“State Employment Agency”. Yeah: About That….

Years ago, I was unemployed. Since I was unemployed, I registered for (surprisingly enough) unemployment insurance payments. THAT necessitated that I register with the state, for assistance obtaining employment.

THAT was a treat! As it developed the folks at the “find this guy a job” office, did not appear to comprehend that I was an RN. Ya know, Registered Nurse. College and everything like that. They persisted in pointing out that they had PLENTY of Nurse’s Aid jobs. “Uh, yeah, about that. I am licensed here in the Great State of The Un Named Fly Over State, as a Registered Nurse. Nurse aids report to the LPNs that work with, and supervise, them. My job is, among other things, when I am working, is to supervise the LPNs. Howzabout you find me a job like THAT, hmm?”.

You might imagine that I did not rely upon them to find me my next job.

Trying to facilitate my return to gainful employment, I observed that I also held licensure as a Physician Assistant. “Oh, yes! Isn’t that like a medical assistant? We have jobs for those!”

Sigh. Another explanation of the collegiate effort required in order to qualify to sit for the board examination. As well as the different responsibilities appertaining to medical assistants, versus physician assistants.

I found employment as a midlevel, through a locums agency. Fat lot of help the unemployment folks were.

Advertisement

Never Fuck Around With A Brooklyn Boy

My Dad was from Brooklyn, He told me, when I was a lad, “Never fuck around with a Brooklyn Boy!”

That is sound advice.

I used to work with a guy who, one time, when his wife was ill, and he was the only income in their two income household, fell behind on some bills. He is an ex street medic, himself, and, well, not in the “shit” business: he did not talk shit, he would not take shit.

So TINS, this one tine he received a call from one creditor, who, once my friend had explained that he, the creditor, would not be receiving money in the near future, and would indeed be paid, once the finances in the household were approaching stabilty, responded (the creditor), “Oh, so you do not think that I can find you?”

My friend paused, and counseled this asshole. “Well, no, I do not think about that issue, one way or the other. But, now that you have brought it up, it is my opinion that, should your luck be exceedingly poor, you just might, indeed, find me. Have a nice day!”

My friend never saw that jackwagon, ever.

Years and years ago, I fell behind on my mortgage. (something about unemployment…) I was in touch with my lender, thinking that absence of surprise would be to my advantage.

Wrong.

I asked about any sort of program for an unemployed soul, whereby I could make partial payments, and have the arrearage added to later payments.

Nope.

Could I miss a couple of payments, and have them added to the tail end of my mortgage? I would continue to pay interest.

Nope.

Well, after buying groceries, and sucklike, gotta tell you that there simply was NOT the money to pay the house payment.

So, one day, a month or two into this niceness, I received a phone call from the mortgage company. The mortgage company asshole on the other end of the line advised me, “We are going to come out to inspect the house.”

“Why are you telling me this? You can drive by any time that you like.”

“Uh, no. We will come in and inspect the house.”

(my response)”Uh, no, you are not. You might make an appointment to come out, when I am home, and it is possible that I might escort one of your personnel to view selected portions of my house, but you are not simply going to ‘come in and inspect the house’. Not going to happen.”

(Mortgage Asshole) “You think you can stop us?”

(me) “Interesting that you should ask that question. Yeah, I know that I can stop you. If you do, indeed, plan to simply waltz in here without my permission, send orphaned bachelors, because whoever you send to walk on in, will be carried out.”

“Is that a threat?”

(me) “Nope, that is a prediction. Let’s consider this: you have just now threatened to have stranger or strangers break into my occupied home, and I have told you that that sort of activity will end poorly, for everyone. You threatened me with a B and E, I told you what my response will be. Your move.”

Oddly, nobody came over to “inspect” the house. What a surprise.

Two more snippets

FICKLE CATS::

When I am in bed, they snuggle up against me: likely due to the warmth from my electric blanket. I can pet them, and they do not beat feet, alarmed, at my approach. They purr, and roll into my petting. On the table in the cat room, similarly, I can pet them, and they purr like miniature motorcycles.

Elsewhere in the house, I approach them, and they elope as if I were the Cat Attacking Golem, or something. Of course, when they are on the counter, or the dining room table while we are eating, I do chastise them: “Are you on MY counter? Bad Cat!” accompanied with a sort of interpretive dance, which most closely resembles an effort to shoo away angry, invisible, hornets.

ANOTHE STORY FROM THE STREET

So, TINS, TIWFDASL….well, no. I was at home, long ago and far away, when The Plaintiff (aka TDW-Mark 1) and I were still in wedded bliss. In the very rural county in which we lived, EMS was provided by a sort of tiered response: in the event of an emergency, dispatch would alert the sheriff’s deputies on patrol, and tone out the nearest fire department to send their rescue. The ambulance would depart from the hospital in The County Seat, and the crew would make their way to the scene. There, the three agencies would address the problem, and then, response complete, resume whatever they had been previously been doing.

I volunteered for the local rescue, since, I figured, I would want SOMEONE to respond when/if we had our own emergency, therefore it seemed reasonable to carry a pager and respond when some neighbor had THEIR emergency.

Let me interject that I had a scanner at home, and so I (and TDW-Mark 1) could monitor the goings on in the Fire/Police/EMS world. Or, our corner thereof.

So, one evening I was home. The pager went off, and I responded to the fire hall. Another firefighter arrived, and we were off.

We arrived to find a sedan crumpled amongst the trees lining the side of County Road Whatever. The deputies had already triaged the scene, and pointed out one soul who was not making much sense. As I approached, my differential diagnosis expanded from head injury, to head injury, or intoxicated, or combinations of the above. This was elicited by the prominent odors of ethanol emanating from my subject.

Well, when you have a soul who was involved in a collision, as this guy had been, who is not able to navigate or articulate, as this fellow was not, one must wonder if the collision had cracked his coconut (not, strictly speaking, a medical term, you know…), and that was why he had his articulation and locomotion difficulties, or was he intoxicated into dystaxia/dyarthria, or (perhaps worst of all potential scenarios) was the intoxication obscuring his intracranial bleed, or something similarly dire?

I, paramedic and RN that I was at the time, was elected to ride in the back as Mr. Ethanol Odor was transported to hospital assessment and management. Of course, he was spine boarded. Of course, he disapproved. Of course, he protested, loudly and profanely, about our handling of him, as well as the fact that he desired to depart our company and be on about his business (not an exact quote).

I recall providing report by radio, his soliloquy in the background. He was describing my character flaws, and errors in my upbringing, at volume. As an exact quote, he suggested the my shortcomings included, “Assholes! M@74erf&25ers! Dickheads!” (I suppose he included my partners in this assessment, come to think about it.)

I unkeyed for a moment, prior to concluding my report, and, rekeying the radio, observed, as he renewed his Short Course On Character Disorders, “As you can tell, patient in no evident respiratory distress!”

I arrived home to find TDW-Mark 1, chuckling. “No distress, huh? Have you told your mother hello for him?”

Snippets VI

The following is a collection of tangents. Please, be tolerant.

I was talking with the midlevel student taking a rotation with me, and, it being her first rotation (…unfortunate soul, to be stuck with The Stretcher Ape as your first clinical!), and was waxing poetic about gestalt, quickie patient assessment, and binary EMS assessment.

I observed that a writer for JEMS magazine, decades ago, observed that there were stages to EMS patient assessment: initially, is the named patient “Big Sick”, or “Little Sick”?

If “Big Sick, particularly in the setting of basic life support services, probably you desired to load that patient, and go.

If “Little Sick”, you likely had time to assess the patient in greater detail, and either rethink your initial assessment that this soul was “Little Sick”, or reinforce that assessment, and then transport in a leisurely and deliberate manner as appropriate.

The application to our walk in clinic, is that should your, or your MA’s snap assessment be along the lines of “That dude don’t look right!” (immortalized as “DDLR”), perhaps you ought to look into expediting that soul’s transport to ED, perhaps via EMS. I told her that “DDLR” is probably The Primary Vital Sign.

Another Story

One night, we had cleaned out the ED, and done all our housework. This was long, long ago, and far, far away, back in my halcyon days in Da City. I was a staff nurse in our ED, and we had “story hour”, many a night when there were no patients, and nothing to clean or restock.

Somehow, the conversation turned to threatening patients. One nurse volunteered, “You know, I have something in my purse that might be a conversation starter with such a soul, with the conversation trending towards, “How do I get my ass out of here, before this crazy nurse kills my ass?”

Another offered, “Hmm. Such a sad sack might, or might not, find himself in a cross fire, not that I would know anything about that sort of thing, myself!”

Another thought out loud, “I wonder why it is that I always place my bookbag in the med room? Could it be that there might be something there that would trigger a reconsideration of life choices, in some bad actor?”

One of my buddies, still on the road, laughed when I told him that story. “Really? Don’t you realize we all on the street know your ED is the most heavily armed ED in Da City?”

A Thought Experiment

If you were married to Nancy Pelosi, and was faced with the choice of having sex with her, or finding a homeless psychotic gay guy, what would You do?

Recounted conversation:

Patient: “I don’t believe in covid!”

Me, responding to my partner who had just quoted said patient (faux-Russian accent) “Da, tovarisch, but, covid believe in YOU! (stifle your cough, and wear your damned mask!)

Bob Marley Tribute Band

Cletus and Jane-Bob came in the other day, accompanied by their spawn. The nominal adults smelled as if they had just sat in with a Bob Marley Tribute band. The children were clean and inquisitive, and engaged readily with me as I inquired about their symptoms.

The childrens’ ear infections were readily identified, instructions provided, and they were off and on their merry way.

With these poor life choices as their life exemplars, I wonder how long the children will remain clean, or inquisitive, or engaged with the world?

Another opportunity to bask in the wonderfulness of legalized, recreational, marijuana.

FPC: Phenomenal Phone Company

A long, long time ago, in a state capitol city not so very far from here, I was seated in the basement of The Enormous Hospital System Mothership, where She Who Would Become TDW-Mark II was undergoing surgery of some sort. I was seated next to, well, let’s simply call him my father in law.

At this point in the celebrations, the divorce from The Plaintiff had concluded, and she and I had a week-on-and-week-off child custody arrangement. My adolescent children had cell phones, and had both me and their mother on speed dial.

So, Number Three Son had occasion to call me, but I could not make out what he had to say, and my attempts to re connect with him were for naught.

I did not know if this was generic adolescent ‘gotta call dad’, or something emergent. That latter was very unlikely, but, after all, I have kinda spent my life in the “this is sort of an emergency” business, and therefore considering that possibility is an occupational hazard. Therefore, since I was NOT at home, and, should my children need me, their ability to communicate that to me in a timely manner was mission critical, well, The Phone Company, and their inability to connect a freaking call something like 12 blocks from the freaking state freaking capitol, well, to understate the thing, I found it unsatisfactory.

Father In Law offered the use of his phone, on Another Carrier. I entered the number of my son, hit “connect”, and, par miracle’!, just like that, I was speaking to my son!

We concluded our conversation, since it was a generic “ought to call dad” call, and I asked Father In Law if I could make one more call. He assented.

I then called “customer service” (spit!) of The Phone Company. I explained my problem, and how this was not acceptable. Phone Company Minion asked my location, and I described myself as being one floor down from street level, in waiting lounge of Enormous Hospital System Mothership. Minion then regaled me with a bit of RF theory, to wit: “You cannot reasonably expect a cell phone to have a reliable signal when you are underground!”

I asked Minion, do you have caller id?

Affirmative.

Could you tell me the originating telephone number for this call we are having, right now?

He read back Father In Law’s phone number.

Is that a Phone Company number? If not, what carrier services that number.

Why do you ask?, responded the Minion.

“Because, that is the carrier who is henceforth going to be receiving checks from me approximating $200/month, because my phone, my childrens’ phones, and the phone of every mo$%#r f@!%&er who will stand still long enough to hear this story, will be giving their business to this carrier, whose phone I presently hold in my hand, in this basement, as you and I converse!”

Having said that, I realized that there is no satisfying way to slam down a cell phone. I miss plain old wired phones.

Gotta Scratch That Itch!

A week or two ago, my MA returned from her lunch, and showed me her parking lot find: a couple of dirty syringes, with bent needles. “I found them on the ground behind my tire”, she related.

My thoughts were, ‘what sort of fool, even among the universe of fools who inject drugs, leaves a freaking needle on the ground in a parking lot, where children come and go on their way to their own physician appointments?’

@

So, just the other day, TDW-Mark II needed to recharge her cash card. Off to her bank we went. The gentleman attending to her transaction appeared to be somewhere in his twenties, whereas I, myself, am approaching 70 (and so closely approaching 70, that 70 has started to tap his brakes, and slow down, in hopes that I would not admire his bumper so closely anymore!).

TDW was making conversation with this gentleman, and he was owning that this sort of transaction was unfamiliar to him. TDW then up and chirps, “It must be hard on poor elderly people, who don’t have computers, or know how to use them! That whole smart phone, and computer banking thing can be rough on the elderly!”

I looked at her for a moment, and spoke up. “Am I not standing right here? You CAN see me, right? Really? I. Am. Right. Here!”

Moar! Random Thoughts!

The other day, I saw some soul, who was vexed by an itchy rash. I interviewed said soul, examined, and prescribed a steroid cream to soothe the rash. My instructions, in the prescription, were “Apply thin layer to rash twice a day”

Later that day, my MA fielded a call from the pharmacy inquiring where the rash was? (as in, I suppose, where on the patient’s body). I therefore had to complete the thought that I was charting on a completely different patient, find the chart for the patient, open that chart, review my note from several hours ago, and answer the query.

Foolishly, I had assumed (…yeah, I know. AssU-ME.) that “the rash” was specific enough, but, it seems, no…

In a similar vein, I continue to receive prior authorization requests. This is maddening, because (a) I typically attempt to prescribe the exact same thing previously prescribed. For, say, asthmatics, that means I attempt to prescribe the-flavor-of-the-month of albuterol inhalers. In addition, (b) years and years ago our Fly Over State Legislature passed legislation mandating substitution of generic, equivalent, medications unless the brand is specified, with the specific instruction of “dispense as written”. Silly me, I had supposed that when I prescribed albuterol, which is the generic name, that this generic substitution law would allow the pharmacist, who has access to the “menu special of the day” that the insurance company will subsidize, could then think, so to speak, “Hmm. McFee wants albuterol, but the insurance company will only subsidize Youcallwehaul brand of albuterol inhaler. Howzabout I simply fix that, and dispense the Youcallwehaul inhaler, just as if it were not a BRAND of ALBUTEROL, but, indeed could be considered equivalent to the generic albuterol inhaler that Our Hero had indeed prescribed?”

Had that occurred, I would not get a paper note spending pages and pages to tell me that the Useless Insurance Company Inc., would not pay for the generic inhaler, but would, rather, pay for the Youcallwehaul inhaler, no doubt reflecting the proud legacy of pharmaceutical excellence that has characterized the Pashmir Valley since January of 2022!

And receive that note several days AFTER my patient encounter.

All the while telling me that they would not pay for a non preferred inhaler until two other inhalers had been employed, and had failed.

So, that means that my patient has NOT had their freaking inhaler for (lessee, now: Friday visit, Monday denial, Thursday, if they are attentive (scoff!), mailing date for the voluminous tutorial on the pharmaceutical excellence of Bagwan’s Pharmacy And Weapons Factory, which I finally see, perhaps as soon as a full week after my patient encounter.) So, something like 8 days, more or less.

Let’s paw through the old chart, and review previous prescribed inhalers, shan’t we? Lessee, there is Ventolin, and then there was that time this soul received…Ventolin, and, of course, the last time when one of my colleagues prescribed…..er, Ventolin. So, imagine my surprise when I prescribed (lessee: what was that stuff?)…Oh, yes. Ventolin!

And I receive the previously described voluminous correspondence detailing why the Behemoth Insurance Company would not pay for the prescription of….er, Ventolin.

I really try to embrace the suck, but geez, ya know…

9-1-1 Follies

So, TINS, TIWFDASL…. er, well, OK: I was NOT FDASL, rather, this was long, long ago, and far, far away, and Doug, my partner, had his car in the shop, and so I picked him up, and we went to headquarters in order to pick up our paychecks.

I was driving him home, and we were chatting about inconsequentials, when I had stopped at a traffic light. Coming from our right, a soul had stopped in order to make a right turn, and once he attempted to make his turn, another idiot (wait for it!) had stepped out in front of the vehicle.

The driver slammed on his brakes, and chastised the pedestrian-idiot (who had not been paying attention), whereupon the pedestrian rejoined with some unwelcome insights about the driver’s mother, and her lifestyle choices.

The driver exited his vehicle, displaying a knife (that was clearly visible from across the street!), and chasing the pedestrian. He (the driver) was bellowing, “You sunovabitch! I could have killed you!”, as the pedestrian retreated around the parked vehicle, retreating for his life.

Just past this dance, was a pair of pay telephones (remember them? Another artifact from my youth!). Doug went to one, and dialed 9-1-1, and I took the other, deposited some change, and called our dispatch Bell line.

My call got answered first. Ronnie the dispatcher answered my call, took my information, and passed it to another dispatcher. Then, he chastized me.

“Mcfee, you DO get, that you are off duty. Right? Why don’t you let the other guys get some excitement, for a change?”

I laughed, said my goodbyes, and hung up.

Doug was still awaiting 9-1-1 to answer his call.

We got back in my car, and drove on.

SNIPPETS PART IV

I hope that nobody is surprised to learn that, since The Un-Named Fly-Over State is in the northern tier of states, it snows here in the winter (And the fall. And the spring.) That has been the case for certainly the past nearly 70 years that I have been here. Therefore I would hope that my neighbors would have figured that shit out, by now.

On the other hand, there is abundant evidence that my hope in this matter is misplaced.

So, TINS, TIWFDASL…well, OK, I was driving in to work one snowy winter day in order to begin my day of FDASL. I was listening to the amateur radio in my vehicle, and monitoring the county’s fire department dispatch. No ill tidings from that front.

I did notice a car off the road, into the ditch, but I figured that the county deputy already on the scene had things well in hand.

So, there I was, listening to the FM radio, and waiting for any alarming traffic on the HAM radio, when I saw this guy, no shit, skate his compact pickup truck completely across the 3 lanes of expressway traffic, having apparently originated from the on ramp. My guess was that he had entered the ramp at speed that was excessive for the conditions. (did I mention that it had snowed the preceding night? Well, it had. Likely had something to do with the other guy in the ditch.)

Anyhow, once he reached the median shoulder, he started to wifferdill his way along that shoulder, inching his way into the median’s ditch. He did manage to stay upright, so, that was nice…..

The thought crossed my mind, “coefficient of friction: words to live by!”

@@@Snippet The Second@@@

You may recall my tales of cat-herding (Farming? Wrangling?). In any event, one of the cats had a recurring conjunctivitis, such that our local vet voiced concern regarding the potential of a ruptured globe (eyeball breach, with vision-destroying loss of the fluid-vitreous and aqueous humor that is within the eyeball), versus a vision damaging occurrence of scars on the (supposed to be) clear portion of the eyeball.

So, we arranged an appointment with a veterinary ophthalmologist.

Of course, this doctor practiced in an office something like three counties over from our home. Of course, on the appointed day, it was a balmy 33 degrees (f), and could not decide to snow, rain, sleet, or what.

Fun times.

I learned on this trip, that driving Trixie T. Cat anywhere, was very much akin to driving your small, furry, outspoken, elderly, mother-in-law somewhere. I was the recipient of a running series of corrections, spoken (of course) in Cat, that likely would have sounded like “You’re driving too fast!”, “You’re driving too slow!”, “Why can’t you stay in one lane?” (this as I signaled, eased over into the -clear-adjacent lane, and in the course of doing so, ran over the ridge of slush built up between the lanes. So the truck jerked.), “Why aren’t we there yet?”, and the ever popular, “Where the hell are you taking me? I don’t want to go there! Let me out of this damned cat carrier!”

That is, would have sounded like that, if I spoke Cat.

As you might imagine, first off, back seat driving is oh, so very welcome at any time at all. Secondly, such corrections are even more welcome when the driving is, oh, gosh, I dunno, HAZARDOUS! Thirdly, let me take a moment to congratulate TDW-Mark II. She successfully suppressed her baseline impulses to shriek, gasp, or otherwise demonstrate her appreciation of her/our impending DOOM! Probably figured that the cat had that well covered.

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.