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

Above and Beyond

So, TINS©, TIWFDASL©…. Well, OK: REALLLLYYYYY!, I was holding up the counter, and awaiting my next patient, when one of the registrars came up and informed me, “Reltney, I’ve got this sick lady out in the drive up, and I really think you need to see her! Like, right now!”

To set the stage, my urgent care has (surprisingly!) urgent care patients, as well as folks who arrange to be tested for Da Rona. This latter group makes their appointment, drives up, telephones in to announce their arrival, and my registrar gowns up, registers them (now, THAT is a surprise, amirite?), and one of the MAs gowns up, strolls out, tests them, and hands a sheet of instructions (prominently featuring the admonition to quarantine for ten days, or until negative results are forthcoming) to the patient.

This particular soul had not made it past the whole “registrar registers them…” part. This particular registrar, let us call her Eloise, has been doing this for several months. She is one of those quiet, efficient, takes-care-of-business folks that make things in general, and our agency in particular, run. She is not a nurse, not an MA, may not have any “medical training” whatsoever.

Nonetheless, Eloise had appropriately identified that this patient, nominally here for coronavirus testing, was way, way, way sicker than (a) coronavirus testing was gonna help in a clinically relevant timeframe, as well as (b) way, way, way, way! too sick to be driving around. So, she came and got me.

I went to the patient, shortly afterwards followed by an MA who had overheard Eloise’s pronouncement. I was impressed by the fact that this woman reported chest pain, nausea. left sided neck pain, left sided jaw pain, as well as being unable to tell me her allergies, or medications, or medical history, and could not state the name of her boyfriend (whom she wanted called to retrieve her vehicle) as I shortly had determined that this nice lady was going to shortly be the recipient of over 50 years of pre hospital emergency care wisdom and experience, as well as diesel therapy. (ambulances nowadays generally run on diesel).

I told Eloise to get an ambulance, and the MA hopped in, to clear a room for this patient. Eloise evidently had delegated that task, as she returned promptly with a wheelchair, and I noted another MA on the phone to dispatch, as Mrs. Chestpain was wheeled in.

As I assessed this soul, engaging in conversation all the while, it struck me that her ability to track the conversation was deteriorating before my eyes. Not a good thing.

Soon EMS arrived, packed her up, and set about their own part of her care.

I called report to the local ED, explaining the above.

I then went in search of Eloise’s supervisor. I informed this worthy that, in my opinion, Eloise had saved this woman’s life. Had she not had her head in the encounter, had she not noted “chick don’t look right” (the fundamental item of nursing assessment), had she not sought me out and had she not compellingly made her case that this was a SICK person, well, Mrs. Chestpain might have driven off, to die from (her heart attack)(her stroke)(a collision from her impaired ability to navigate), or (all three).

For some reason, I had occasion to speak to my physician supervisor around that time. I repeated the foregoing story, as well as the foregoing analysis, to her.

“Well, you know, Reltney, you also saved her life!”

“Ma’am,” I responded, “I have dozens of years of schooling, decades of emergency and clinical experience to enable me to do that sort of thing: it’s kind of what you are paying me for! Eloise, on the other hand, has none of those things. You are congratulating me for doing my job. I’m applauding Eloise for thinking outside of the box, outside of her job description, and acting effectively to get this woman the help she desperately required. Thank you, but Eloise went above and beyond her job. She is what made everything else happen.”

As a side note, here’s what the preceding paragraph looks like, when your cat helps you:

“Ma’am,” I responded, “I have dozens of years of schooling, decades of emergency and clinical experience to enable me to do that sort of thing: it’s kind of what you are paying me for! Eloise, on the other hand, has none of those things. You are congratulating me for doing my job. I’m applauding Eloise for thinking outside of the box, outside of her job description, and acting effectively to get this woman the help she desperately required. Thank you, but Eloise went above and beyond her job. She is what made everything else happen.”pppppppppppppppppppppppppppppppppppppppppppppppp

Thanks, Kitty. i do believe that I have this under control.

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

“Reading the Room”, or, Situational Awareness

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

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

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

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

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

Random Thoughts, Part VII

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

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

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

She was not. “Yep!”

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

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

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

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

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

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

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

And, good luck with that!

LIGHTING UP MY LIFE

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

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

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

Alrighty, then!

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

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

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

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

Having A Good Partner Is Very Important!

“Do what you you think is best…”

A long, long time ago, in a little burg so very far away, I was married to The Plaintiff, and we were living in conjugal bliss.

No! Really!

I was (and am) an amateur radio operator (“a HAM”), and was relatively new to the hobby. So, this one time, I was perusing QST, which is the magazine published by the national association of amateur radio operators (said association known as the American Radio relay League, a name rich in meaning regarding the early days of radio). Therein I came across an advertisement for a new radio, which, after reflection, I desired.

Now, mat that time, The Plaintiff and I had an agreement, wherein larger expense items would be presented to The Spouse for approval. Therefore, I went to The Plaintiff, and showed her the ad.

“Look at this, Honey! It will do all this neat stuff, and I can use that neat stuff when I do public service events with the HAM club! Remember that one time we all went to that bike-athon, and I couldn’t hardly reach net control? Well, this radio will cross band repeat, so I could have parked the truck a little ways up the hill, reached the truck with my hand held radio, and then been repeated into net control!”

She took the magazine from me, perused the advertisement, and noted, “It even receives weather band! That would be handy, like that time we were camping, and the severe weather alert went out!”

Excitedly, I agreed. “Yep! And, since it is dual band, notice that it can receive VHF on both bands! So, I could monitor both fire department diapatch, as well as the local severe weather net!”

The Woman Who Would Become The Plaintiff looked up at me, and asked, “So, how much does a radio like this cost?”

I thumbed to the back, showing her another ad, from an amateur radio shop. “Look! Right around $700! And, I have nearly that much in my ‘toy fund’!”

She appeared thoughtful, for a moment. “So, it’s what, July, now?”

I was agreeable. “Yep!”

“Hmmm. Ya know, buying the kids’ school clothes will cost us around $600, you know.”

I was surprised by what appeared to be a tangent. “Uh-huh?”

She handed the magazine back to me. “Honey, you do what ever you think is best!”

Well, her head did not start to spin around, and spew out nasty green stuff, so, THAT was nice…..

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

“From the mouths of babies…”

Last week I worked with a resident. She had recently completed a rotation at The Big Pediatric Hospital, in the ED. One of her stories involved a child with a fracture. She related that, as she was showing this child her fracture on the x ray, the child exclaimed, “That’s the broken part, isn’t it?”

This stimulated me to recall a tale of my own (for, does not nearly EVERYTHING, stimulate me to recall a story?). Long ago and far away, I was working urgent care at a distant clinic. In this facility, my MA was an x ray tech, going to school for MRI. One day, a family brought in the matriarch, who had hip pain after a fall. Indeed, this elderly woman was pained by the movement elicited by the cracks in our flooring (our flooring was in very good repair!) Well, (let us call my MA…) “Ashley” determined that there was an x ray in this lady’s future, and figured that one movement onto the x ray table might be superior to a move into the room, an exam, another move into the x ray room, and THEN onto the table. Good call.

Ashley took only one image, before exiting the x ray room, at speed, and summoning me. “Reltney, you need to see this film”.

“Oh? Is it interesting?”

“Well, I believe you will be irate if you delay another minute before you see this film. I think that it will have a serious impact on your medical plan of care!”

Well, alrighty, then!

I had previously casually mentioned the concept of “the ophthalmologic fracture”. That is a break so obvious, so lacking in radiologic ambiguity, that should an ophthalmologist happen by, that physician would stop in his/her tracks, do a double take, and exclaim, “Hey! That looks broken!”

This lady had a ophthalmologic fracture of her hip. I had Ashley copy this image on a CD, and had my clerk summon EMS. I called The Local Trauma Center, and described the events to the attending physician. Once EMS had arrived, I invited them to view the film. They were, as well, impressed. She was backboarded, and transported to the hospital for further evaluation and care.

My physician colleague (remember her? She led me into this tale, after all!) nodded. I concluded, “You, doctor, have just introduced me to the concept of “the pediatric fracture: a break so obvious that a child can identify it”!

Fun And Games · guns

Small Town Clinics

TINS©, TIWFDASL© in Da Nawth. I was working my weekends off in a rural hospital’s walk in clinic, and, surprisingly, saw folks who walked (and limped!) in to obtain care for their particular maladies. One snowy weekend, a gentleman limped in, with a complaint of bruising and knee pain after rolling his snowmobile.

Once the nurse had finished her interview of our friend, I entered for my share of the proceedings. I introduced myself, and asked him to tell me what happened.

“Well, Doc,” (No, I’m not a doctor, yet folks persist in addressing me as a physician, notwithstanding the fact that every single time I begin an interview, I introduce myself as ‘Hello, I’m Reltney McFee, a Nurse Practitioner. What can I do for you?’), he began, “Yesterday I rolled my snowmobile down an embankment, and it wound up on my leg, pinning me to the road. I rolled it right in front of a DNR officer, and he and one of my buddies rolled it off me. My knee feels pretty sore, even though I can walk on it. I have another bruise, here on my side, I guess from my Sig 365, that I had in my pocket.”

For those in our studio audience who are not “gun guys”, a Sig 365 is a striker fired semi auto 9 mm handgun, with a 10 round detachable box magazine. It is relatively small sized, being just under 6 inches from muzzle to the back of the slide.

I asked him where his pistol was presently, and he responded, “Well, this is in the hospital, so I left it in my car. That’s what the regs regarding my CPL (concealed pistol license) call for.”

I performed my exam, and we chatted about firearms while I did so. I contributed, “My wife is looking at getting another concealed carry pistol, and she has considered the Sig. What do you think about that?”

“Well, I really like my Sig. It carries well, and I am pretty accurate with it. You read about firing pin drag on the primer, and some guys say that the firing pin may break because of that. I haven’t had any problems myself. Just in case, I carry it with the hammer down on an empty chamber.”

TDW bought a Springfield Armory Hellcat. And loves it!

Another, tangentially related, small town story. Several weeks ago TDW-Mark II and I went on vacation. We set our camper up, and decided that this night was a good choice for pizza. We went to the local pizza place, placed our order, and settled in to wait. It was getting on towards dusk, and I noticed that, as I turned on the lights, there did not appear to be any illumination from the passenger side tail light. Since I did not feel any particular desire to explain to Officer Friendly how this light might have failed, nor my plans to remedy this failure (let alone the conversation that begins, “Well, officer, you see, I have my CPL, and my sidearm is on my right hip. How would you like to proceed?” I have had a couple of friendly roadside conversations about carry sidearm choice, but, wouldn’t it be nice to not encounter Officer Friendly as the traffic stop just after he received a soliloquy regarding his mother’s poor life choices?)

So, the next day, TDW and I set off on our day, and detoured to the Rural Town Truck Dealership. I explained my need to the service advisor, and he said that one of the mechanics could set me right, once the present job was complete.

Cool by me.

I settled in for a spell of a wait, and soon met the mechanic, who identified my bulb type, and led me to the parts counter, there to pay for my bulb.

I typically wear a ball cap, and this one is from Freedom Munitions (no payola, simply a satisfied customer). The parts guy asked me if I worked there, and a conversation about The Ammo Drought ensued. We chatted about caliber, about carry choices, and about setting ammunition by for a “rainy day”.

At the end of the chat, my taillight was repaired, I was NOT charged for the mechanic’s time (despite the fact that I asked what I owed for his time!)

The moral of the story is that, as Commander Zero (http://www.commanderzero.com/)often notes, there are Like Minded Individuals all over the place, if you look carefully.

Having A Good Partner Is Very Important! · Pre Planning Your Scene · Sometimes You Get to Think That You Have Accomplished Something!

Neighbors

One fine day, TDW-Mark II and I were at home, doing some sort of chore or another. Our doorbell rang, and I answered it, to find the neighbor girl, a seven year old classmate of Grand Daughter Number Two, standing there with her three year old younger sister, hands clutched one in the other.

“What can I do for you?” I asked.

“My grandpa fell, and he hurt himself, he’s not moving. Can you help us?”

I hollered, “Honey! Emergency at the neighbors!”, and headed out the door, TDW-Mark II watching me turn the corner into their yard.

The girls led me into their home, where I saw an elderly gentleman (now, THAT would be the pot calling the kettle over-the-hill!) prone on the floor, at the foot of the stairs, with a pool of blood about his head. The girls stood by, anxious appearing, until TDW-Mark II appeared, and led them into the kitchen, and attempted to distract them from the front of the house drama.

I asked the gentleman if he was OK, and his answer did not inspire confidence. Looking over the scene, multiple bad scenarios played out in my imagination, all leading to the conclusion that I did not want to manage this scene alone, and I really, reeally wanted EMS here, pronto.

I dialed up dispatch, and abruptly realized that I did not know the house number.

Fortunately, all those years of Street! Medic! Experience! started to pay off, as I realized that the house would have the number displayed prominently on the front. I walked out front to familiarize myself with that little detail. Oh, yes. AND the name of the street one block East of my residence.

You don’t have to say it, I already know. Bad Stretcher Ape! Situational awareness fail!

So, anyhow, I shared my new-found wisdom with dispatch, and summarized what I knew. She assured me that our little town EMS would be on the way, and then proceeded to start into pre arrival care instructions. I played along, until she paused, and I observed, “So, I’m an ER nurse. he is breathing, he is speaking, sort of, and I am reluctant to move him in any way, because it appears that he fell down the stairs.”

“Oh. Right. Well, if things change, call us right back!”

“Yes, ma’am, will do.”

The medics arrive shortly thereafter, and I reported the little that I knew. The one medic was surprised. “You don’t know any of his history?”

“Nope. We’re the neighbors. The little girl came over and got us, when he fell.”

At about that time, the mother returned home, and TDW-Mark II filled her in on what we knew. We turned the kids over to her, said our goodbyes, and departed.

Housekeeping · Pre Planning Your Scene

Staging your CAT Tourniquet

I found this, here: https://elmtreeforge.blogspot.com/2021/07/some-good-information-on-setting-up-cat.html Known as “Irons In The Fire blog.

As is likely no surprise, I consider myself a sort of “Surprise, BAD!” guy. Since I might not always have my medic bag right in my hand, well, enter the concept of “everyday carry”.

I have a CAT tourniquet on my belt, well, pretty much all the time that I am wearing pants. Similarly, I have a SWATT tourniquet in my off hand pants cargo pocket, again, pretty much all the time that I am wearing pants.

To date, I have never required a tourniquet, either in a scramble, nor RFN. Still, as Bat Masterton is reputed to have said, “When you need a gun, you really, really need a gun!”, which, given today’s discussion, might be paraphrased as, “When you need a tourniquet, you likely will really, really need a tourniquet. And damned quickly, at that!”

Having stumbled over this video, I felt compelled to pull out my own front line tourniquets, and have a look see.

It develops that my McFee Tourniquet Stowage Plan-Mark I, was one of the featured fails in this video.

Oops!

I guess that makes July, “Medic Bag And First Aid Kit Review, Repack and Revise Month”!

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

My resume is on Indeed. Read it!

The other day, I received an emailed solicitation to work as a locums. I *have* worked as a locums, and it worked out OK for me at that time. By way of scene setting, I have worked ED and urgent care as a PA, NOT as a neonatal provider of any stripe.

(paraphrased) “Hello from Erewhon Locums Company! With our national reputation for placing the right provider, in the right position, we are looking for a provider to fill the opportunity described below!

Job Highlights: 

  • Location: (some other state)
  • Specialty: Locum Nurse Practitioner
  • 7/18/2021 – Ongoing
  • Will Wait for (some other state) License / BC
  • Schedule includes day and night hours. Usual shifts 8am-5 pm, 5pm-8am or 24 hours- a combination could be required based on needs of service. Weekends and holidays required as needed. No call required.
  • Procedures Required: Intubation, umbilical lines, PICC placement, lumbar puncture, reservoir taps, thoracentesis, exchange transfusion
  • EMR System: (Infernal EMR)

Why Erewhon Locums?

  • $1,000 referral bonus opportunity
  • Personal travel and housing concierge 
  • Dedicated support specialist for payroll 
  • Experienced credentialing team 

My e mailed reply:

Well, yes, it is a great match, aside from the fact that I’m a PA, not an NP, that I am no sort of neonatal practitioner, none of the procedures listed is in my skillset, and that I will not work in (other state) for any amount of money that you are likely to pay me. 

But, other than that, yeah. Great fit. 

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

“You’re Gonna Miss This”

Trace Adkins had a song, several years ago, entitled “You’re Going to Miss This”. The narrator recounts telling his adolescent daughter she will miss the security of having her parents around to take care of things. Another verse has him counseling his now adult, now married, now a mother, daughter, that “you’re gonna miss this”, “this” being her cramped apartment with her new husband, later her house with young children.

In the two years before my mother’s death, I remembered that song. During hour plus drives to visit Mom, in her apartment across the state. I told my wife, “ya know, I’m gonna miss this!”, followed by a synopsis of that song.

When, visiting Mom, she had Chris Cuomo (spit!) on her television, the volume set at “11”, likely to accommodate her diminished hearing, I breathed deeply, and thought, “You’re gonna miss this”.

(realize that I supported Mr. Trump, and thought that Mr. Biden ought to be allowed to spend his waning days in the company of his children and grandchildren, spending his Chinese money as he saw fit. Oddly, Mom had a different opinion. Who knew?)

With the above parenthetical comment in mind, when Mom would attempt to drag me into some sort of political debate, such as how Mr. Trump was ill mannered or something similarly important to me (or not. Please, Ghawd! More mean tweets, less food and energy inflation!), I would placidly respond, “Hmmm. Mr. Trump sure elicits controversy, doesn’t he?” And I would remember, “You’re gonna miss this!”

I would take my mother shopping. THAT was entertaining! If you have successfully committed every one of my posts to memory, you will recall my joy at obliviots who would threaten to collide their shopping carts with my children. I, naturally, *did* recall this experience, and noted assholes who appeared entirely willing to knock my century old mother onto her ass. Since that would would have elicited a General Nguyen Ngoc Loan aisle side justice response on my part, and, well, people would talk (And scream. and so forth), I felt that prevention was easier to explain. I redeployed my “Colossus With Bad Attitude” persona, and blocked the aisle upstream of where my mother was shopping. She, of course, required ONE PARTICULAR Brand of baked beans, in one specific size, none other would do. This required considerable searching. After that PITA, well, I’d drive Mom back to her apartment, thinking, “You’re gonna miss this!”

On one visit, I thought that it would be nice if I were to prepare some lasagna for my mother, placed in “unit dose”, single serving plastic containers. Thereby, she could fish one out of the frig, microwave it, and enjoy.

Of course, I did it wrong. She laughed, and asked me, “Do you think that I am some kind of helpless old lady, who cannot even cook?” (Not exactly, but, reports from my sister in law, Donna- Praise Be Upon Her for orchestrating my mother’s household, doctor visits, medications, dog vet appointments, and every other kind of appointment- suggested that burned pans were a foreshadowing of other culinary, and perhaps incendiary, mishaps to come)

Once we had eaten, and I was washing dishes, she asked me, “That was not my recipe, was it? I think I like my recipe better!”

And, I thought, “you’re gonna miss this!”

Trace Adkins was correct.