Thursday, April 30, 2015

Thought For The Day

"A good shift is one where you get to go pee twice, and neither time is in your pants."

Monday, April 13, 2015

Real American Heroes


So this week, after spending the weekend at St. Sisyphus (if you're hazy on mythology, look it up) see if you can spot the hidden trend:

--- 20-something dude, too drunk to skateboard, so he walks into traffic, gets hit by car, ambulance ride to ED, elopes (forgets skateboard), brought back by PD from his home a few blocks away, found drunk off his ass and returned for trauma work-up, alcohol level 240
--- guy who jumps off second level of building, breaks fall with face, blood alcohol level >300
--- guy who's drunk goes out to get more beer, falls down on head, comes home, family notices he's way more dopey than when he left, and he full on seizes in ED due to a massive brain bleed, alcohol level 180
--- guy comes into ED claiming to have been shot in face, actually has minor trauma from getting bounced from club after acting like an a-hole, blood alcohol level 250
--- homeless guy takes all his daily psych meds and drinking beer, passes out, does faceplant on concrete, alcohol level 225
--- drunk chick falls in parking lot, breaks fall with face, alcohol level 225
--- way underage coed waiting in line to get into illegal rave, passes out before she even gets in, blood alcohol level 270

And that's just a random HIPPA-compliant mix-and-match sample of the week's actual patients, with descriptions/sexes/etc. scrambled at whim.

If you guessed the common factor was an overdose of braincell-killing Judgement Juice, buy yourself another round.
These aren't lifetime problem drinkers, these are simply young jackasses whom society needs to stop rescuing. (Seriously, let's just let a few of them go under, to drive the point home.) A couple of those are going to be effed up for life already, and then, surprise surprise, will probably drown their problems in alcohol for another 40 years.
Just to pile on, this is the week after Spring Break, which brought out hitherto unheard-of levels of alcohol-induced assholery, judging strictly by a few media stories from around the country. So my sample were merely the Everyday Drunkholes.

I shouldn't complain, because Budweiser et al will be paying for my mortgage and cruise vacation tickets at this rate, and it's barely April.

But when you can afford to get so f****d up you can't walk straight and not play in traffic without a keeper, but you can't afford health insurance or a hospital bill despite the government handing you that shit on a platter, it's time to bring back galleys, where you could work off your hospital bill by rowing at wages of 10 cents a mile, or by being chained between two poles on a street corner, and letting people kick you in the junk for $1 a kick.

Ill be the guy in line with a wad of singles bigger than a pole dancer's on Monday morning, and wearing a pair of steel-toed boots.

And either solution would keep those a-holes from procreating anytime soon, which would be a net plus for society. But the next time some soopergenius bitches that their hospital bill listed a Tylenol for $65, remind them how much it costs to subsidize these ignorant jackasses who rang up a $40,000 trauma bill at the hospital while on welfare and food stamps, or while still living in momma's basement. Then tell them to STFU.

Friday, April 10, 2015

High Blood Pressure PSA

Those of you in the trade already know this.
Move along, or share it with those who need to hear it.

This is for the laymen (and women) out there who read this, and their cute doddering parents and grandparents, uncles and aunts, older siblings, and dopey next door neighbors.

The medical word for "hypertension" is High Blood Pressure.
They are not two separate ailments.

If you're taking medication for it, YOU HAVE IT.
It did not go away, it's simply "controlled". We hope.

The only way you know this, is if you CHECK your own pressure at least once a week, if not daily.

If your pressure is too high, you have to check it at least daily for several days until it returns to normal, to know that you're doing it right.

Yes, EVERY TIME it's too high.

Anything higher than 140/90 is TOO HIGH.

And BTW, Anything higher than 140/90 is TOO HIGH.

Did we mention that anything higher than 140/90 is TOO HIGH? Okay then.

If you're on anything that makes you pee more, you should be checking your weight DAILY.
And yes, a "water pill" is called that because your kidneys make more.

If you gain more than a pound or two in a day, and it's not the Friday after Thanksgiving, you're retaining water.
And need to call your doctor.

You can't take your blood pressure medications only when you "feel bad".
They don't work when you take them randomly like that.

They also don't work when you don't take them at all.
Even when you "ran out of them last month."

They also don't work when you stop them abruptly, because you don't like some/any/all of the side affects.
That's what the telephone number to your doctor's office is for.

When you do any of the above bone-headed steps, the medical term for what you have is UNCONTROLLED HYPERTENSION.

The laymen's medical term for what you are is IDIOT. (cf. MORON, JACKASS, FUTURE STROKE PATIENT, etc. )

When you walk around with a blood pressure of 200/anything, it won't kill you today.
Probably not tomorrow. (But avoid sharp objects.)
But eventually, like driving your car 100MPH from red light to red light, something's going to blow up.
But it won't be in your engine, it'll probably be in your head.

BTW, when grandma's face looks droopy on one side, and she's babbling incoherently, and/or can't move her arm and leg, it's not okay to wait "until the playoff game is over" before you come to the ER.

It's not okay to "wait a couple of days" afterwards "to see if the symptoms get better", or listen to her when she says "I don't want to go to the ER now, I'm fine".
(Or when she says, "Ib dwwwn wahhh du koh du the blarg marfletthhhwwffft.")

We can fix some strokes, IF you get to the hospital right away.
Two days later is NOT "right away".
Even on "island time".

Call the effing ambulance.
That's what it's FOR.

If you want to spend most of your golden years re-learning to talk and walk again, sort of, or worse, being used as a doorstop because you can't walk and talk anymore, but your family/kids/friends don't have the heart to put you down like Old Yeller, please, ignore all these notes, skip/stop your meds, and get ready for a decade or more of falling down, drooling in your lap, crapping and peeing your pants, and wearing really badly-coordinated clothes, and socks with sandals, because you can no longer move around or dress yourself, as you decompose slowly and agonizingly for a decade or more in some elder-care purgatory you wouldn't send terrorists to, but which is all your family can afford.

Or, lose 50 pounds, take your goddam BP meds now, EVERY DAY, know what meds you take, why, how many milligrams, how often, keep it written on a card in your wallet/purse 24/7/365, check your BP and weight every day, write it down, bring it to your regular doctor check-ups, and enjoy your sunset years doing whateverinhellyouplease without having your family look at you like a cat that needs to take that last trip to the vet, or having people like me deal constantly with your irrationally ignorant and generally jackassical non-compliant behavior.

Or a least have the decency to have "DNR" tattooed on your forehead, and forbid anyone from calling an ambulance to drag your stroked out big-old-brain-bleed ass into the ER, so the ICU nurses can treat you like plant life after your next massive stroke: by feeding you, watering you, and turning you towards the light.

And remember, I yell because I care.

Monday, April 6, 2015

How To Tell This Isn't Going To Be A Good Shift, #2,317

Open wound + flies = party!

So you know things aren't going to be fun on your shift:

A) When the radio call report is "infected leg, with maggots".
B) When said patient arrives with the leg involved wrapped in a plastic trash bag from toes to thigh.
C) When the paramedics are taking hits off their SCBA breathers.
D) When the patient is assigned to your zone.
E) When, as part of the meet-and-greet, you have to remove the bag to visualize the situation.
F) When the funk miasma coming off the leg would knock a buzzard off a pile of guts, and you haven't even gotten the socks and pants off yet.
G) When you finally get to the base layer, and are greeted by a menagerie of several tens of thousands of little brown rice grains, all doing the entomological version of "The Wave", in a pile an inch thick. Bless their hungry little hearts.
H) All of the above.

Back off, everyone, this one is all mine! Sigh.

I would like to sound heroic, but in fact I contented myself with doing the usual business-as-usual primary assessment and trying not to flinch or start itching all over.
The arrival time being a-quarter-to-day-shift (what else?), my uninvolved co-workers' foolish curiosity overcame any native common sense or desire for self preservation, and while I happily avoided any little friends when patient decided to command spasm the leg (Dude, seriously?!), they busily applied sterile saline and suction, and vacuumed up upwards of 10,000 of the little nibblers, after doing a photo-documented wound assessment at my behest. Some things require photographic proof for posterity. 

They are my heroes for stepping up to the plate.

The maggots probably saved the patient from gangrene. Pity.

And day shift received their patient all buffed and fluffed, and ready for the metric shit-tons of sepsis-thwarting antibiotics necessary. And by the time they got there, the patient was the only living thing in that bed.

But I don't think any of us there in the room will be eating any fried rice for awhile.

Wracking my brain here, but I'm pretty sure they never mentioned the true technicolor glamour of this job in nursing school.
But I spared you any of the illustrative internet pictures at the header.

You're welcome.

Wednesday, April 1, 2015

What Ebola? Where?

As noted yesterday, Ebola is not, in fact, gone from any of the three most heavily impacted countries in West Africa.
In fact, the weekly tallies right now are running at a fairly steady percentage of what they were during the apparent peak weeks last fall.
And without laboring yesterday's point, based purely on admittedly bogus numbers of dubious reliability, for any given point in this outbreak, including now.

In the past, outbreaks have burned out; usually by killing 90% of everyone in some remote village, and then going away because the other 10% survived/were immune.

We don't know how the Index Patient in this outbreak contracted it. Just like we don't know where any other Index Patient in any prior outbreak contracted it.

But this time, it hasn't gone away. Because this time, there's a near limitless pool of new victims, because it isn't confined to some remote little village. It's gotten loose across entire countries, and in the large cities thereof.

And it simply hasn't disappeared in any of them. It waxes and wanes, but it's still infecting people, and still killing them in droves. Despite everything we know (and don't know), and despite everything we've done and not done, it just keeps on keeping on.

It keeps infecting the careless, the stupid, the ignorant, and even those taking special precautions and wearing frickin' hazmat gear.

We did not duck this bullet, it just went over our heads last time.
There is absolutely NO reason to assume this will continue to be the case. In fact, rather the opposite: every day it doesn't spread just makes the day it does more inevitable. Like against terrorists, we have to get lucky every time, this virus just has to get lucky once. The calculus on that argues for preparation for what is clearly inevitable.

So how's that going over here?
No ban on flights here from there.

But why do that? No one has gotten here since they started the screenings.

Yeah. A signs prohibiting it are what keeps elephants out of the trees at the local park.

Which argues for several things:
* the screening measures, shoddy as they are, have been good enough to stop obviously infected people from travelling, in most cases (they wouldn't have stopped Duncan)
* it's harder to spread early on, and thus early infectees who are pre-symptomatic are the only ones who can make it past the screening
* we're dealing with a target population for whom taking an airplane flight is only slightly more likely than flying to space.

Unfortunately, that means that:
* those who do travel will have the means to go anywhere
* they won't raise suspicions until they're far from the minimal screenings that exist
* they'll then become symptomatic amidst their home populations, long after they're not under any sort of organized and mandated surveillance, and thus all reporting is completely on their honor and best behavior.

And as witnessed with Dr. Special Case, Dr. Special News Reporter, and Nurse Mimi Crybabypants, people, even trained medical professionals, are self-serving lying little shits who will endanger the public recklessly and repeatedly, left to their own devices, where Ebola and the horrors of quarantines (which latter have been instituted and accepted by all civilized people since medieval times) are concerned.

And that's just assuming the disease stays in West Africa, behind the current zone of interest.
If it gets out of that zone, like the Germans going around the end of the Maginot Line, there isn't anydamnthing to stop it or even slow it down.

And what about here?
We still have a treatment capacity of 11 beds, nationwide. And several of those are permanently reserved for military research casualties, so it's really only 7-8 beds.
I.e., the same number of Ebola cases in any of the three originally affected African countries by Week Two.

Then, it's back to local hospitals.
Which is to say, the Worst Of All Possible Worlds.

Dallas gave you a glimpse of what to expect.

As I've related, I've been flitting hither and yon locally in my professional capacity.
I'm here to tell you, having now seen multiple local hospitals, it's far worse than I could have imagined.

Most hospitals have no supply of protective gear for even a single outbreak case.
Many have no negative airflow room in which to place the victim(s).
None have more than a very few of them.
All of them require moving an infected patient through the entire ER, from lobby to treatment area, completely exposing not only visitors, but their entire staffs, to potentially infectious material.
None of the ERs I've worked at has any personal protective equipment rapidly available.
None of them has adequate PPE available for more than a few staff members.
None of them has conducted anything but cursory training in dealing with potential infectees; most have conducted none at all, and a few don't even address the possibility of it ever becoming necessary.
None of them has any capability to sort infected people before they enter the hospital, nor do most have any plans to do so.
The ones that do have plans are mainly limited to vague incantations about setting up some ad hoc magical whatsis. None have actual sorting facilities, decontamination abilities, nor have held any training or exercises to practice such implementation.
None of them has any capability to treat so much as one potential case, and still safely stay open to other patients, yet that is precisely what they have done and will continue to do, until it becomes apparent that they've already contaminated their entire staff, the entire ER, and recklessly and deliberately exposed dozens to hundreds of unprotected people to the disease.

Go back and read that last sentence again.

Bear in mind we're talking about busy ERs in a diverse, multi-lingual major metropolitan area, wherein reside approximately 10% of the entire US population, countless international tourist destinations, multiple international airports, three major seaports, and an international border within 1-2 hours' ground travel distance. Not the 2 bed ER in Podunk, Inner Wyoming.

Now let's talk about your ER, especially if you're within a tank of gas of those five major destination airports for flights from West Africa.

Then let's talk about your ER if you don't even have that going for you.

And now I'm not even on the home team in those ERs?
Potential Ebola Case walks in, I'm out. Period. Done. B'bye.

And the difference for me is, at least I'll know something there, because they'll come in with suspicious symptoms.
What are you going to do when someone coughs in the market, or is sitting next to you in the theatre or the bus with a fever? Wait until blood is shooting out of their eyes?

Best wishes with that plan.

I repeat, Dallas was a warning shot.

IIRC, Duncan was sick in hospital for a week or so before he died. I don't know how many nurses cared for him there; at 2/day it could have been as many as 14, plus ancillary staff, or as few as two. And with their inadequate protective measures (the same ones I've seen ready or not at most local hospitals) that means he successfully infected between 14% and 100% of his direct caregivers.

All of whom KNEW he had Ebola before they walked into his room.

His one case closed that entire ER for the duration-plus, and the ICU, and for all intents and purposes, a 400- or 500-something bed major acute hospital became a ghost town overnight. It may yet stave off financial ruin and bankruptcy.

Based on the early reports of the first nurse's lawsuit, I wouldn't hold my breath there, and despite the blow to the community, they probably don't deserve to stay open.

Then there was the disruption and expense to the city and county, from a grand total of three actual cases: Duncan himself, and the two nurses. (And both of them were evac'ed to two of those eleven beds mentioned earlier pretty rapidly.)

So the moral of the story is, the first eight or so people infected here have a shot.
Patient Number Nine and following will stand about the same chance as victims in Africa.
Which is somewhere between a 10 to a 40% chance of survival.
And, evidently from recent news, with a lifetime's major permanent disabilities and sequellae, including lifelong vision deficits up to and including permanent blindness in many cases.

So yeah, Ebola has plateaued at a fraction of its peak, but refuses to burn out.
Which is merely that same exponential growth curve, on "Pause".

And given the current mutually-agreed-upon news blackout, your first clue it's rolling again will be when they announce on the news that someone is at County General, and came in shooting blood out both ends after they collapsed at the mall.

And then it's last September all over again.

Oh, BTW, for reference, at one of those ERs, in one week's time I've taken care of ten patients who came in with such routine symptoms as coughing blood, vomiting blood, and/or bleeding out their back end. We won't even talk about how many had fever, headache, and body or joint aches. So yeah, we'll get right on catching that Ebola patient the first time they come through the ER, because it's so easy to spot.

Just like they did in Dallas.

Sleep tight.