cats · Fun And Games Off Duty · Life in Da City!

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.

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

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.

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

Telemedicine: Threat, or Menace?

One fine day, I was at work, FDASL, and received a text from my daughter, let’s call her Brenda. She related that her second child had developed what looked like pink eye, to Brenda’s assessment. She (Brenda) had contacted whoever, and that medical soul had video chatted/e-visited/virtually visited/some other bullshit with my grand daughter, and had prescribed an ophthalmic antibiotic.

Brenda was not altogether certain that this assessment was spot on, and wanted her clinician dad’s take on things.

As you may have surmised, MY take on non patient contact, not in the same room “visits”, is not filled with much enthusiasm. There is something to the gestalt of being in the physical presence of somebody, that provides you with clues that are neither evident, nor are they provided across a video screen of any sort. (Ever smell the fruity breath of diabetic ketoacidosis? Ever smell it over a phone?)

Placing that aside for a moment, I asked for some pix. (I am aware that this amounted to the very same thing I had just, 11 words ago, railed against. Wait for it.) My grandchild’s eye appeared red, and (uncommonly in pink eye), so did the tissue surrounding her eye.

I asked if this grandchild could move her gaze left and right, upwards and downwards, painlessly. Was there any change in her vision?

The response I received was that the vision in her affected eye was “blurry”, as well as “it hurts when she looks up”.

My response text, verbatim, was, “Who is going to see her in person, in the next half hour?”

Brenda took her child to our local urgent care, which clinician, to THIS clinician’s credit, is reported to have entered the room, taken one look at my grand daughter, and turned to her mother, and said “So, I’m not going to charge you for this visit. Do you know the way to Big City Referral Hospital? Good. Do not dawdle. Go directly there, now. Yes, I mean the emergency department. Thank you. Drive safely.”

THOSE folks examined her, CT’d her, and started an IV (a process that Grand Daughter did NOT approve of!), and IV antibiotics, and admitted her for several days. The CT had revealed a peri orbital cellulitis (mild, but, nonetheless…), which responded to the medication.

She is now home, sassy, and none the worse for the experience. Take home points: Brenda demonstrates many, many of the affirmative attributes of The Plaintiff: she is smart, decisive, has a finely calibrated and high functioning “shit don’t sound right” detector, and is a bulldog advocate for her children.

I loathe “telemedicine”.

Sometimes I am both blessed and lucky. This time, to the benefit of my grandchild.

Fun And Games Off Duty · Pre Planning Your Scene

Sleigh Bells Jingling, etcetera

So, TINS, TIWFDASL something like 60 northern Un-Named Flyover State miles from home. This was several years ago, of course, when we still had snowfalls (…he said, snarkily!) One night, I got out of work after 12 hours in our windowless ED, to find it had SIFAO. (Snowed….). AND, for bonus points, was still SIFAO. My daily driver was a 2008 FWD Hyundai Sonata.

So, it turns out that, at 45 mph, my typical 1 hour drive approaches 2 hours. Particularly when, SIFAO as it was, I followed the exit ramp, thinking I was still on the expressway.

You start to wonder about that, once the stop sign appears.

I re entered the highway, and plowed my way home, white knuckling it the whole way. I got home safely, the car gave me STELLAR gas mileage that trip, TDW-Mark II worried, and I galumped my crabby ass, along with considerable snow, into the house, unbruised.

Thanks Be To Chthulu.

More thoughtful observers, than I apparently am, might wonder why I simply did not obtain a motel room, and sleep my happy ass away, in the town that I was already in, and thereby allow the unsung heroes of the road commission and the state highway department, to work their magic and clear the roads?

Well, to be honest, that would require more foresight than, evidently, I possessed at that time. One might wonder if I had contemplated the McFee Four Stages of Snow Emergency. I had not.

To review, here are The McFee “Four Stages of Snow Emergency” Scale.

Level 4: wear your damn boots
Level 3: bring a coat, bring a shovel and a scraper
Level 2: do the s#!t you have to do and go the hell home
Level 1: Ermagerd! French toast by candlelight!

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

Partners. Or, Not.

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

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

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

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

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

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

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

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

Snippets, again

@@ Please, do NOT tell me that Bonine is 125 (or 12.5: she was not speaking clearly) milligrams, over the counter. I happen to know that OTC Bonine is Meclizine 25 mg, the same strength anti vertigo medication I prescribe as Antivert, and I know this for reasons. These reasons include (a) I kinda went to school for this stuff, (b) I prescribe Antivert/Meclizine several times a week, (c) TDW and I enjoy taking cruises, and she is somewhat susceptible to seasickness. Therefore, I am familiar with Bonine in it’s seasickness/motion sickness indication. Therefore I purchase it, OTC. Ya know, like last week. (d) When I acquire a medication, I (pay attention now! This one weird trick will help you manage your medicines!) RTFL. (Read The Freaking Label). (e) I have a functioning memory, not blown out by continuous applications of high serum levels of cannabinoids. Therefore I can remember this stuff, along with other stuff I find useful.

Finally, please, Please, PLEASE! Consider the possibility that I, indeed, am trying to both help you, as well as make your life easier.

The above is my internal monologue, which is considerably lengthier than my first pass response, also stifled, of “Hmm. Weird. Ok, then, don’t take it. Good talk. Have a nice day! Buh-bye, now!”

@@ So, TINS, TIWFDASL, as an ED nurse, long ago and far away. It came to pass that my manager invited me to join her in her office, where she told me that several of my colleagues had come to her, concerned with what they esteemed to be my taking overly long to triage patients.

For those in the studio audience who do not know, “triage”, in the ED setting, is the process wherein a nurse interviews the patient to elicit chief complaint (“What motivated you to come to ER tonight?”), history of present illness (“How long have you been ill? What have you done to address it? How did that work for you?”), allergies/medications/history, and vital signs. In the course of that conversation, the goal is to identify unstable folks, and truck them right back to care, and differentiate them from stable folks (like a broken limb with intact downstream circulation), and invite those folks to be patient.

I asked my manager how long I was taking, on average, to triage? This information ought to be readily available from our electronic medical record system.

“I don’t know.” was her reply.

I asked how my triage times compared to the average of my peers.

“I don’t know.”

I asked if the acuity of the patients I triaged was similar, greater, or less than the average of my peers.

“I don’t know.”

I asked if the complexity of the patients I triaged differed in any identifiable way from my peers (think psych requiring lots of redirection).

“I don’t know.”

I contemplated this for a second. “Wouldn’t it be a lot easier for me to improve, if I understood the manner in which I am falling behind my peers? I had thought that one of the advantages of an EMR was the ease with which just this sort of information could be abstracted.”

@@ In my clinic, folks who are currently afflicted with covid, or who fail the screening interview/temperature taking, get seen as “covid + other” patients. They are invited to wait for their turn in their vehicles (or, in nice weather, outside), rather than in our waiting room. Inasmuch as we are a walk in clinic, there are no appointments, and, if you are at the shag end of “The Wave”, well, you face a lengthy wait.

Some of these individuals drive off, thinking (not altogether wrongly) that a lengthy wait=an opportunity to get other stuff done.

The problem with this plan, is that, should a number of the other folks in line ahead of you, either spontaneously cure themselves, or decide, in essence, “F&@k this, I’m not all that sick”, and depart, your turn may arrive earlier than your errands anticipated. So, when the MA calls you on the phone number you provided today at registration, (a) it might be useful if you answered it, as well as (b) if the phone in question was actually in service.

Among the souls who successfully pass these two tests, there are those who respond, when told that their turn was at hand, and we (the MA) had some questions for them preparatory to actually seeing them in the office, “I can be there in 25 minutes!”

Well, that is kind of a fail. The MA will then tell them, “Sorry, we’ll call the next person on the list, who is here now. You will be at the bottom of the list, since leaving the line loses you your place in line.”

Pains in my Fifth Point of Contact

Z-Pack! Arrgh!

Those of you who have suffered along, reading my scribblings (uh, I mean…) been frequent visitors to this blog, likely know that, in addition to spending years in The Sick People Business, I am, well, conservative. This works out both politically, as well as with regard to my life choices. I have heard that everybody is conservative about things that they know best. Firefighting is renowned with the deliberate pace of accepting new innovations, probably due to the fact that if the innovation tanks, firefighters (and civilians) die. The military once was very conservative, for similar reasons.

So, TINS, TIW, driving my happy, fuzzy, disease fighting ass home after another fun filled, exciting day of Beating Back The Scourge of Zithropenia (Azithromycin+/penia=Zithropenia. (n) The state or condition of having a pathologically low blood level of azithromycin. (fictional malady)). I was listening to a talk radio host, and this worthy declaimed that they “Know my own body. I get this same bronchitis every year about this time of year, and I always get the Z Pack!”.

Let’s pause, and “bookmark” that statement. There are three things that I want to address therein. Once I unclench my teeth, that is.

This soul continued: “So, I went to a doctor, just like last year, because I had this bronchitis, just like last year. I mentioned that I wanted the Z Pack, just like last year, because I got better after taking it. I guess that was the wrong thing to say, because he prescribed something else, which took longer, and didn’t work as well”.

Another bookmark, please. Generally, this commentator makes sense, and I agree with their perspectives. They typically make valid points, in my view, and their analysis of events makes sense: they appear generally internally consistent. HOWEVER, I need to contemplate whether there becomes a variety of what I will call a “reverse Halo effect”, for lack of the precise term. That means, if this commentator can so badly err in this regard, perhaps I ought to view their perspectives with greater skepticism.

Now, about those “bookmarks”. Let us begin with (1) “I know my body”. Let us agree, “know my my own body”, and “know whereof I speak in matters medical” is not a circle in the Venn diagram of facts. Generally, the soul with whom I am interacting (placing myself in this person’s clinician’s place), is not a physician of any stripe, commonly not an RN, and likely does not know the manner in which antibiotics (for azithromycin-The Z Pack-is an antibiotic, of the macrolide class thereof) function. In some regards, this is similar to presenting to your mechanic, and asserting, “I know my car, and I need a new framistan!”

Perhaps, should your mechanic pull the OBE codes he/she might have some insight into the, oh, I dunno, correct analysis of why your vehicle is making that funny noise, that, just maybe, you ought to listen to.

On that same topic, the imp in my head often suggests that, in response to that conversational gambit, that I ask, “Indeed? What is your opinion of the role your amygdala is playing in your illness?”, or, “Are you certain the the Z Pack will be strong enough? Shouldn’t you take imiprimine for your cough-worse-at-night, or sniffles?”

I rarely listen to the imp’s advice.

Secondly, “I get this same bronchitis every year around this time”. While I am by no means a microbiologist, nor do I play one on TV, and the last Holiday Inn Express that I stayed in was in 2016,

in my Nursing studies, and in my midlevel studies, I do not recall a single instance of our instructors informing us that microbes possessed awareness of the seasons, let alone calendars. My assessment, assuming that my examination does not provide contrary evidence, is that the seasonal nature of the malady likely reflects seasonal changes in the environment. Here, in The Un-Named Northern Fly Over State, that likely means, in the fall, that you finally became cold enough to turn on your furnace, and, generally, that means a forced air furnace. Said furnace has been dormant for 4-7 months, allowing all the dreck suspended in the air to settle out in your heating ducts, and, once you get chilly again, and the furnace is activated, which means the the blower is energized, air begins to move through your ductwork, and all that dreck, quiescent for lo, these many months, is aerosolized once again, and you again breathe it all in.

Since, in the interval, your mucosa has grown UNACCUSTOMED to these irritants, you, once again, have irritated sinuses, which swell (“my head is plugged” and/or “I cannot breathe….through my nose”), and, in the manner in which your mucous membranes respond to irritation, they pour out mucous. Since it takes a while for you immune system to again achieve equilibrium, the delay until you go to the clinic + the delay before you fill your prescription + the delay until you complete the course of azithromycin of which you speak so highly, roughly equals the time frame required for your immune system (read: mucous membranes) to adapt to the new, dust laden, environment your autumnal activation of your heating system elicits.

Rinse, repeat, for spring “bronchitis”, likely elicited by mold finally being unburied from the snow that we enjoy months at a time. Ibid, spring pollen release, similarly, summer lawn clippings, or whatever.

Finally, “I always get prescribed the Z-Pack” (implied is “and it always fixes me”.) Please contemplate the logical fallacy of “post hoc, ergo propter hoc” (“this follows that, therefore that caused this”). To illustrate, I purchased a new pickup truck in the summer of 2020. Therefore, absent my truck purchase, Mr. Biden would not presently be in The White House. Right? See above regarding seasonal irritants to your sinuses, and their effects, along with the timeline described two paragraphs above.

There is an additional factor, segueing into the next point, wherein azithromycin interacts with other medications (betcha they didn’t know THAT, eh?), as well as particular medical conditions (go internet search “black box warning”. I’ll wait here while you do so.) To translate the medicalese into english, “QT prolongation” refers to an alteration of the heart conduction system, which, occasionally, can produce alterations of the heart rhythm that can be lethal.

We generally consider that to be a bad thing.

So, these are prominent among the reasons that I am considered “the Z-Pack Nazi” by my co workers.

With reference to the assertion that “…he prescribed something else, which took longer and did not work as well”. Please refer to the timeline outlined above, consider the drug-drug interactions, as well as drug-medical history interactions cited above. Now consider the possibility that Doxycycline, over ten days, was every bit as effective as azithromycin (which is to say, not), and perhaps the speaker went to the clinic earlier in their course than historically.

All that is with absolutely no knowledge of this radio person’s medication list, allergy list, past medical history, review of systems at the time of the office visit, nor of the physical exam findings. Simply, it elicits teeth grinding, and reminiscences of actual patient encounters that I personally have had.

Thanks for riding along.

Duty · Fun And Games · guns · Pains in my Fifth Point of Contact

SNIPPETS

So, TINS, TIWFDASL, and one of the registrars walked back, and informed us, “They say that there is a man out there with a gun!”

My response was to ask, “Is there any reason that you are NOT telling the police this, rather than telling me?”

“Oh, should I call the police?”

“Ah-yep! Right freaking now would be very nice!”

@@@

If you have COPD (emphysema), it is likely not so very helpful to smoke marijuana.

@@@

Me: “So, you’re here for your cough. When is your cough worse?”

Them: “When I cough.”

@@@

Please, after I have explained my plan of care for your cough, which is caused by the irritation caused to your throat by the mucus in your throat, mucus originating in your sinuses, Please do not correct me with the observation that “My mucus is in my throat”.

It is very likely that, when I illuminated and inspected your throat, I DID notice, and, indeed, did comment upon, the tsunami of snot therein. Further, it is likely that every child of Ghawd that I have seen today has, also, snot streams running down their posterior pharynx: their throat.

So, when I explained to you that that mucus is irritating to your throat, since your throat is not well designed to tolerate that event, and that irritation manifests as a sore throat, or a tickle and a cough, or both, did you consider the possibility that the mucus originated, oh, gosh, I don’t know, IN YOUR SINUSES, AS I, INDEED, MENTIONED IN MY DETAILED EXPLANATION OF YOUR MALADY AND MY PLAN TO MANAGE SAME?

So, the nasal steroid that I recommended to you, over the counter, will suppress the inflammation (that I mentioned was the root cause of your woe), and thereby suppress the outpouring of snot which is the proximate cause of your cough, and, therefore, end (or really, really suppress) your cough, which was the ostensible purpose of your visit in the first place.

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

“So, I just have to deal with my pain!”

So, TINS©, TISFDASL©, and was in the midst of winding up my plan of care tutorial for the patient du jour. This soul had been experiencing their pain for several weeks. They had not, of course, contacted their primary care. (To be fair, it is not uncommon for a walk in patient to respond affirmatively to my query regarding attempts to meet with their primary care, and to note that they indeed HAD an appointment, several weeks from our conversation.)

In any event, I had elaborated on management of their problem, featuring rest, ice, elevation, and ibuprofen. I observed that it was likely that their physician would consider things like physical therapy, or maybe a referral to orthopedics. Given how insurance reimbursement works, if I, NOT the primary care, order these things, it is entirely likely that the insurance company will NOT subsidize them, and an initial visit with a specialist, like an orthopedist, can easily run around $500, before the insurance company pays their share.

Personally, I would be happier if the insurance company chipped in.

This soul replied, “Well, I guess that I will just have to deal with my pain!”

I replied, smiling, “Well, that is certainly an option. Alternatively, you might consider the measures that I have just outlined, and those that your doctor might order, which might moderate or eliminate your pain. You could do that, instead!”

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

SURPRISE!

So, there I was, fighting disease and saving lives, and my MA came to me, regarding somebody who had arrived for a subsequent Covid inoculation. This soul had informed my MA, AFTER THE INJECTION HAD BEEN ADMINISTERED, that she, the patient, had had a reaction to her first inoculation. She described this reaction as swelling, itching, and feeling ill. This had developed in a couple of hours after the injection.

It turned out that, today, this patient had, indeed, developed swelling, runny nose, cough, and whole body itching within FREAKING MINUTES after her injection. (those of my studio audience who have some sick people experience might recognize these indications as harbingers of anaphylaxis)

Weellll, we administered some IM Benadryl, some IM steroids, a breathing treatment, and close attention from my MA. Several repetitions of vital signs and reassessments later, this lady had seen her breathing improve, her itching subside, her swelling tapered, and the cough and runny nose reduced.

So, pro tip: If you swell up after the first dose of whatever the frack you are being injected with, tell a motherfucker, ya know, like, BEFORE you get the next injection. Personally, my geezerly ass will very, very much appreciate it.