Alaska Tails

Sherry is safely back from her annual back-country paddling trip in Alaska. You may recall that last year, she had a real problem being stalked by grizzlies. Her husband subsequently failed to keep his word by purchasing, and learning to use, the necessary weapon that would ensure their safety.

Fortunately it was a remarkably griz-free adventure this year; except for the last day.

Sherry and her husband are dropped off by a bush plane, paddle to a certain point and then rendezvous with the pilot at a pre-determined time and place. This year, because her husband was doing some type of observation for the Park Service they were given a satellite phone (and a Jr. Ranger badge). This would serve to be a fortunate happenstance.

At the end of their trip, Sherry and her husband Dick were awaiting pickup on the appointed day by a small float plane; a little pond was to be the landing area. Sherry told her story:

"The wind was blowing a gale, and there was quite a bit of chop on this pond; it was relentless. These float planes have to land precisely, otherwise they would tip over and crash. The pilot made three or four passes, and I knew he wasn't going to be able to land. Sure enough, he called us on the sat phone and said there was no way. He has to come from two hours away, so he said he would come back the following day, and for us to call him at 6:30 AM to let him know about the wind conditions".

"I didn't sleep all night. The wind kept howling, and I was concerned that we would be stuck another day. It was so bad we had the tent tied to the gear bags so it wouldn't blow away. Finally, just about 6:00 AM the wind died down. Dick called the pilot who said he would arrive about 9:00. I was relieved and settled back in to get a couple of hours nap at least".

"At about 8:30 I got up, and Dick and I packed up the tent. We were pretty much out of food, but had a couple of granola bars so we pulled them out to eat while we sat on the gear bags and deflated canoe to wait for our ride. That's when we saw it: a giant grizzly. It was down at the end of the pond eating a caribou. Dick and I kept our eyes on the bear, but he seemed pretty engrossed in his breakfast and didn't seem to notice us".

"About this time, the wind picked up again with a vengeance. Now I was nervous, as if I wasn't when I spotted the bear. Maybe 10 minutes later we spotted the plane. I was thinking we were in some pretty serious trouble if he couldn't land, because the wind was gusting."

"The pilot had to come in low, right over the bear in order to land, so I know he realized we had a serious situation. The bear was pretty pissed off about it, too, roaring and waving a paw at the plane. The pilot tried to land, twice, a third time, then a fourth; each time the bear was roaring. I really didn't think we were going to get out of there; I had no idea how much fuel was available to burn on failed landing attempts, so I was feeling pretty desperate by this time. All I could imagine was spending another night with this really angry bear in our back yard".

"Finally, there was a lull in the wind; I had a feeling that this was going to be the last attempt. The plane came in so low I thought it was going to hit the bear, who was definitely not happy. At this point,the bear did something really odd; it THREW the caribou at the plane! I have never seen this before, nor had the pilot.

"The plane landed safely, loaded us in and we were on our way. The bear retrieved the caribou and continued with his meal, paying no attention to us at all. It was a great trip, but boy, was I glad to get out of there".

We are all happy to have Sherry home safely, but the phrase "when caribou fly" has become our new favorite saying.

We saw 24 patients last night. This, in a 6 bed ER with two nurses and one doc. Plus, the doc was Gil. Lord love the guy, but he is a cautious soul and we had some sick patients. Plus at least 6 dental paineurs, of which two left because the wait was at least 90 minutes. Can you imagine?

The campers from the several overnight camps kept coming. I don't know, perhaps it is the first time in a year many of these kids have been outdoors; they have fractured fingers, been stung by bees/mosquitoes/ spiders and one camp hamster (a campster?). As my son used to say, "ham comes from a hamster".

One day a week we offer a free walk-in blood pressure clinic. Not too many people use it, maybe a dozen or so. But for some of these crusty Yankee old-timers, it is perhaps a day out; and free to boot. One of the cranky old ladies never remembers to bring in her little booklet, so she gets a new one every week. We give these out gratis; I envision her house with about 3,000 little booklets, each with one or two blood pressures written in it. I seriously doubt that her PCP ever sees these readings. Or anybody. She is a little ritualistic, needing to sit for at least 5 minutes to "settle", then another 5 minutes to rummage around for the booklet she does not have. Several minutes are expended in divesting "only the left arm!!" from about 4 sweaters. Finally, she will squint up at me suspiciously and ask me who I am, and if I am new. We go through this every week. After taking her blood pressure and writing it in the new booklet I have provided, and she clucks and mumbles and frets her way back into her clothing, she is out the door, pushing a walker sporting 4 tennis balls in the legs.

Having your triage area tied up for 20 minutes on a free service: priceless.

One woman came in who just wants me to check her O2 saturation. Why? "I just had an asthma attack and if the reading is normal I don't want to be seen".

OOOOOOOOOOkay. We offer a 15% discount on ER co-pays that are paid right away; we take major credit cards even. But, you can't collect on this type of time-wasting activity which included informing the patient to return if she stopped breathing. Or whatever.

New Cathy emerged from an extended visit with one patient. "Well, she wanted to know if I had found Jesus, and I couldn't get out of the room; any suggestions for next time?".

"As the token atheist at a Catholic hospital, I am perhaps the last one to ask; I could give you some talking points from my perspective, but I doubt it would go over well", I said drily.

Gil says, "That happened to me once; the patient was jumpig up and down, waving his arms and yelling, "Praise Jesus! Praise Jesus!", so I just started jumping up and down yelling "Praise Jesus!" too. Then security took over".

"My son suggested that this might be an effective way to deal with telemarketers; I can just imagine. 'Hello, I am calling from XX Loan Corporation, are you interested in refinancing your home?'. 'Why no, but have you found Jesus?'. Could work pretty well", I said.

The hits just kept on coming. One little guy, I don't know how he managed this, fell off his bike and cut the soft palate in his mouth pretty badly. The rubber grip on the handle bar was mostly worn away, exposing much of the hollow metal edge, which wound up piercing the roof of his mouth. He was so scared, but did OK. It could have been so much worse.

The Last Patient of the night (whom we finally saw about midnight) was actually having an anxiety episode. She insisted that it was "overactive kidneys". I was too tired to pursue that she perhaps meant "overactive adrenal gland" that is located ON the kidney. The adrenal gland produces cortisol, a hormone that is important for several body functions, such as blood pressure regulation and release of insulin; it is also released in increased amounts in response to stress. Also, it is responsible for anxiety reactions, which is pretty much a "flight or flight response" gone haywire. That is tonight's science lesson, class.

Ativan helped, and she left with happy adrenal glands.

Summer Stuff

It has been a hot month. Even here in the arctic tundra it has been over 100 degrees some days. It is so hot the face of the Old Man of the Mountain would have slid off by now, if it had not already done so.

I hate the heat, there is nothing about it I like unless I am floating in water with a frosty drink in my hand. Can't eat, can't sleep, have no energy to do anything. Plus I stick to my leather sofa.

Mary, my kayaking buddy won't even go paddling if the temperature is any higher than about 93 since she doesn't do well in the heat either. Now she is being treated for Lyme disease since she discovered that pesky bulls-eye rash after a couple of days of fever.

If you have pets, and they tend to be outdoors a lot, ticks are a part of life. If I have fallen behind with the tick treatment for Tina, I can pick 7 or 8 of them off at a sitting. Tina loves it when I check her for ticks...she gets the most marvelous massages.

So I really don't get why people come to the ER to get a tick removed...and we get a lot of them, sometimes 3 or 4 per night. And these are ticks that I could basically pull out on my own in triage...but I won't, now, will I? Everyone pretty much gets treated for Lyme anyway, just to make the visit worthwhile.

One young man was brought in by an aunt; I suspect he had some sort of developmental delay. He was spending the summer working in the area.

Auntie had just returned with her nephew from her PCP; he had diagnosed his rash as heat rash. While not a classic bulls eye rash, the aunt was unsatisfied, and insisted we test him for Lyme.

Sure, no problem; and based on some of his other symptoms, Lyme was not completely out in left field. We treated him for Lyme anyway, something the PCP had not done. Several days later, the test came back positive. The kid was already being treated and everyone was happy.

We also get a lot of 'spider bites', 'allergic reaction to bee stings', and bug bites in general.

One mother brought in a 2 year old with "hives"; turns out there were about 30 mosquito bites, the poor kid looked miserable. Discharge instructions included "keep child away from mosquitoes". Ri-i-i-ght.

A 17 year old was brought by EMS with allergic reaction to a hornet sting; hives, swelling, itchy mouth, and epinephrine administered prior to her arrival. THIS, people, is the kind of thing that you SHOULD call 911 for. We watched her for a couple of hours while we waited for a parent to arrive. Nice kid, beautiful girl. A pleasure to care for.

Once the hornet sting was squared away, we get a very "interesting" 18 year old girl who "passed out" (at least twice) while lying down in the car on the way back from the beach. Huh huh. Her boyfriend came racing into the ambulance bay door; I was on the phone with Kerry at the time who had forgotten to tell me something when she left. I hung up on her and never did get back to her. Anyway, boyfriend looked to be about 35; scruffy; tattooed, body pierced and about the same age as her father, who was equally scruffy in appearance.

The young lady walked into the ER, albeit leaning heavily on the boyfriend. She lay down on the stretcher and immediately closed her eyes and pretended to be unconscious; I really hate that. Please don't waste my time and make me dig my knuckle into your sternum. We kicked out the rest of the young lady's fan club, started an IV and drew the appropriate labs (as well as a pregnancy test), all of which were entirely normal, of course. She complained and moaned about the IV so much I pulled it out and handed her a glass of water and told her to drink; I had long since lost interest in this "interesting" patient.

It must have been the heat that caused the co-worker of an 18 year old to pick him up and hurl him into a wall; a metal edged dry-wall wall. He had a 4 inch gash on his scalp which was easily fixed with about 11 staples. Gil of course asked him if he wanted the police notified. He did not, in part because it was a misunderstanding. Also, he had gotten up after being tossed around like a bean bag and clocked his assailant, splitting his lip. Gil jinxed us by joking that we would probably get the split lip as a patient, which we did. He didn't offer much information about the incident.

Hot weather brings out the nut bags; 95 degree heat is sure to inspire individuals to go to the ER with maladies they have suffered from for, oh, say 2 years. Like swelling in the head that was diagnosed as an infected hair follicle. The long list of psychiatric meds should have been a tip-off.

Cathy was taking care of a patient with chest pain, left over from day shift. We were waiting for an in patient bed assignment; yeah, that's not such a quick process. The day shift reported that the lady was on 2 1/2 pages of meds (never a good sign), had fibromyalgia (yawn) and a "mystery illness" that nobody could figure out (read: crayzee woman with vague nonsensical symptoms). This was confirmed when Cathy took her temperature, and it was a shade under 98.6. "That is usually a sign that something is seriously wrong!", the woman exclaimed. Clearly, with a laundry list of medical issues and drugs, and the dreaded mystery illness, it should have come as no surprise that she would obsess over a non-issue such as that.

Cathy had some insight. "You know, I read an article that it is no longer politically correct to call anyone a hypochondriac; they are individuals with 'heightened symptom awareness'. I blame the Internet".

" I think that it is a lot of non-medical people thinking up stupid names for garden-variety crayzee", I observed.

Yeah, it's gonna be hot again tomorrow.

CRNA and Cellulitis

In my youth, about the time that dinosaurs roamed the earth, I had a tendency to be intimidated if I had health care types for patients. Docs and nurses are not the best patients. For myself or my family, I don't (unless I am wearing scrubs) come right out and say I am a nurse with about 1000 years experience simply because it can be intimidating.

Case in point; my husband was admitted last year for a cellulitis in his hand. Since he was being discharged with the need to have IV antibiotics at home he required an IV change (yeah, that one: the one I had put in 2 days earlier). I gave the young nurse 2 tries, then I (nicely) bullied her into fetching me a warming pack and put the damn thing in myself. I really tried to stay out of her way but my husband is a hard stick; I was just looking out for him, not judging the nurse.

So a guy came in over the weekend with a pretty nasty infection; he would require IV antibiotics for a couple of doses, but could come to the ER for his medicine; hey, we're a full service ER.

As I looked over his arms for a suitable spot to place his IV, his wife helpfully shrieked, "You can't put it in that arm, that's the one with the infection!".

Um, ok. Gee ma'am, don't know what I would have done without that useless bit of information. I quickly intuited that she was some sort of health care person and she wanted me to know it.

In my experience, the degree of effort expended by an individual to inform me in some roundabout way that they are in health care:

a. is inversely proportional to their level of experience or years of practice

b. has no relation to the level of acuity said individual practices

c. is a clue that they are either a student or an LNA

or

d. just want me to know that while they may not be a kick-ass ER nurse like me, they are indeed a kick-ass school nurse, office nurse, camp nurse, etc.

Second case in point: the aforementioned unhelpful wife, once I had decided on my target vein and was moving in for the kill, asked, "will you put in a butterfly since he has to come back tomorrow? They are so much smaller".

This tells me that unhelpful wife is an idiot since a butterfly, while small and perhaps really useful for short term use (ie, minutes) under direct supervision is inappropriate for longer term use. People who exhibit health seeking behaviors such as migraneurs who capriciously use the ER for their chronic pain condition will often ask for a butterfly. I usually don't make an issue out of it, but explain that those are METAL needles which are not good for extended use. Then I promise to use a baby needle, usually inserting something like a 20 gauge. This is a good size stick and certainly not a baby sized needle unless the baby is a full grown adult. Which they are.

I decide to ignore unhelpful wife and address my comments to the patient who was being very quiet. I explained that the site I had chosen in the middle of his arm would not be as compromising to his lifestyle as one in the hand or the crook of his elbow.

"Oh, he knows all about it, he's a CRNA"

Ah. A nurse anesthetist. Cool. Scary damn specialty, though. Too much chemistry and opportunities for it all to go horribly, tragically wrong.

Mr. CRNA looked up at me and mused, "How am I going to work tomorrow?"

"Well, I'm pretty sure you have sick time; use it".

"Oh, he never takes any sick time", said unhelpful wife.

"Well, think about it, do you really want to go into the OR with this raging cellulitis? Hmmm? Is that a good idea?" I asked, hanging his bag of IV antibiotic.

"Guess not".

Unhelpful wife accurately intuited that I had lost interest in her and chose to regale me with tales of her horrible experiences in ER's. This not only bores me, but in most cases, this sort of discussion is about as tactful as telling me about the time you farted in church. It tells me a lot more about the kind of person you are than "scaring" me into believing you are an astute health care consumer or that you have any native intelligence at all.

To his credit, the CRNA patient was cool. Maybe he knew he was kind of screwed with that albatross of a wife.

"So, what what do you do for work?", I asked unhelpful wife, "are you a CRNA as well?". I knew she wanted me to ask. Really.

"Well, I work in dermatology".

"Wow, really, you're a dermatologist; that's great" I gushed, knowing damn well she was not. It is less than full disclosure, sort of like me saying I'm in MEDICINE; I work in the medical FIELD, but to say I work in medicine might lead one to believe that I was a physician. You can see my point, I'm sure.

Unhelpful wife squirmed noticibly and replied, "Oh no, I work in a dermatology OFFICE".

I moved in for the kill; "Oh, so what do you do there?"

"I'm a med tech, but I run the appointment desk".

Uh huh. Thought so.

July 4th Patient Parade Notes

With the 4th of July being my weekend to work, I was naturally despondent that most of my family were partying up at the lake.

Without me. That included Mr. Ednurseasauras and Tina, my daughter K and her boyfriend, Rockstar, my mom, two of my brothers and their two kids apiece, a random niece of my youngest brother who is a firefighter and my hero (an who, like me is a lowly public servant destined to work weekends for the rest of our lives) and about 1/2 ton of legal fireworks. A good time was had by all, except perhaps for Tina who hid under the house for most of the fireworks display, and K's new kitten, whom Tina apparently wanted to eat. I can't blame the dog, the cat is about the size of a chipmunk, and probably good eatin'. It is, after all, the Other white meat.

My weekend partner and second nurse is New Cathy, who replaced Dan. She was an even trade from the Mother Ship for Dan, whom I liked but others didn't warm to; he liked to play with his iPhone, but was a good nurse and I had fun working with him. He worked at the Mother Ship for about 3 months, bitching the entire time because it is disorganized and lacks leadership, then moved on to greener pastures. I have said there are no Utopias in emergency nursing, but anyway, good luck to Dan. New Cathy is great to work with and enjoys patient care. The Mother Ship cannot have her back.

July 4th is a funny holiday. Sometimes it's busy, sometimes not. I'm 3/4 of the way done with a four-day stretch, Friday through Monday. The first two days were pretty quiet, seeing only 18 or 19 patients for the entire day; that doesn't exactly pay the rent when you consider that we need to see a lot more than that. Probably double that considering many of our patients use our ER as a free-care clinic, and some days as a public toilet. The usual complainers, worriers, and nothing-better-to-do's who frequent our delightful establishment on mundane weekends apparently had other plans, were on vacation, or visiting other ER's.

There are several overnight summer camps who like to use our facility as much as we like to have them; for them, it is 17 miles closer than the Mother Ship, and for us, lots of lovely, polite young campers and counselors. Also they have insurance, not that that is really an issue but it is a refreshing change.

One day last week I kept track of how many of our patients had no insurance, private insurance, or Medicare and/or Medicaid which reimburses at a ridiculous $.30 on the dollar:

Out of 30 patients for the day, 7 had private insurance 4 had Medicare, 1 had Healthy Kids and 6 had Medicaid. That translates to 23% of patients whose treatment would be reimbursed at an inflated rate in order to make up for the 40% who have free care (ie., no insurance and no intention of paying) and the 36% whose treatment would be reimbursed at pennies on the dollar. Also, 4 other kids were eligible for Healthy Kids, but the parents "hadn't gotten around to it" yet. Which is really asinine, considering it is free and the social workers will pretty much do the paperwork for you if you have less than a 5th grade reading level.

Yesterday business picked up; it was a day for bringing families together in the ER for mundane reasons. Just a few observations here; all of the mothers were smokers as evidenced by the reek of tobacco, had artificial nails, didn't work, and requested such items as free sample of drugs, money for the vending machines, coloring books, crayons, stickers, took several pairs of gloves to make balloons, and had the nerve to ask for syringes to make squirtguns. The unruly kids trashed the waiting room, triage room, exam rooms while the oblivious parents chatted on their cell phones. White trash tornado.

On rare occasions we have patients who are interesting. One really nice young guy came in with a red banadana around his knee; he had sliced himself a tasty gash with a freshly sharpened chain saw; a running chain saw. I have seen some pretty chewed up flesh in my time from these dangerous things, but somehow he managed a clean laceration; it must have come in contact with his flesh for a milisecond, luckily for him.

New Cathy and I were working with Dr. Cripes (cause he says it all the time) who is fast but thorough, decisive and funny as hell. He usually has a running dialog going, but you have to really listen to hear the funny bits because they come out so quickly. Witty guy. Fun to work with, plus he lets us play with his iPad when he isn't using it; I LOVE that thing.

"Whatcha got?" he asked as I wandered into the treatment area from triage.

"Chain saw massacree", I replied. "It's gnarly but neat".

"Carving ribs, was he?". Cripes is so droll, isn't he?

"Nah, carving up the neighbor who borrowed his rake last fall. He didn't return it", I grinned.

Cripes chuckled. "You let him sit in the waiting room?".

"Nope", I assured him, "he refused a wheelchair. He missed the femoral artery, though if he had hit it, I would have insisted. Just to be thorough. Besides, Helen likes to keep her registration desk free from pesky bodily fluids". Today Helen was harboring blueberry cupcakes somewhere, with little American flags. They looked yummy, too.

After Cripes injected lidocaine into the young mans knee and went off to examine ather patient (to give the lidocaine time to work) the young man was trying to take a photo of his laceration with his cell. The first two were in shadows.

"Here, let me adjust the light", I offered. "It really needs some perspective, I think", as I got a ruler out and placed it next to his knee.

"Yeah, that's great; much better shot. You're really into this, aren't you, sick like me!" he mused.

Busted. "Oh sure, that's why I love my job so much. We'll take another picture after it's fixed, OK?", I said.

15 staples later, another photo-op and a nice dressing and he was on his way. I just love things that we can fix.

One man came in and was immediately whisked into a treatment room; he had been experiencing weakness, lightheadedness, palpitations and chest tightness as he lay on the living room floor. For two hours. His EKG and all other tests were normal.

"He's wound tighter than a drum; if you poke him he would probably vibrate like a tuning fork. Can I give him some Ativan? And maybe some for his wife, every time I walk into the room she scurries into the corner", I asked Cripes as the man lay rigidly on the stretcher.

"Sure; I'm going to give him a 'script for some anyway. Man, he is anxious", said Cripes.

This patient, being a typical Type A personality was:
a. dentist
b. college professor
c. bike mechanic
d. engineer
e. landscaper

If you guessed anything other than choice D, you are wrong.

Mary, Diana, and Helen were very unbusy toward 8:30 PM. I thought it would be nice to put the July 4th Boston Esplanade concert on the TV, but they were engrossed in Extreme Makeover. Move that Bus indeed. "I just want to see how it ends" begged Diana, who is our lab tech. She is fast, fast, fast. We are spoiled when she works because our lab results are done at lightening speed.

"Music haters!" I accused. I really didn't care, I had other stuff to do. I do like Toby Keith, though.

The Milltown fireworks, we anticipated, would be visible just over the tops of the trees across the park adjacent to our ER. About 9:20 PM Mary and Diana had commandeered wheelchairs, popped corn and were settling in for the show. New Cathy and I finished up with another camper with a broken finger and, since we had no more patients, thought we might get to see the show.

Nope. The floodgates opened; the parking lot started filling up before the first shell was fired. Non-urinating 8 year old; fractured wrist; firework cinder in the eye (no corneal abrasion, but she got Vicodin for it) and the idiot who let a pack of firecrackers explode in his hands.

Fireworks + alcohol= stupid.

He had mostly 1st and 2nd degree burns; I gave him a big tub of water and some face cloths so he could bath his burns to his face and hands. Also to wash off the aloe that he stupidly put on.

Within moments his "bathing" had saturated my entire treatment room. Really, he was splish-splashing like it was a giant bird bath. Soon he had abandoned the tub of water (and the saturated side of the room) and proceeded to saturate the other side of the room by running the sink at top (and continuous) speed.

"Dude, please. You are saturating equipment and other things that should remain dry, and now we can't use it. Please (just grow the fuck up)be more considerate; I will give you something for pain as soon as Dr. Cripes has had a chance to look at you".

After two injections of Dilaudid, a handful of Vicodin to take home, and 50 gallons of water covering every surface of my treatment room AND two bathrooms, he left. Hopefully to think about what he had done and how not to repeat it.

Finally, at 10:50 another bonehead comes in for a non-healing wound he has had for 2 weeks. It wouldn't have been so bad but the idiot had called at 7:30, presumably to make an appointment or try for "call-ahead" seating, like Chile's. Yikes.

The poor lady with the wrist fracture was splinted, given pain meds and sent on her way to follow up with ortho.

New Cathy and I scurried around for 10 minutes putting things back together, leaving witty notes for the day shift (which is notorious for leaving tattle-tale type notes and reminders for evenings- I thought I would return the favor).

Hope all of my friends had a great 4th, especially Anne and Debbie who watched the Boston fireworks from Debbie's new apartment overlooking the Charles River. Hate you, mean it! Oh, and Happy Belated Birthday to you, Ps2ue!

Happy 4th of July to us. Wonder if Cumby's has any Coffee Heathbar ice cream? Nah, I'll just have a beer.