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

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.

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“Warn-A-Brutha”, in action.

So, TINS©, TIWFDASL©, and my MA, let us call her Maryann, exited the room that she had entered, shortly before, to assess and obtain vitals on a child.

“Reltney, this child here is working kind of hard to breathe, and he is coughing a lot: it seems to interfere with his taking a breath!”

I entered the room, and noted a child coughing approx every 10 seconds (and I mean a full throated cough, not some modest little “harrumph!” kind of thing), and, as I observed his breathing, noted a rate of around 60 breaths a minute.

Not so good.

We administered a breathing treatment, and he had kind of, sort of, maybe improved just a little bit.

I finished my assessment, and went to chart, intending to return and re assess him once my (generally 4-7 minute) charting was completed.

I did so, and noted that his breathing had dis-improved (is that really a word?). I invited the physician with whom I was working to lay eyes upon him, briefing her upon my observations and actions thus far.

Once she had assessed him, she was not favorably impressed. She, also, thought he was working kind of hard to breath. She, also, wondered if this was fixing to run him out beyond the end of his reserves, whereupon he would crash, likely biggly, and become a no shit emergency. She wondered if sending him to emergency, prior to that happening, might not be more wise than waiting until he did, indeed, crash.

I agreed.

I wrapped up my charting, once the child was safely on the way, and hunted up Maryann. I congratulated her. “You did good. Your prompt assessment that this child was not breathing right, set in motion events necessary to get him to the appropriate level of care, in a timely manner. Well done!”

Duty · Having A Good Partner Is Very Important!

WARN-A-BRUTHAH!

I was on vacation, early last year, and saw a t shirt, with the Warner Brother’s logo, and the script, above and below the shield, admonishing the reader, “If ya see da poleece, WARN-A-BRUTHA!”

https://www.topseasonshirtz.com/view/114/if-you-see-the-police-warn-a-brother–t-shirt

(this will be relevant soon. Be patient.)

The other day, I was watching our grease board, where the registrars enter each patient’s name, and a summary of their complaint. I was (unpleasantly) surprised to note one fresh entry, asserting that the named patient, an infant, had “difficulty breathing”.

I directed my MA to go see that patient, and assess this complaint.

He promptly entered one of the exam rooms with this child, obtaining vital signs, and telling me, “Reltney, I think you want to see this kid, next!”

I entered to see an infant, with audible rhonchi (coarse breath sounds). The heartrate wasn’t awful, the respiratory rate was sort of elevated, and the oxygen was 94 %. Not perfect, but OK. This child was retracting wherein the skin beneath the lower margin of the ribs was being drawn in, a little, with each inspiration. We administered a breathing treatment, in hopes of resolution of the rhonchi, and less effort of breathing.

After the treatment, the rhonchi had improved, just a little, and the retractions might have maybe, sort of, kinda improved. I asked the parents to hold on a while, to see how the child progressed.

I rechecked in another ten minutes, and the retractions had definitely gotten worse. Vitals were still not awful, but one of the principles of treating children is that they generally tend to do OK when ill, until, abruptly, they do not. I was concerned that this child was running out of steam, and approaching a crash. So, I called ED, gave report, and sent the child over.

Subsequently, I was talking to the registrar supervisor, and told the story with which I started this story. I amended it to read, “If you or the mother think that the child is sick, warn a brotha!”

And, in this scenario, my pale ass is the “Brutha” in question.

Duty · Pre Planning Your Scene · Protect and Serve

Another post, from another website

Bad Dancer (commenting at Gun Free Zone blog) says:

October 21, 2022 at 9:50 am

Thank you for the article and links Reltney McFee I’ve read it several times and will go through it again to make notes soon. I appreciate you sharing your experience and advice.

I’m building a few kits as Christmas presents this year. Are there any supplies you recommend added for a family that has a 1-2 year old?

Thank you for reading. Outstanding question! With regard to families that have toddlers (or infants), my first pass suggestions would sound very much like, “What did you want on your last camping trip, that you did not have?” along with, “what sort of comfort item does your child love?”

If I were to add to that, I would look to my own “Grand Kids Are Here: What Might I Need RFN?” (GKAHWMINRFN) supplies. Now, remember, I’ve been a paramedic, paramedic instructor, ED Registered Nurse, and mid level provider since Jimmeh Cahteh was the HMFIC (OK: President).

On the top of my “GKAHWMINRFN” bag is a pediatric BVM (Bag-Valve-Mask: commonly referred to as if they were all branded as Ambu Bags). You might be happy with a pediatric sized rescue breathing mask of some sort, or, easier to pack, mastery of mouth-to-mouth resuscitation.

Near the top would be comfort items, so as to both distract the child, as well as help the child “buy in” to the procedures to be performed. Blankets, pacifiers, stuffed animals: whatever floats the child’s boat.

Remember that children, particularly infants and toddlers, are NOT simply pint sized adults. Due to differences in body surface area, kidney function, maturity of their livers and other factors, they may metabolize medications quite differently from adults. So, just slapping some QuikClot on Little Johnnie’s wound may be a problem. OTOH, here is what I did find in a reference that I use, myself, clinically every day:

“Compared with standard sponges, the use of the kaolin-impregnated sponges in 31 infants undergoing the Norwood procedure had a significantly lower intraoperative use of blood products and lower incidence of perioperative bleeding requiring return to operating room for hemostasis (0 versus 41 percent) [44].” (source: https://www.uptodate.com/contents/overview-of-topical-hemostatic-agents-and-tissue-adhesives?search=quick%20clot&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H2249912903

That means, better bleeding control. THAT suggests that a kaolin-impregnated sponge (QuikClot), at least, is not inappropriate for use on bleeding in children that is not otherwise controllable by dressing, direct pressure, and (in extremis) tourniquet-ting. So, small (2×2, 3×3) dressings impregnated with QuikClot appear to be reasonable.

Splinting materials for fingers, limbs, or whatever, are going to be a challenge, both because children do not, as a rule, comprehend the entire “lay still while I splint you” thing, nor the bit about “do not wiggle about, you will work you way out of this splint, and your injured (whatever) will hurt, and be injured further.” So, however much tape or gauze you THINK that you will need, you are wrong, and will require considerably more than you guessed. Unless, of course, you have made it a habit to secure IV armboards to infants and toddlers, several times a day, for the past several years. If you have done so, and done so successfully, please tell me when/where your classes will be, and save me a seat.

Another tangent from adult IFAK/Jump Bag/Holy Fertilizer kits, and child directed emergency care, is that children will both dehydrate, as well as become hypothermic way, way more rapidly than adults, and, once they have burned through their reserves, will crash and burn, often irretrievably. The axiom is that children generally do OK with their injuries, until they don’t. And, when they don’t, they crash biggly. Adults generally slowly decline, until they die. Therefore, measures to protect a child from heat loss are important. That means blankets and knit caps in appropriate sizes. The foil “emergency blankets” are a mixed bag: they are not going to get saturated in whatever bodily fluid is present (good thing), but they are not going to trap heat in a maze of air pockets formed by a Mark 1, Mod Ø fuzzy/fleece/wool blanket. (and you will notice the difference). Select thoughtfully.

Another feature of kid injuries, particularly infants and toddlers, is that they are top heavy. Their heads are a greater proportion of their body weight than adults, and that means that their initial point of impact may be more likely to be their heads, than their hands/wrists/forearms. Therefore, when you are in the hot seat, you need to be suspicious of the possibility of a head injury, when children fall. You have learned to spine board/cervical collar/secure for transport, head (and that is often spelled N-E-C-K) injured patients, right?

Right?

Another needful skill, that you pray is never needed.

That is it for my off the cuff, just got home from work and warmed up my laptop, answer to your question.

Thank you for the stimulating inquiry. Gonna be food for more rumination!

Reltney McFee

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

Revelations, and Pride In My Child

A couple of months ago, I was chatting with my daughter, Brenda. She somehow revealed that, years ago, when she was a single mother, working part time and going to school, money was tight.

I had kinda known that.

Just HOW tight, I evidently had not appreciated. She revealed that several times, she had gone to bed without supper, in order that her child could eat.

Let’s consider that, for a moment. It certainly elicits mixed feelings in me.

Foremost, pride. My daughter is professional, committed, and decisive. Her revelation reveals outstanding triage skills, as well as monumental commitment to her child.

Secondly, frustration. It is not as if I could not/would not remedy her pantry problems. Hell, I have been an overtime working fool nearly all my life, and another day of OT, in order to feed my child and grandchild, well, I suspect “BFD!” communicates my feelings adequately. (that is “big freaking deal”, although the second word generally refers to certain ancient and generally highly regarded fertility rites…).

Thirdly, frustration. (again). It is not as if I do not buy groceries, to this day, just as if I were still feeding four hungry adolescents. That both provides me with plentiful left-overs for my meals at work, as well as abundant food-in-waiting. The only thing stopping me from a pantry filling visit to my child, is her failing to tell me such might be useful.

Finally, it reinforces my appraisal of my child, that she is A WOMAN, and, like her mother, knows not of this “back down”, you might speak of, with regard to her children. Formidable, competent, decisive.

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

Family Business

My daughter, let us call her Brenda, got married a couple of weeks ago. She has found a man who is made of righteous stuff, who complements her, and fathers (dad-s?) her children.

Since I am a step father, I respect men who step whole heartedly into the role of fatherhood, even if ready-made fatherhood. This man is such a man.

So, several insights occurred to me over the past couple of weeks.

First off, without The Plaintiff, I would not have this wonderful woman, who calls me “Dad”, in my life. For all The Plaintiff’s (and my, to be honest) imperfections and shortcomings, if she had not married me, there would be a Brenda sized hole in my life.

So, as the Father of the Bride, when asked, “Who gives this woman?”, I replied, “Her mother and I”.

Secondly, this amazing woman put herself through college, as well as grad school, working full time, and mothering what would turn out to be 4 children. Proud Poppa moment, right there.

I took the chance to tell her how proud I am of her, and in so many ways that she has earned that pride.

When she responded, “Thank you, Daddy”, well I nearly melted. I had told her how meaningful that Christmas powerpoint was to me, how, even now, it moves me to tears.

So, of course, the Father-Bride dance was to, “He Didn’t Have to Be”, by Brad Paisley.

Thirdly, The Darling Wife-Mark II is an unequivocal blessing to me, in my life. TDW labored to make the decorations, to make everything at this wedding Just Nice. Brenda nearly gushed over the wedding decorations, multiple guests made a point of approaching TDW, and complimenting her over how well her efforts had turned out.

Life in Da City! · Protect and Serve · Sometimes You Get to Think That You Have Accomplished Something!

Proud Poppa Moment

Thank you, ERJ, for the inspiration for another blog post. One of your commenters to your post about the fiscal consequences of “kicking the (payroll and benefits) can down the road”, and the implications of same for actually MAINTAINING a given level of government/police/fire/EMS services, presented the following:

“I suspect another reason for services eroding is lack of employees.
I know that many police departments have openings for lack of qualified candidates, as do many county agencies. Whether their qualification requirements are reasonable is another question. I know that some places intentionally understaff so that existing staff can easily justify overtime, occasionally to a ridiculous degree.”

This ties in, very neatly, to a conversation I had with The Darling Daughter the other weekend. She was talking to somebody with whom she works, this somebody being involved in some manner with providing EMS services. This Somebody (hereinafter referred to as “TS”) was sharing with her the difficulty of obtaining personnel to staff ambulances, in the numbers required to provide ambulances, 24/7/365/surge capacity in the event if BFD emergency.

The Darling Daughter (to be referenced as “TDD”) pointed out that she spent her childhood in the household of a medic, and noted to her correspondent that “You DO know, that McDonalds is paying more than you are, right?”

That elicited an observation about insurance company reimbursement for ambulance transport (TL:DR: meager), and the difficulties that provides in paying personnel more.

TDD noted that for mothers who might contemplate a career Fighting Disease, And Saving Lives, child care, and in particular child care after 5 pm, is AN ISSUE.

Her correspondent, TS, was reported to have metaphorically waved his hands, responding “I KNEW you were going to bring up child care!”

I agreed with TDD, noting that should a crew pick up a transfer to, say Ann Arbor at something like 3 pm, (the drive alone is on the order of 90 minutes, one way, from, oh, let’s pick a town at random: Eaton Rapids, and Sparrow Eaton Hospital. Not mentioned is unload time, as well as the drive back, restocking the rig, and tootling home.), then Our Heroine is looking at being, maybe, in the parking lot of University of Michigan Medical Center, heading home if she is fortunate, just about the time that her day care provider is beginning to blow up her phone with warnings of five-dollar-a-MINUTE late charges for EACH of her children, now that she is late.

At a pay that compares, sort of, with minimum wage.

So, hell YEAH, child care is an issue.

She (TDD) then noted to TS, that there does not appear to be any sort of career ladder for EMS. So far as she knew, it went something like

Basic EMT–>Paramedic–>Do Something Else.

She relates that this sort of issue might adversely affect retention. Which will, as a readily foreseeable follow on effect, “thin the herd” of individuals entering that pipeline. Leading to just this conversation.

Another Proud Poppa Moment!

Duty · Fun With Suits! · Pains in my Fifth Point of Contact · Pre Planning Your Scene

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.

Duty · Having A Good Partner Is Very Important! · Pains in my Fifth Point of Contact · Sometimes You Get to Think That You Have Accomplished Something!

PARENTING STRIPES

Another blog had an entry that reminded me of one of my own parenting moments. As I recollect, Number One Son was misbehaving, and so The Darling Wife-Mark I and I imposed some limits: grounding or some such thing. We observed that a repeat performance would elicit a spanking.

He responded, “Well, I’ll just call the police!”

I smiled. Told him to get his shoes, and get in the car. Now.

We had a leisurely drive to our local small town police department. I asked if I could speak to an officer. The nice desk lady asked, why?

I responded, “This child just informed me that should he require a spanking, and I administer it, he will call the police. I simply do not want to wait. May I speak to an officer, please?”

She bade us sit, and soon an officer arrived. I introduced myself and Number One Son. The officer asked, had I spanked the lad yet?

I replied, no, not yet.

He asked, in what manner would I spank the child?

I responded, with my bare hand, since the point was not pain, nor injury, but, rather, recalibration of his behavior. Once my hand started to hurt, likely my purpose had been accomplished.

So, the officer asked, you intend to spank this child, if other measures do not change his behavior, in order to discipline him?

Yep, was my answer.

“Isn’t that kind of your duty as a parent, to correct misbehaving children? I do not see anything you are describing as actionable by me. You’re simply doing your job as a dad.”

I turned to my son, and asked, “Do you have any other questions for the nice officer?”

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.