Gift Wrapped

You had a heart attack a couple of years back.
Undeterred, you're still smoking every day.

But you had chest pain the other night.
So you came to the ED.
No, not by paramedic ambulance called to your house, with all the latest technology and pharmaceutical wonders at their fingertips right there in your in your living room.
(Too easy, right?)
Instead, you waited a few hours - to make sure this was really something - then had your wife run a few red lights driving you in to see us.
Then you came in, went to the bathroom, and then waited to register to be seen.
Without telling anyone why you were here.

Of course, your full arrest in the waiting room a minute later kind of let the cat out of the bag.
Lucky for you it was late at night, during the slow time, and we all came running.
And somebody jumped on chest compressions for you in about 10 seconds.
And kept on doing it until we got you onto a gurney and into the code room.

And you were in V-fib, of course.
So we zapped you a couple of times, cranked on your rib cage for a few cycles in between, and pumped you full of code drugs, sunk an ET tube on the first try, and got a pulse back.
(Did it sting? Do you remember any of this now? Just wondering...)

And then we shipped you off to the cath lab, and then they sent you to the ICU.
Who fixed you, and sent you home again.

As much fun as we had, we hope next time you'll call 9-1-1. First.
And not risk your wife plowing into a vanload of innocents when she's running red lights on the way to the ED.
Or you arresting in the passenger seat 10 minutes away.
Or dropping somewhere between the cars in the farthest reaches of the parking lot, and us playing hide-and-seek in the dark after your wife runs inside and tells us about it.

So maybe it's time to lose 50 pounds and ditch the Marlboros for good, eh?
Because you did nearly everything wrong, and evidently God's not done with you. Yet.
Congrats, man.

Happy New Year.
Enjoy it.
Oh, and you're welcome.

Refugees, Politics, and an instructive fable

In reference to the most recent post at Florence Is Dead, regarding the thought that 2,290 Syrian refugees here since 2011 is not enough, the following:

We currently accept around 1,000,000 immigrants per year to the U.S., and that's just the ones who come here legally. (We can ignore the other 10-20 million here illegally we're currently supporting every day for another discussion another time.)
That's more than the sum total of legal immigration for all other countries combined, on the entire planet, and has been so for decades, year in and year out.

So given that the "refugees" in question are some 5,000-10,000 miles away (depending on where in the US we're talking about), and have to pass over any two of three continents, or over two complete oceans between them, to arrive here in this hemisphere, skipping past any 40-50 other countries en route, the correct number of Syrian refugees we ought to be accommodating here is therefore right around zero.

If you can find any of them who relish individual liberty, representative government by democratic republic, long for the benefits of our Constitution and Bill of Rights, the blessings of (mostly) free market capitalism, and eschew enforcing religious tyranny on all others at the point of a sword, and they have a working knowledge of English and our American history, by all means, send them - to get in line behind everyone else seeking a better life.
Just because 8 billion people want to move here (or to Europe) as part of the Free Sh*t Army doesn't nor should it grant them any claim to American citizenship, nor even to legal immigration status. Which is precisely the reason most of Europe is calling up troops and building fences to keep their hordes out, and why the governments there who ignore that are about to find themselves ousted. Or worse.
(That's the best event, assuming another couple of Paris-style incidents don't push the entire continent to the cattle trains and barbed-wire camps stage, which is hardly a new or surprising thing over there, historically speaking.)

But importing hordes of people to this nation from Third World poverty, without any marketable skills, and saddled with an allegiance to a repressive theocracy which authors the most brutal forms of repression, torture, and slaughter against women, gays, and every other religious faith is right up their with someone wondering what would happen if a person shoved a grenade up their tailpipe with the pin pulled out.

The two clearest examples of what that looks like for real need be gathered from no further back in history than Beirut in the 1980s, and Sarajevo in the 1990s. Anyone in any doubt should vacation there, and report back to the group on the experience.

And the enclaves of precisely the second generation economic refugees in Europe already admitted in better times (from Syria, Lebanon, Algeria, etc. - all former French colonial leftovers), and now without prospects, plus bearing no love for the country that sustains them, were the precise breeding grounds for those who conducted the Paris attacks. The correct term for those who kill their hosts isn't "refugees", it's "parasites". So let's be scientifically and pathologically accurate, shall we?

If someone is feeling the call to help Syrian refugees (who comprise some single-digit fractional percentage of the hordes now descending on Europe - the rest are from anywhere and everywhere other than Syria), then by all means, send as much of your personal resources as you'd like: to help them survive and make their way on their own continent, ideally in some safe enclave in their own country, or at worst nearby and geographically much closer. They belong in a place where they have some reasonable hope of someday returning to their own native homes, and staying alive in the meantime without resorting to trying to float to Europe on a raft made of floating debris, or walking on foot to the countries with the best welfare payments.

Better for them, better for us.

Anything else is tongue-kissing syphilitic lepers, and doing mouth-to-mouth on drug resistant TB patients, because compassion without cogitation.

Nursing is about using our heads along with our hearts to help people.
My namesake's fable about The Scorpion and The Frog comes to mind.

 

Bonus points for bravery/stupidity: putting this question to nurses at Loma Linda UMC in San Bernardino, today.

Keeper

Subject: New (to me) nursing blog

Title: Florence Is Dead

Instructions:
Go.
Read.
Repeat.

Florence kicks @$$.
Made my day. Added to the Bloglist--->.
MOAR please!

(h/t to Shrtstormtrooper, and her bloglist )

Financial Education For The Learning Impaired

Way too many shots of booze downtown on Saturday night:                       $167
Facial adjustment by Rocco and his 3 friends after lipping off:                  FREE
Ambulance ride to the E.D.:                                                                              $500
E.D. CT scan and lac repairs:                                                                         $4000
Admission to the ICU for subdural hematoma:                                         $12,000
Price for signing out of ICU AMA, going home, and waking up dead: LIFELESS

Scientific proof #3,467,882 that brain impulses cannot swim upstream against the current of alcohol.

Oh, and your Darwin Award nomination is in the mail.

I can tell people the truth, but no matter how hard I try, I can't make them smarter...

Take A Bow, Douchecanoe @$$hole Mouthy Visitors

It never ceases to baffle me how people who would never lip off at the DMV, or when getting dinner at a restaurant, or while standing in line at Starbucks, or anywhere else, think that when they show up at the hospital, the rules of civility and decency have suddenly magically disappeared - for them.

Dear fuckweasels: Thought For The Rest Of Your Life
Didja ever lip off at a restaurant, and show that dumb waiter who's the boss?
Didja ever notice afterwards that your food all tasted like spit??!!!
WORD!

Take a lesson: some of us won't be badgered by your rude assholerry, and will not only give you worse than you send, and that right in front of your friends and family, we're big enough to make it stick, including sideways up your ass in the parking lot if you think you can go there.

And nota bene: your friend/relative in the bed is the patient. They have an actual reason for being here. Your presence is a mere courtesy, and a revocable one at that. The minute, no, the second dealing with a knobjob like you interferes in the slightest way with patient care in my room, I don't care if you're the Pope's uncle, your ass is out, for good, permanently. I will make you persona non grata, with no visiting privileges, and I'll happily swear out the restraining order in the morning to make that a permanent situation. Test me, I triple dog dare you.

If you shut down your mouth long enough to engage your eyes and ears, you might also notice that your friend is
1) Getting damned good care
2) Not very happy when you're being an obnoxious litter box nugget
3) Eager to forget he/she knows you when you bring your Inner Jackass, and let him/her out to play in front of God and everybody.

So instead of "advocating for your friend"*, realize that you're just another pain in my ass, because all you're really doing is demonstrating your impotence to do anything more helpful than dropping a hand grenade into the outhouse just to watch the shit fly.

My cure for your problem is sending you to Siberia, forever, and if you want to go double or nothing, you can find out what the bail is on Monday morning for disturbing the peace, trespassing, and/or assault and making terroristic threats. See if the judge thinks it's as funny then as you do now. Especially if you blow a point-anything on the jail breathalyzer.
BTW, I document the antics of lunatics for a living; good luck with "your side" of things after I file my totally accurate notes of the encounter in a legal document, for the permanent record, right after it all happens, while you're still hitching up your trousers and looking for that missing piece of your hindquarters, sobering up in a holding cell, or trying to get someone to go good for your bond.

Or just cowboy up, and realize that if we're taking care of a friend or family member who's having a heart attack, a stroke, or bleeding out, fucking with us while we're doing our jobs probably isn't in their best interests either.

So do yourself and your buddy a great big favor: sit your ignorant ass down, or go get yourself a nice steaming hot cup of STFU, while people smarter than you do the job they're being paid to do, instead of dealing with dumbasses like you interfering with other peoples' care.

Momma may have pinned your diapers up on the family refrigerator and told you they were art since you were two years old, but now that you're only acting like a two year old, the rest of us can see your handiwork for exactly what it is, and reality is about to slap you real hard right in the back of the head. With a sock full of quarters.


*(After 20 years of this BS, it's no longer anecdotal evidence: 99.98% of these Special Snowflake Wannabe Patient Advocate douchenozzles are the visitors, not the patients. If you like watching Wheel Of Fortune for hours, and reading old dental hygiene magazines, keep bucking for Permanent Waiting Room Flourescent Light Therapy, proud soldiers of the Dumbass Army.)

Trauma Is Never Pretty

I've been working trauma cases professionally since the early 1990s. (Before that was simply happenstance.) And while all trauma is the same after the first 500 times, no two are ever exactly alike.

Something you have to know, in a way most of you hopefully will never learn from bitter experience, is that some wounds are non-fixable. Whether you're working with a victim of a car accident or someone attacked by a mob, or simply one dedicated assailant, you have to know going in that you will not fix certain things, and that in many cases, no one can.
Not even if the injury in question happened inside a trauma surgical suite, with the doctors and team prepped and ready to go, even if you had 20 units of O-negative blood hanging ready to transfuse.

HIPPA and concern for a certain family prevent me from getting detailed at this point.
But suffice it to say that sometimes, a gunshot or blade will create more damage than can be fixed, and that person is simply going to die, rapidly.

There's a scene at the beginning of the plane crash in The Grey, when Liam Neeson's character is surveying the injured and dead, and he finds a guy with traumatic abdominal bleeding, and he tells the man, in his final moments, that yes, he is indeed going to die, right there, and rather quickly, which he then proceeds to do on screen.

That was truth: it works just like that in the real world too. When someone pumps out all their lifeblood in ten or twenty pumps, like they will, that's it. Getting an IV won't work, you aren't going to cut them open and crossclamp their aorta, and an IV or five isn't going to save them, because there's no hemoglobin in normal saline.

That means you can start IVs, even IO lines (that's an IV in your bones for the laymen in the audience), and pump in liter after liter of fluid, even with whole blood, and it ain't gonna do anything but come out the hole(s) you can't fix. And run all over the place outside. They'll still get no oxygen in their vital organs, and they'll simply be warm and dead and white as a ghost when you're finished, and that truth is ordained before you ever lay hands on your patient.

That's going to be true in a disaster, or even a trauma unit. In the latter, you do every damned thing you can, especially on a young healthy victim, because they have the best chance. Best being relative when the absolute odds are close to absolutely zero.

In a disaster or worse scenario, you aren't going to - and probably shouldn't - do all that. At that point, you're simply wasting precious supplies to feel better about someone dying that you couldn't save. Which is both wasteful and unwise.

God help you and your conscience if you haven't wrapped your head around that reality long before the day you get there. Even knowing the truth, the moments will hang around in your head for a good long time.

If you're going to do this, yeah, you save the ones you can.
But you have to know in your bones that there will be plenty you can't save, and you have to let them go. Physically, mentally, and emotionally.

And I can't even begin to tell someone how to do that when it's someone you know, or care for deeply.

Dewey Defeats Truman

From the fishwrap of record:

MONROVIA, Liberia — More than a month after Liberia was declared free of Ebola, at least two new cases have emerged, the first discovered when the body of a 17-year-old boy tested positive for the virus, officials said Tuesday. 

The World Health Organization declared Liberia Ebola-free on May 9, a landmark moment in the country, which has suffered more deaths from the epidemic than any other.

But on Tuesday, Tolbert Nyenswah, Liberia’s deputy minister for health, announced at a news conference here in the capital that a new case had emerged.

It occurred in a small town just outside Monrovia. The family of Abraham Memaigar, 17, who died over the weekend, called a burial team that took swabs of the body and sent them to a laboratory. It confirmed that the boy had been infected by the virus.

On Tuesday, an Ebola response team exhumed the body and had blood drawn for a more precise swab test. That test also came back positive.

Dr. Moses Massaquoi, the case manager for the response team, said the blood test was necessary because investigators could not find the source of the infection and were trying to determine whether it was an “isolated outbreak or new strain of the virus.”

Late Tuesday, a person connected to Abraham tested positive for Ebola, and tests of two other people were inconclusive, Dr. Massaquoi said.

Thirty-three people who had contact with the teenager were isolated in their homes and were being monitored, he said. Three people will be sent to a treatment unit here Wednesday, he said.

“The Ebola fight is not over, but we must not lose hope,” said Dr. Bernice Dahn, Liberia’s newly appointed minister of health. She contended that the quick response to Abraham’s case, including the rapid testing and confirmation that the boy had the virus, demonstrated Liberia’s preparedness to deal with another outbreak.

Liberia has recorded close to 5,000 lives lost to the virus.

The country reactivated an Ebola treatment unit at a time when the facilities, built with the help of the United States military, had stood empty and Liberia was beginning to close them.

Mr. Nyenswah said it was not yet known whether the infection came from Guinea or Sierra Leone, West African neighbors that still have small numbers of new Ebola cases.

Abraham, who sold used clothes at a local market, fell ill at his mother’s house a week before his death, experiencing fever, diarrhea and vomiting.

Abraham’s father, James S. Memaigar, 49, a shoe salesman, said a local clinic had told him just three days before his son’s death that Abraham had malaria. The clinic had sent him home with a handful of tablets, Mr. Memaigar said.

Abraham died Sunday in his father’s home in a community known as Smell No Taste, a few miles from his mother’s home and a short distance from Liberia’s international airport and the Firestone rubber plantation.

Mr. Memaigar had contacted the burial team and dragged his son’s body out of his room on a mattress. Abraham was buried the same day by an Ebola burial team in an overgrown cemetery a short distance from the house.

Dr. Dahn said investigators were trying to determine how the boy had become infected.

Points of note:
1) In a country ravaged by Ebola, and desperate to convince everyone they're free of it, with purportedly only one case to deal with, the crack Liberia medical care system missed the initial diagnosis. Until it had doubled. Perhaps multiple times. Stop me if you've heard this one...
2) The virus, certainly not a new strain, but the same one that's been rampant since December 2013 in West Africa, has done its main thing: it has already spread to at least one other person, and perhaps a dozen symptomatic ones and/or a hundred asymptomatic soon-to-be diagnosed ones. A month later. Stop me if you've heard this one...
3) Liberia has proven competent to confirm two cases, now that they don't have people dying by the hundreds this year. Yet. But as far as stamping out the disease at such a low level, they are about as competent as the Iraqi Army against ISIS.
4) We have no idea how many other cases they've missed/mis-diagnosed since outside attention has waned.
5) With the uninterrupted media blackout of most all Ebola-related news, we never will, either there, nor here. It's frankly almost a miracle that the NYT even chose to publish this piece.

Don't worry, though.
Ebola will never ever get here from there, so there's no need for flight quarantines, and our superior health care system and dedicated medical practitioners would stop it in its tracks if it ever...oh, wait, nevermind.

The Real Thing

One interesting bit of apocrypha, is that the way they teach (or used to teach) bank tellers to distinguish counterfeit bills is by giving them the real bills to handle. After handling actual currency, the failings of counterfeit bills are immediately evident. Why this is germane may become evident as you read on.

For a wee decade or so, I took my prior job at Callous Bastard Hospital for granted. I was staff, I aced the interview, and I was senior in time served to most of the people there except the doctors I worked with. I also knew my job, both generally, and specifically with regard to that facility, and I was damned good at it.

But as my shifts were pre-ordained by scheduling fiat, I could guarantee several weeks in advance when and how much I'd work, and by dint of seniority had carved out a schedule that was about as sacred as it's possible to get. I could pick up extra days, but Uncle's confiscatory withholding made that option a fool's errand.

I also didn't notice, being the frog in the frying pan, how The Powers That Be had consciously and unconsciously (mostly the former) made the place progressively more of a hellhole to work in, by short-staffing, under-equipping, micromanaging, nannying, neutering, hamstringing, and generally undercutting everyone trying to do excellent work, mainly because Managerial Head Up The Ass Syndrome On Crack (times) Who Gives A Fuck About Actual Results As Long As We Meet Our Overlords' Asinine Goals.

The end result was that when I was set adrift with about as much concern as scraping mushrooms off the lawn, I was both depressed, because I felt like I'd failed to do something, and unaccountably relieved at not having to go to work there.

Flash forward to working a registry gig: I can't tell you how many days' work I'll get next week, next month or next year. I've been in quite a number of local E.D.s, all new to me before. I've been universally asked to return/stay/apply for a permanent position at most of them. I know I can work 9 days a week forever if I choose to. As it is, I've been pulling 5- and 6-day weeks with 12 hour shifts, pretty much non-stop since I started this in January. And I've noticed a few things.

1. You can tell a bad hospital in about one shift, after you've worked in a couple of good ones.*
2. I look forward to going to work now pretty much every day.
3. I've been told more times by patients and their families in the last 10 weeks (something like 50x) that "You really love your job, don't you?", than the total number of times I heard that in the prior 10+ years.
4. I'm smiling at work, even when it sucks whale turds, most of the time.
5. Measuring myself against the yardstick at a dozen other hospitals, I'm damned good at what I do, and I always was.
6. I really do like my job. A lot. And it isn't about the paycheck.
7. And oh, by the way, my paychecks have doubled.

So thanks for canning me, Callous Bastard Hospital. I got rid of everything I didn't like, I've maxxed out my income, and I've increased my personal job satisfaction tenfold, simply by not working for you. And now your staff is leaving in droves, and you're begging for people to replace them. Funny old world, i'n'it?

Among the few things you can change frequently in your life are your underwear, your location, and your attitude. If something in life isn't right, it's probably because you've skipped one or more of those three for too long.

And when life give you lemons, freeze them.
Because when you throw them back, they'll hurt more.





* I learned this lesson with film and television productions. But I expected most of them to suck. Realizing the principle applies universally To Everything was a real "Doh!" moment.

Nurse Week

When anyone wishes me a "happy Nurse Week", I feel about the same way as I do whenever someone who finds out about my military time says "Thanks for your service."

Which is, specifically, that I think, "Yeah, whatever."

I know the vast majority of them mean it in both instances out of sincerity and a desire to say thank you for a couple of largely thankless professions. So I respect them for making the effort, and I know their hearts are in the right place.

But
1) I knew the jobs were tough when I took them;
2) I was (fairly) well-compensated for both of them, and I was just doing my job;
3) Random thanks don't cost anything, especially as they largely come from the sort of people who probably say thanks to their actual nurse when it actually matters.

But in my heart of hearts, what I'd rather have a cup full of, rather that the wheelbarrow of thanks from people I didn't likely do anything special for is this:

1) Pay your goddamned hospital bill, and on time, so my employers won't be such penny-pinching cheesedicks when it's time to hire enough staff to do the jobs
2) When you have to wait for any sort of care, write a letter to those MoFos, for not properly staffing everything from the registration desk, to the OR, to the recovery ward, to the outpatient clinic, which is why your dog or cat gets better care faster than you do (and cheaper!) for the same injury and level of care.
3) When you're in the hospital, stop pulling the kind of crap and general assholery that would get you punched in the dick with brass knuckles if you tried it at the supermarket or the mall.
4) Go back and read #3 again, and then go back and read it one more time. Then make your spouse/relative/friend/coworker who was probably a big @$$hole the last time they were in the hospital read it too. Or, punch them in the dick.
5) Tell your congressman/woman to kill Obamacare, before it kills all of you and the entire medical care sector, replacing it forever with care that will make the VA look good by comparison, before it gets even worse than that.

Those things would mean more to me than another mountain of cutesy Nurse Week cupcakes in the break room, and more than all the "thank yous" do from people who I've never directly cared for ever will, regardless of how well-intended both are.

Part of my bittersweet outlook on Nurse Week is the fact that every year since forever, it seems I get $#!^ on the hardest during Nurse Week. And not just figuratively, as I've related in an earlier post.

This year has set a new personal world record, although it's nothing so clinically related, and nothing I can share at this point in time; maybe I can at some point down the road. Maybe.

At any rate, I'm pretty sure getting craped on from great height during Nurse Week is in the contract somewhere, kind of like when the SAS holds selection, and the trucks pull away just before the guys trying out finish their 20 mile march can get to them, and have to march another 10 miles back to base.

That's pretty much every day in nursing, one way or the other. Those of us doing this gig shrug it off, but it takes a toll on our backs, and on our souls, even so.
So does the fact that my personal number ( a la a certain scene in The Guardian) is now 13.
Not my fault, but still my patients.  And every once in a while they come back into memory for a bit, and it gets dusty if you think about it very long.

Some of my colleagues "fix" that with a bottle, or pills, or turning a blowtorch on the part of a person that makes us human. As Will Rogers said about the two theories on arguing with women, none of them work.

So I blog from time to time. And I try to spend a lot of time not thinking about work once I leave it.

I like what I do as a nurse very much.
But sometimes, being honest, if I had a good Plan B that'd pay the bills, I'd probably walk away from the entire profession without a second's hesitation or a backwards glance, and even odds I'd toss a lit Molotov cocktail over my shoulder as a parting gift.

And then I get a good night's sleep, wake up tomorrow, and go back to work again.
Even if it's Nurse Week.

Emergency Vs. Not So Much

For the benefit of about 85% of those of you who visit Emergency Departments annually, this helpful guide:

Having a heart attack: Emergency
Not giving you a pillow during your heartburn: Not So Much

Having a stroke: Emergency
Not getting you a cup of ice: Not So Much

Having acute appendicitis: Emergency
Not letting you eat your flaming Cheetos while we rule out appendicitis: Not So Much

Having febrile seizures: Emergency
Not letting you have 27 warmed blankets with an oral temp of 103F: Not So Much

Admitting you for acute status asthmaticus: Emergency
Not fetching you OTC cough syrup during your asthma attack treatment: Not So Much

Your child having bacterial meningitis: Emergency
Not allowing you to bring in the seven not-sick siblings to the same room: Not So Much

Admitting you for suicidal ideation: Emergency
Not getting you a blanket, a pillow, two turkey sandwiches, three orders of juice, and two varieties of crackers while waiting for a transfer to a psychiatric facility for same: Not So Much

This is not intended as any sort of comprehensive list, but I offer it as a guideline, to assist you in deciding firstly whether or not to come to the Emergency Department at all, and secondy to further assist you in Shutting The Eff Up vs. complaining to my supervisor about my alleged attentions or failings regarding any of the above situations, and perhaps towards explaining why, after your piehole closes regarding such complaints, their response is hysterical laughter, and a hasty exit from your room to go deal with actually important things.

If afterwards you really feel peeved off about things, do what most people do: don't leave me any tip in the tip jar, and don't go back to that restaurant, m'kay?

As a bonus, if you think you might wish to elope from the ED at any point, I heartily suggest you do so while still in your car before even darkening the door mat on the lobby door, rather than after taking up 4 hours of valuable time when I and your doctor(s) could have been treating one of the other patients for actual emergent illnesses and injuries instead of wasting it on your drama queenery. For you, there's Oprah, not the ED. Just drive the eff through and go back home, and I won't mind a bit, pinkie swear.

And it's also why if I ever meet Mr. Press or Mr. Ganey alive and in person this side of the hereafter (or even beyond it), I'm going to tenderly and lovingly beat the ever-loving shit out of them with my bare hands until the desire to continue to do so passes away, and/or they do. Nothing less will suffice, and it will be worth the charges, I promise you. I'll probably only be able to raise several million dollars in legal defense funds, if I only get a dollar apiece just from my medical colleagues. (Seriously, you two, you're that evil and worthless, and you should kill yourselves now as a service to humanity, ideally by setting fire to yourselves inside your corporate offices with all your employees locked inside, and I'm not kidding about any of that one little bit.)

Hear me, God.

Thought For The Day

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

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.

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.

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.

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.

Okay, That Was Annoying

 

Employment has resumed.
With roughly four times the amount of grief, annoyance, and general PITA fucktardery as I experienced filling out a Top Secret/SCI special background investigation back in the day.

Jeebus crispies!

My generic advice:
Keep your resume updated.
Including all your contacts and references.
Keep 7 copies of every bit of vital certification and testing information, including DNA swabs and urine samples of the personnel administering such testing and certification. It WILL be asked for. Demanded, actually.

Working 18 days straight may give me a heart attack, but at after running around like a headless chicken for a month with no income, in the feast-or-famine sweepstakes, I choose feast.
Especially when a 20% average pay raise is involved.

Oh, and a hearty FU Very Much/ESAD to my former employer, Callous Bastard Hospital.
The last three places I've worked this month are already asking me to fill out permanent status employment apps after seeing me work as temp registry for them for a couple of shifts. It's nice to be popular.

But clearly, you have to run away from home (or be booted out the door in my case) to get any respect.

Normal posting will resume in a week or two.
With extra sarcasm flavoring.

Over there someplace --->>>
there should be a new addition to the blogroll:

Hogwarts' School of Grid-Down Medicine.

AKA providing medical help for you and yours, when you're all there is, or is likely going to be, for any number of reasons.

Doc Grouch, Ivymike, and myself had it suggested upon us courtesy of Concerned American over at WRSA.
We promptly all fell all over ourselves thinking what a great idea it was. Doc Grouch and Mike did just about all the work of launching it.
My input was some tinkering, and then I got a vacation, and then my return to reality, as previously noted, has been a bit...bumpy lately.
Thus any credit due to me for it so far is right about nil, so I'm not being immodest to tell you the site looks great, and there's stuff there you should read, learn, and pay attention to, if you think big shiny white hospitals and endless streams of Government Bux to pay for visits there will not last forever, in all places and times, for the rest of your life.
In other words, if you have any grasp on medical and sociological realities, let alone an awareness of the frequency of life's normal allotment of natural disasters.

Doc and Ivymike have done great things there thus far.

As my situation stabilizes, and I get back to regular posting, I'll have more of a share carrying my end of the log, along with Doc Grouch, IvyMike, and anyone else we can cobble together to keep it a going concern, and improve it.

Start at the beginning, read the posts, do the homework.

Our goal is not online medical school. (There are probably laws against that anyways.)
It is that everyone with the time and inclination be provided with the guidance, resources, and gentling prodding (of a solid boot in the ass, metaphorically) to be as prepared as they may choose to be to deal with medical emergencies anywhere, with what's in your pockets, or even better, with the prudently-stocked contents of your home version of Somewhere General Hospital. And anyplace on that spectrum between those two. Guided by what we have invested and reaped from a combined goodly number of decades each and all trudging through the corridors practicing our medical arts.

Go.
Pay attention.
Learn stuff.
Practice it.
Save Lives.

Potentially even those that mean the most to you personally, at a time when you may be their best, or only, chance.


(And though Life's been kicking my butt a tad lately, I'm kicking back, and I'll shortly be back with more Shepherd stories - from a host of new assignments, and a number that have been kicking around for awhile, as well as seeing what Ebola is doing these days besides killing people as efficiently as ever. So whatever you've been coming here for will return in short order, once things settle down a bit for me. thanks for your patience.)

And the other shoe drops...

My vacay was lovely. As will become apparent, I should have stayed there.
(If you have the chance for two weeks on Maui, I highly recommend it. Anytime.)

Upon my return, I found out the reason they were so cheerful about letting me have time off for the holidays, was that in their ceaseless efforts to not go broke implementing ObamaCare, my facility will be "re-organizing", and wished me their best in securing another position. Just. Like. That.
The fact that I'm experienced, at the top pay tier, and recently passed the half-century milestone were all purely coincidental, they assured me. And I have a bridge for sale too, right next to some beachfront property in Kansas.

Step Two was dusting off the resume, and getting a gig with any number of nursing registry agencies hereabouts that are swamped with the need for ED nurses locally, because for some reason, there are a ton of facilities with openings for non-permanent personnel on all shifts. Everywhere.
Doubtless this is just another purely random coincidence, I'm sure.

The sweetener is that they pay on average 10-20% more than my former employer, for doing the same job, and (after a few months not there), even including my former hospital home. So they laid me off to get me a raise, and set my own days and hours forever, including no more holidays at my discretion, and all it cost them was any shred of loyalty or concern for their best interests I might have had after the last ten-plus years in their trenches.

Such a deal.
The other bummer was instantly being ripped from amongst the greatest bunch of people, doctors, nurses, and staff, I've ever worked with. $#!^ happens.

The fly in the ointment was that I needed to do all the pre-employment hoops I haven't jumped through since Clinton was president, and dig up paperwork from the late Pleistocene, as well as document my decades of competencies in everything, from scratch. (Satisfying my inner hyper-anal control freak, I have so far aced everything they've thrown at me. And thank the Flying Spaghetti Monster I can do this stuff online, at home, in my pajamas, whenever I feel the urge. Yay, 21st century technology.)

During which, it turns out that between eating like a teenager, no small amount of it grazing on craft service, and the very same two decades of dealing with nightshift ED work and the lovely people deposited on my gurneys, my blood pressure seems to have decided to translate into flight data from a space launch liftoff, after being textbook normal up to at least six months ago.

Oh goody. After a quarter-century in healthcare, I always wondered what it'd be like to be the patient. (Not.)

I have consequently been just a wee bit pre-occupied with securing gainful employment, and not having my head explode, while finding a regular physician for the first time since I was a teenager, managing new meds, and embarking on a new quest to burn off at least a decade of crap daily diet and not enough cross training. With my former health insurance a distant memory.

So the 20 extra pounds around my gut are my fault, and the ED is the ED, but a hearty "Fuck You" to president for-life? HopeyDopey, and his ceaseless efforts to destroy the 17% of the American economy that has been my career, by mucking up the revenue stream for all hospitals. The only silver linings are that having discovered my new health situation, I won't be stroking out from his upcoming State Of The Union, 'cuz I've got meds to fix that now, and because of totally screwing the pooch for the medical industry, there are suddenly no shortage of doctors happy to see me for cash-for-service, indefinitely.

Regular blogging will resume when the recent roller coaster comes in for a landing.

The fivefold teaching moments are thus:

The government is not here to help you. Ever.
Neither is your employer. Loyalty is for dogs. Their end of the contract comes when the paycheck clears. Anything else is icing on the cake, but don't count on it.
Keep your resume current and updated.
More veggies, less pizza.
More PT, sergeant, more PT. Because I miss the Daily Seven like BUDS candidates miss getting wet and sandy in January.

And if you thought I was a non-cheery cranky caustic SOB before all this needless personal drama,

GET OFF MY LAWN.

 

 

Back regularly as soon as I can. The medical chances of me shutting up on the internet are about 8 billion to 1, against.