed out of my EMS uniform that morning. So, there I was, once I had registered Mr. Cat, and requested a “walk in” visit (“Be patient, no telling when a slot will open up.”), seated in one of the chairs, cat in lap, uniformed, sleepy (although, that was kind of my ground state in those days), next to a grandmotherly Black woman at the vet.

She asked me what had happened to my cat, noticing the splint he still wore, and (score!) pretty much as I had designed it. I told her the tale, truncated a bit for the waiting room retelling, and she made sympathetic noises. We conversed a bit about pets, and how they fare in our absences, and so forth, passing the time.

Her name was called, and she looked at me, and at the vet tech summoning her, and then she performed a no shit act of Christian charity. She said, “His kitty has been injured, please take him before me, I can wait a bit longer”.

If you have read more than a couple of my posts, you likely realize that I am generally a cynical bastard, a curmudgeon. I commonly have low expectations of people, and they commonly fail to meet them. This tale took place something on the order of forty years ago, and, retelling it now, I am tearing up. This woman, who I had never met, showed herself to be more giving, more compassionate, than I was. She showed me that individuals can be beacons of community, of respect, of sympathy, for folks that do not look like them. She took pity on a white guy, and his cat, because she could.

Because she was capable of empathizing with another, not of her “tribe”. And, being capable, did so.

My cat recovered from what the doctor determined to be a sprain, and lived a long and (cat) happy life.

I moved out of Da City, married, got divorced, remarried, watched my children grow, and have families of their own.

And, today, I offered a prayer on behalf of that woman, my neighbor-in-fact, who bathed me in her compassion, and for whom, today, I cried.

Ma’am, thank you for that lesson.

Fun And Games · Sometimes You Get to Think That You Have Accomplished Something!

Bradycardia and The Cough

TINS©, TIWFDASL©, nursing in the ED of this community hospital in Northern The Un-Named Flyover State. A gentleman arrived, somewhere in his forties, and he told his tale of chest pain. He shortly thereafter sported the latest fashions in IVs, EKG monitoring, oxygen, and much blood drawn and sent to lab for analysis.

Two things you should know about me. I am a bottomless well of generally useless trivia, for one. For example, the relevance of which will become apparent shortly, I read a bunch of stuff, including a report, years and years and years ago which asserted that individuals undergoing a cardiac catheterization would be instructed that, should they be commanded to do so, they should cough vigorously and repeatedly. This would, or so the article asserted, increase pressure inside the chest, compress the heart, and thereby expel blood from the heart. This was important because occasionally the catheter, introduced into the heart, could produce irritation sufficient to produce fibrillation. (an uncoordinated trembling of the heart, which produces no blood flow. A Bad Thing.)

Once they drew in another breath preparatory to coughing once again, the negative pressure inside their chest so produced would encourage their heart to again fill with blood, which would be expelled with the next cough. This could temporarily produce enough blood pressure to keep things idling along, until the cath lab staff could intervene and set things right.

The other thing about me, is that I am somewhat chatty. (“No! Say it isn’t so!”). Okay, very chatty. So, there I was, chatting with this gentleman, and noting his cardiac rhythm and heart rate as displayed upon his cardiac monitor.

I noticed that his heart rate, originally in the 90’s, was trending downward. (normal is around 60-80). Once it dropped below 55, I stopped congratulating myself on wonderful patient care, and began to worry.

He began to report feeling dizzy and weak. I directed him, “When I tell you to cough, do not ask any questions, simply do it!”

He, of course, asked me why, but at that point his heart rate had dropped below 30 (Very Not So Good!), and I was a bit terse. “Stop talking, and cough!…Cough!…..Cough!….”

I repeated myself at about one second intervals. Now, I am sure that the other nurses heard me, and wondered what variety of insanity had afflicted me. Once they came in to investigate, and I waved my hand at the monitor, continuing my coxswain like commands of “Cough!….Cough!….Cough!….”, they noted his very, very slow intrinsic heart rate. That, coupled with this guy, eyes fixed upon me, coughing every time I commanded him to do so, told them everything that they needed to know, and things got considerably more active in short order.

He soon received a temporary external pacemaker and and an ICU admit.

And we all lived happily ever after!

Fun And Games · Pains in my Fifth Point of Contact · Pre Planning Your Scene · School Fun And Games · Sometimes You Get to Think That You Have Accomplished Something!

More Paramedic School Stories: The First:

Years and years ago, before I left Da City’s employ as a medic, I had completed nursing school, written my boards, received my license and was living large. For certain values of “large”, that is.

I had been offered, and accepted , a position teaching pharmacology, part time, for the program that I had graduated from. The textbook we used (Nancy Caroline MD: “Emergency Care In The Streets”) was outstanding, and provided a clear template around which to build my lesson plans.

One of the innovations that I introduced, from my own nursing school days, was a particular format for drug cards. The point thereof was to have, on a 3 x 5 or 4 x 6 card, the names of the drug in question (trade and generic), the common dosing and route of administration of the subject drug, indications for using the drug, contra indications for using the drug, the mechanism of action of the drug, and the class (often, these last two overlap: a drug classified as a “Beta Blocker” worked by blocking beta agonism on the sympathetic nervous system. If you had mastered that point, you knew that the drug would serve to slow heart rate, mildly constrict arterial muscles (net effect of lowering blood pressure due to slower heart rate and decreased strength of contraction leading to diminished cardiac output), CONSTRICT bronchial muscles, and reduce intra ocular pressure. Or, you could write all that stuff out. For every beta blocker you encountered. Fun times. I simply earned what beta agonism tickled, and knew that blockade thereof reversed those effects.)

In addition, the cards noted nursing considerations (things the nurse, or paramedic, ought to have in his/her mind when employing this medication. Like, Beta blockers: check and recheck heart rate, blood pressure, and monitor the EKG, looking for slowing conduction of the elelctricity that controlled things).

Now, some of my students were first timers. They were folks who, as you might imagine, were taking paramedic classes for the first time.


In The Un-Named Flyover State, the licensing drill went something like this. You successfully completed the course, and took the exam. Pass it in one, bingo, license in hand, go out and fight disease and save lives.

If you failed the exam, then you got one chance to re take the test portion that you had failed.

If you failed the retest, you had to successfully complete a refresher course, whereupon you could re-test, again.

If you failed THIS test, you had to take the entire generic paramedic program, from step one, all over again.

As it happened, a couple of students had, indeed, found themselves taking the paramedic class, in order to qualify for a FOURTH retest.

So, TINS©, I laid out my expectations, had conjured up a 1,000 point, tow semester grading scheme, wherein around ½ of the grade (250 points each semester) would come from the midterm and final, combined. Another 25 points came from each quiz, administered each week in class. 16 weeks in a semester, no quiz on mid term or final weeks, and two other weeks off for review for the mid term and finals, 20 quizzes.

I announced at the beginning of each semester that I would consider extra credit in the event that any student came to me in advance, suggested something that would reflect additional pharmacologic study, and be pertinent to paramedic practice.

So, STORY NUMBER ONE: Somewhere around mid terms, one of the students rose in class, and delivered a pronouncement: Reltney, paramedics don’t need to know all this stuff. Nurses, yeah, I get that nurses need to know this stuff, but paramedics don’t!”

I invited him to hold that thought, and we could speak, in detail, after class. After the end of class, this fellow, along with a couple fo his work mates, all met with me, eager to set me straight.

As it happened, all of these folks were of the looking-at-a-fourth-retest group.

I invited my correspondent to state his case. He did so, as outlined above, with no new explicative material, no new rationale for his position.

I deliberated a moment, and fact checked myself. “So, you have taken the paramedic exam, correct?”

“Yep!”

“And, you failed it, is that correct?”

“Uh, yeah…”

“Then, you took it again, did you not? And, failed it, again, am I correct?”

“yeah…”

“And, again, after a refresher course, you took the paramedic exam, and, again, you failed it, is that also correct?”

(much more quietly) “yes…”

“So, I’m confused: you are not an RN, are you?”

“Uh, no…”

“So, let me see if I am understanding you: you are telling me, who has taken, and passed, the paramedic exam, and who is, also, an RN, that you are in a position to have an opinion that I ought to find persuasive, regarding what it takes to successfully take and pass the paramedic exam, based upon your experience in taking the exam, and failing it, what, three separate times?, did I hear you correctly?”

He mumbled something indistinct, and found somewhere else that he felt the need to be.

And, I did not hear THAT particular argument again.