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

The Reveal!

You may not be surprised to learn that I spend considerable time meeting folks, and some of those folks do not bowl me over with the force of their intellect.

Occasionally, somebody who does not otherwise impress me as being particularly dull witted, appears to decide that The Reveal is needful, NOW!, and therefore proceeds to impress me that they are, in fact, an idiot.

So, TINS, TIWFDASL, and I was interviewing some soul about his particular malady. As is my usual practice, I inquired about what symptoms had precipitated today’s office visit, duration of symptoms, what had been done prior to visiting me to address the symptoms, simply as a beginning.

So, this soul related that his symptoms had been treated on a couple of previous occasions, in the past month, and had transiently improved, and then returned. He had, so he told me, been treated with “an antibiotic”.

“What antibiotic?”

He did not know. “The antibiotic that they prescribed for me.” (as helpful as THAT is….)

“How long did the doctor have you taking that antibiotic?”

“Until it ran out.” (Certainly. Of course.)

I attempted to discern how long it had taken before the antibiotic had run out, since treating Malady “A” might call for a 5 day run of The Z Pak (boo! Hiss!), whereas Malady “B” might be addressed by 28 days of Doxycycline, for example. Ya know, just as if I cared what had elicited this gentleman’s symptoms, with an eye toward, oh, gosh, I don’t know, maybe TREATING HIM EFFECTIVELY, or something.

At this point, he felt it relevant to review some of the high points of his resume. For some reason.

“I’m college educated! I’m not an idiot!” (uh, sir? First, college educated maps poorly onto “not an idiot”. Not a very high correlation. Secondly, in circumstances where you wonder if it might be appropriate to reassure somebody that you are NOT an idiot, it is very likely that you are about to reinforce the impression, that you ARE an idiot. That certainly has been my experience in my own life, you may want to consider if there might be some parallels in your own.)

I somehow got back on track, and began my review of systems. At this point, he revealed that, in his estimation, “You are being dismissive of my concerns!”

HUH? Inquiries about your allergies, medications, and medical history are not “my attitude”. That’s how I attempt to avoid prescribing something to you that you either are allergic to (and you did not mention to my nurse….), or that might interact malignantly with your regular medications. For example, I dislike eliciting a GI bleed (stomach bleed: think bleeding ulcer) simply because you did not think that it was relevant that you take coumadin (a blood thinner), now that you are here for your orthopedic injury. Should I prescribe ibuprofen (popularly known as Motrin), that in combination with your coumadin might lead to a life threatening GI bleed, and I feel that to be a bad thing. Occasionally, that review of systems elicits something kind of important, like chest pain or difficulty breathing, that you forgot to mention, because your ankle pain is the only thing that (for some reason) you are concerned about.

But you are paying me to be concerned about that other, life threatening, stuff, and have the wit to not miss it.

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

Parenting Skills

I was interviewing a soul, who had brought their spawn along with them (because, why WOULDN’T you bring your 5 year old to your urgent care visit?). Said spawn (of course) had no self entertainment skills, likely due to the screen the named patient/parent placed into his hands immediately upon his whining that he wanted the phone, right now! While I was endeavoring to elicit nature of present illness (eg: what are your symptoms, and why did you determine that coming to urgent care was the thing to do?), duration of present illness (and, please Ghawd, please, say something more specific than “a good little while!” Pleasepleaseplease!), and provocative or palliative factors affecting this illness, said sprat was entertaining himself with the phone, and, it developed, felt the burning need to experience the sound track in his very marrow. In order to accomplish this task, he set the volume at eleven. Of course, in the confined space of the examination room, it was deafening.

I stifled my initial impulse to wrest the device from his hands, dash it to the floor, and grind it beneath my heel, all the while shrieking “Kill! Kill! Kill! Kill!…”, and then, settle upon my seat, and, calmly, ask, “Now, where were we?”

Instead, I continued to ply my patient with the appropriate questions, in a normal, soft, tone of voice. Of course, the named patient could not hear a damned thing I was saying. I smiled, and repeated my queries in the same, soft, calm tone of voice.

Still, the cacophony drowned out my every word. I smiled, and paused. The light began to dawn in my patient’s eyes. She turned to Little Jimmy (or whatever this child’s given name was), and directed him to silence the device.

He whined that he could not hear, should that happen. She repeated herself, and he again whined.

Then, in a feat of effective parenting nearly unsurpassed in my clinical experience, she retrieved the phone, silenced it, and pocketed it. Little Jimmy whined and groused, but his mother turned to him, directed him to quiet down, lest they “have a chat” in the vehicle, and turned her gaze, again, in my direction.

Miraculously, Little Jimmy settled down. I completed my examination and interview, and everybody went their separate ways.

Duty · Pains in my Fifth Point of Contact

Dr. Google. Again.

Shocking as it may seem, when I interview a patient (and examine same), I actually have a plan in mind. In the course of that interview, and that exam, I have both findings that I anticipate finding, as well as findings that, should they be present, redirect me from my initial assumptions.

That might be considered “testing my hypothesis”. Sort of like, oh, I dunno, as if it were derived from the scientific method, or something.

So, therefore, when my next patient’s opening conversational gambit, in response to my introduction and query, “what can I do for you?”, is something like, “Give me something for my bronchitis”, well, it is sort of at a tangent to the information that I am seeking.

For some reason, I assumed (yeah, I know….) that the diagnosis part of the interaction was, also, **MY JOB**, along with the plan of care part.

I tried again, in a different manner. “So, what sort of thing led you do conclude that you have bronchitis?”

“I googled it.”

Not helping. For some reason (perhaps I am a glutton for punishment), I tried again. “What sort of thing did you google, in order to establish that you had bronchitis?”

“My symptoms!”

I had a couple of competing thoughts right about then. One was, ONE MORE STUPID ANSWER! JUST ONE! would lead me to remedy their zithropenia and depart. Another was, I was soon going to have problems buying hats, due to the hornlike callus that I was certain was growing from my forehead, secondary to beating my head against just this sort of wall, repeatedly. The third thought, and the one upon which I acted, was that I both had a professional obligation, as well as a morbid fascination, to pursue this conversation, and determine if I was, ever, going to elicit a recitation of symptoms, history of those symptoms, efforts already undertaken to mitigate those symptoms, and how those symptoms have progressed, if indeed they have progressed at all. Oh, yes: and if there were any illness among this soul’s acquaintances.

The conversation continued, with, painfully extracted, the retinue of symptoms seeing light. I conducted my exam, and, unsurprisingly, found this individual had mucoid post nasal drip (just like every other soul in The Un-Named Flyover State!).

Mr. Google asked about an antibiotic. I reviewed my examination findings: breath sounds did not indicate any pneumonia or bronchitis, and therefore, an antibiotic directed at same would be targeting problems that he did not have. Eardrums were not red or bulging, indicating the absence of a bacterial middle ear infection, and therefore an antibiotic for a bacterial middle ear infection would be treating a problem that he did not have. The back of his throat was not red, nor swollen, and did not have the patchy exudate universally described as “white spots”, and therefore strep pharyngitis was not among his maladies, and treating a strep infection that he did not have, would provide him no advantage.

I concluded with the observation that he **DID** have post nasal drip, one’s throat was, apparently, not well engineered for post nasal drip, and commonly became irritated, with this irritation manifesting itself as pain and a sore throat, or a “tickle” and a cough, or both. I continued to note that reduction or resolution of his post nasal drip, accomplished by my stated plan of care, would remove the stimulus for his cough and therefore, address his symptoms as well as his problem.

I refrained from asking if Google had explained THAT shit to him? Hmmmm?

Fun And Games · Pains in my Fifth Point of Contact

BEFORE GOOGLE

Gather ’round, my children, and listen to a tale of long ago, and far away! In those far away, long ago times, there was electricity, yes, and telephones as well (although they were anchored to the walls of our homes, by “wires”). Why, indeed, we even had the Goddam Noisy Box, which you young ‘uns call “TV”.

Once upon a time, I was volunteering at a free clinic, serving as a nurse therein. The volunteer physician would interview, and examine the patient, and then provide orders for the treatment indicated. In those days, should one have symptoms of gonorrhea, the therapy was two injections of procaine penicillin g.

This turned out to be around 3 cc each, of a very, very viscous fluid, made particularly slow flowing because it was kept in the refrigerator.

At this point, I had been an RN for several years, working full time in ER. I had administered many, many, many injections intramuscularly as well as intravenously. I was familiar with injections, as well as strategies to mitigate patient discomfort while they were administered.

So, one gentleman was diagnosed with gonorrhea, and I received an order to administer two injections of 2.4 million units, each, of procaine penicillin g. I secured the medication, verified it’s outdate as well as the order, and made sure that the other medications the patient took, as well as his allergies, did not contraindicate this treatment.

I entered the room, and checked that the patient had been told of our plan of care. His reply? “Doc, doc, just shoot it on in!”

I informed him that he did NOT want me to “just shoot it on in”, and he would very much not enjoy the result of my doing so.

He reiterated his demand. I told him,” Sir? You are going to get two of these shots. You do not want me to simply ‘shoot it on in” because you will find it to be way, way more uncomfortable than it needs to be.”

Unmoved, he repeated his demand.

“Sir, how about I do as you insist, for the first injection. Then we can talk, and see if you would like to try it my way for your second shot, okay?”

He stated that he would not change his mind. I injected the first syringe of medication, rapidly, as he had insisted. It took some effort, because the penicillin was very thick, and did not want to flow through the needle at all rapidly.

My patient was very, very impressed by his first injection. Not at all favorably.

He stood up, once I had removed the needle, and commenced to hopping around and swearing. “Goddam! That really, really hurt! Shit, shit, shit! Doc, let me cool myself for a while!”

I corrected him. “Sir, I am an RN, not a physician. Once you calm yourself, you have another injection coming. Why don’t you allow me to administer it in the way that I know I ought to, and you can tell me how it is compared to the first one?”

He soon calmed himself, and I administered the second injection, steadily and slowly. The advantage of doing so correctly, oddly enough, is that the deliberate pace of administration allows the medication to spread out, rather than remaining a single, irritating ball of foreign material in the muscle, eliciting a cramp and muscle spasm. A cramp about which my patient had testified loudly.

Once I was done with the second injection, he stood, adjusted his clothing, and rubbed the second injection site. “Ya know, doc, that second one was not anywhere near as painful as the first one!”

Gooll-llee, Sergeant Carter! Just as if I had gone to school for this stuff, or something!

Fun And Games · guns · Having A Good Partner Is Very Important! · Life in Da City! · Pains in my Fifth Point of Contact

Retail Pharmacy, So To Speak

A long, long time ago, in an ER very far away, I was a night shift ER nurse.

Surprise!

So, TINS, TIWFDASL, well, uh, not so much. I and the other nurses were capitalizing upon a slow moment and gabbing away at the nursing station, when one of our security officers ran in (literally!) and announced that “We got a shooting in the driveway!”

Having heard no loud noises, I was puzzled, but, these officers were not prone to overstatement, so I asked a couple of the other nurses to grab a cart, I grabbed some gloves, and off we went to the ambulance entrance.

Now, by way of background, this was in the early days of the crack cocaine epidemic (although, how one contracted “crack cocaine” from another person without active, willful action on one’s own part is unclear to me). A couple of blocks away was what might be considered to be an open air drug market. Folks (commonly suburbanites) would drive up, engage a soul in conversation and arrange a transaction, another confederate would be summoned and the exchange would take place, money from the buyer, drugs from the vendor.

We were told that in this particular transaction, the named patient, seated in the back seat of this two door vehicle, appeared to believe that he was the designated quality control inspector. Indeed, the tale appeared to paint this fellow as believing that he ought to remonstrate with the vendor regarding the unsatisfactory nature of the product that had been delivered.

As the History Of Present Illness unraveled, the vendor did not seem to have fully committed to a “Zero Product Defect”, nor a “Every Customer Fully Satisfied, Every-time” merchandising philosophy, as, when the shootee indicated that he, the shootee, intended to enforce his product quality complaint by with holding payment, he, the vendor, is reported to have produced a handgun, and shot the shootee.

Bad times ensued. The driver, unsurprisingly, panicked, and sped away. A few blocks later, he, the driver, noticed our bright “Emergency” sign, and pulled in, bellowing an incomprehensible narrative.

So, security cleared the car of the terrorized goslings, and I (and security, and my nursing partners) tried to extricate Mr. Beenshot’s inert form out of the rear seat of a coupe, indeed, a compact coupe.

It only closely resembled a cluster fuck. For a while.

We maneuvered Mr. Beenshot into our code room, and commenced to resuscitating. Before things had progressed very far, our doc had determined that this guy had a “STAT!” transfer in his very near future, and so the nursing supervisor, who had come at a run upon our paging a Code Blue overhead, peeled off to arrange with our transfer ambulance service that they produce a crew and truck RFQ (Right F*%king Quick), and then phoned TBTCIDC to provide them a heads up.

We eventually got him stabilized (kind of, sort of), and the physician had a detailed chat with TBTCIDC senior physician. Off Mr. Beenshot went, and we sought out the entourage, intending to elicit more history, more circumstances leading up to the shooting, more pretty nearly anything, so we could provide that information to TBTCIDC, as well as, well, notify next of kin.

Alas, the posse had unassed our waiting room sometime while we were distracted, trying to save the life of their friend, I mean, co conspirator.

Pains in my Fifth Point of Contact

Doctor Google.

Those of you who have read more than a couple of my musings, might not be surprised to hear that I genuinely attempt to do the best for my patients that I can. It seems to me that I ought to allow you, the patient, to benefit from my two years of ADN RN school (community college), another two years of RN-to-BSN school (Bachelor in Nursing), 30 + years of experience as an RN, layered upon 1 year of Basic EMT school, another year of Advanced EMT school (ie, “Paramedic” school). All this leavened by 3 years of Physician Assistant schooling, culminating in 15 + years of clinical experience since obtaining my PA license.

Not to mention something on the order of 2,000 hours of continuing medical education, over those 15 years of clinical midlevel practice.

So, therefore, please contemplate the possibility that, when I appear reluctant to prescribe The! Z! Pak! for your stuffy nose, postnasal drip, and cough, it may not be solely motivated by the fact that I am an asshole. Indeed, it just might be because, after all the aforementioned clinical experience and schooling, I might doubt that antibiotics will successfully address your discomfort, and the alternative, over the counter course of medications that I try to suggest (in between your interrupting me every several words) will, in my judgment, actually make you feel less ill.

Jess’ sayin.

Uncategorized

Self Own (or) EMR follies

It occurred to me that I have been venting, recently, on a tear about my encounters with third parties that, well, are not dazzling me with their brilliance. Perhaps, in the spirit of full disclosure and honesty, I ought to own up to a couple of episodes that tell one and all why my pencils no longer have erasers. Here’s one recent experience.

When I first encountered electronic medical records (EMR), many, many years ago, one of my precepting physicians walked me through his office’s EMR. In the course of his narrative, he observed that, “One of the follies of the EMR is that it will allow you to thoughtlessly chart very stupid stuff, easily and repeatedly. You have to be careful of that, or you will look like an idiot.”

I was reminded of that physician’s wisdom the other day. I had a gentleman in my clinic, seeking care for a sexually transmitted disease (STD). He reported that he had been notified by his paramour that she, the paramour, had been diagnosed with some STD or another, and therefore he would require treatment before another round of Happy Fun Times could be arranged.

Cool. I performed my exam, obtained the specimens required to verify the particular sort of affliction that had been visited upon him, and ordered the appropriate medications. Then I sat down to chart.

In order to save charting time, I have a pre populated template, citing various common or normal findings. I reviewed my template, preparatory to signing off on this chart and moving along to the next patient, and noted my common finding of “post nasal drip”, “runny nose’, and “sore throat”.

I corrected these entries, thinking at the time, “If you have a runny nose, sore throat, and post nasal drip because of your venereal disease, you are likely way, way too sick to be seen by my midlevel self!”

Duty · Fun With Suits!

SURPRISE!

One day, not so very long ago, I arrived at work, and went to log into the electronic medical record (EMR). Generally, there is no drama. I power up the computer, click through the labyrinth of password prompts, web pages, and suchlike preparatory to actually accessing the charts of the patients that I would see that day.

On this day, I could not access the EMR. Since I am somewhat geezerly, computers are NOT in my wheelhouse. I assumed that I had mis keyed my password, and checked it, and re entered it. No joy. I re checked it, and re-re entered it. Again no joy. The computer steadfastly ignored me.

I finally determined that I was not going to be able to cajole the computer into opening up and allowing me entry into the charts. Therefore, I called tech support. Of course, I was electronically placed into the queue, and serenaded by somebody’s version of soothing music.

Since I try to arrive early, so as to allow me to still be on time should traffic be screwed up in my commute, I placed my call around 10 minutes prior to my start time.

Something like 40 minutes later, I spoke to a human being, who took my information, placed me on hold (again!), and soon returned. She informed me, “Oh! You cannot log in, because we changed your login name!”

Now, let us consider this. If you or I were to, oh, let’s say, figure that for some reason we needed to change somebody’s log in name, you, or I, for that matter, might wonder if it would be a good idea to, oh, gosh, lemme see….. TELL A SUMBITCH WE HAD CHANGED HIS FREAKING LOG IN!

Maybe, even, before his next duty shift, perhaps?

I shared this with the young lady. “Wouldn’t that have been useful information to share with me?”

She had no reply.

I thanked her for her time. I turned to the floor staff, and announced that I was, at last, logged in. I observed to my colleagues, “If only, if only, I had provided my personal e-mail, so somebody could change my log in, and, gosh, let me know!”

Duty · Fun With Suits! · Having A Good Partner Is Very Important! · Life in Da City! · Pains in my Fifth Point of Contact

Improvise, Adapt, and Overcome!

TINS, TIWFDASL at Medic 13, and we caught a run. Initial dispatch information suggested that this was a heart attack.

We arrived on the East Side of Da City, at the stated address, and discovered out patient was awaiting us, upstairs. The folks who were encouraging us to step right up and set to business, were pretty excited. As we arrived and entered the bedroom wherein our patient awaited us, well, we could see why.

Our initial patient survey was, to be charitable, not encouraging. The bedroom was nearly entirely filled by a double bed, and that bed was nearly entirely filled by an unbreathing human being. Unable to detect a carotid (big ass neck artery) pulse, we concluded that this soul was in cardiac arrest. Doug and I knew that there was NO WAY we were going to move this person, let alone move them down the stairs, into our ambulance, continue a resuscitation en route, and offload same at DBTCIDC.

While I started CPR, as best as I could on the bed, Doug called dispatch on the handi talkie, and brought them up to speed. “Dispatch, we need an engine company, or two, for manpower. We have a active cardiac arrest, on a patient estimated weight of 800-1000 pounds. That is a stat call.”

Dispatch acknowledged our call, and responded, “We will send you help”.

Doug and I both set to resuscitating this soul, until our help, a second MEDIC UNIT, arrived. This crew, Mariel and Don, while welcome, came nowhere near the lifting power we anticipated in ten firefighters. Doug relieved me, and I shared this insight with dispatch. “Dispatch, we need at least one full engine company, perhaps two, and we need them several minutes ago! This is a working cardiac arrest, and there is no way we can move, let alone lift, this 800-1000 pound patient!”

Dispatch informed us that that would be a chief level decision, and I was happy to buy into their decision making process. “Very good dispatch. We need our superintendent on this scene, stat. This is a patient safety issue, and our patient is in full cardiac arrest.”

The field supervisor, a captain in our division, jumped in. “Dispatch, this is shift captain (insert name here). I am on the way to Medic 13’s scene code one. They need an engine company. Please dispatch one immediately.”

Soon, a DCPD scout car arrived, disgorging two of the single tiniest female officers I had ever seen.

Right behind them came our captain. He (the captain) edged his way through the crowd of civilians (who were, helpfully enough, insisting that we simply “snatch him on up, and carry him on down to the hospital!” (while NOT climbing the stairs to lend a hand!)

Our captain surveyed the four rescuer CPR taking place, and retired to his vehicle to have a chat with dispatch.

Mariel had removed our cot from our ambulance, securing it in their rig, wisely determining that our patient, upon the floor, would fill the entire module. As she returned up the stairs, bringing every backboard strap that she could find, the first engine company arrived.

The officer of that company trotted up the stairs, took one look, and about-faced, running down the stairs. Shortly, he returned with 5 firefighters, and a salvage cover. Everybody heaved, and the cover was stuffed ½ way beneath our patient. Everybody “Ho!’-d, and it was pulled out from beneath him. Now we had a carrying apparatus, and the firefighters set themselves at each corner, Doug in one middle, me in another, Don at the head, and Mariel at the feet, and we slowly maneuvered our patient down the stairs, and into our ambulance. Mariel and I climbed in the back, Don took off to meet us at the ER, and Doug set out.

I had the walkie talkie in my pocket, and I could hear his conversation with dispatch while Mariel and I CPR’d our little hearts out. Doug suggested that another engine company ought to meet us there, and that the ER ought to be notified of our patient’s girth. Initially, they seemed unenthusiastic, until our captain suggested that either they dispatch an engine company to the ER, or the Chief of the Firefighting Division, since he, the fire chief, would be the one explaining everything to the news media.

Engine 5 met us at the ER. TBTCIDC had lashed two cots together outrigger style, and everybody moved our patient onto the cot. Once he was in the ER, our part of the show was over.

We effusively thanked our captain, as well as the fire crew.

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

O’BEAST

A long, long time ago, in a galaxy not so very far away…Ok, it was something like 40 years ago, and Doug and I were working Medic 19 on nights. We caught a run on a sick person of some sort, and arrived to find a not-so-very-sick person, in an ill humor.

For some reason, this soul appeared to believe that employing us as a lightning rod of sorts for every missed opportunity, failed hope, crushed dream, and malign bit of luck that had befallen them, would in some manner alleviate their misery. I was not seeing it, but, whatever.

Since Doug was of The African Persuasion, whereas I, myself, was very much of the White Bread Persuasion, well, Ms. Misery, herself melanin enhanced, took him under her metaphorical wing, and expected him to commiserate with her in her plight.

Horrible fail.

I was driving, and so stood off to the side whilst Doug negotiated with Ms. Misery. He had worked pretty damned hard to get to where he stood, and was, let us say, unsympathetic to those who did not appear to exert themselves even minimally to better their lot. While he attempted to conceal his views from the folks on the street, we had detailed conversations in the firehouse on this, and other, topics.

Eventually, Ms. Misery concluded that the only succor we were about to offer her involved a trip to the ER, where she anticipated spending her evening, with no benefit to her pity party prospects. Therefore she directed us to depart, bidding us (and our mothers) farewell.

Once back in our truck, as Doug completed the run sheet (and I moved us to a neutral corner, several blocks away), I noted our friend’s considerable girth. “Glad she SNR’d herself. Obese as she is, I’d hate to attempt to carry her large self anywhere.”

Doug chuckled. “Obese? Were you there, as she yelled at us? With that attitude, she was Oh-Beast!”