sk732

Yet people get upset about safe supply sites... Irony is that if you kill your clients, it's hard to make money - not a lot of forward business thinking there, unless it's being done to kill people for things like terror aspects and such - my conspiracy theory for the day

Of course they won't let that happen...down play it, even if it's a mass shooting...

I've had discussions with medical directors about getting dart guns for ED use for standoff Ketamine or olanzapine/haldol use so all concerned are less likely to get injured in a fight to subdue/restrain them...apparently the optics of shooting someone in the ED/Nursing Station are poor, but the admins are of course just fine with people and facilities getting the living Bejeezus beat out of them. I'm not sure if the meth is getting stronger or if there is some other adulterant in it or what...I'm hoping to not have to go the ketamine route, since we've only got a BS 10mg/10ml concentration of the stuff ...and the Rez "police" aren't sworn peace officers and the nearest Mounties are 20 minutes away IF the ice road is open on the lake...longer if they have to boat it or chopper over in spring/summer.

So got called in 0 Dark OMFG for an overdose and a second person with a laceration that fell outside scope of practice of the RN. OD was relatively straight forward...I thought the lac would be - smoked some meth, fell down, hit face. Stair laceration to lip though vermillion border, had some contralateral jaw pain - so, I arranged to send them out. Going through the chart, find they're diabetic and have evolving nephropathy. Pt noted that they've been fainting a lot lately, not just when smoking their meth...to close the loop, ordered some labs prior to transfer...Na 112, K 2.3, Cl <65, BG 26.7 mmol (Canada here), so corrected Na~118. Cr went from baseline 178 to 775 and BUN 7.5=>22. pH was 7.60'ish. Dude's awake, talking, vitally (N) save mild tachycardia at 106...called the receiving ER back and we had a good little chuckle, and called the IM o/c to let them in on the joke as well, to get some advice on how to deal with this ...as did my doc that I handed over to at 0800. My call Kharma lately is getting to the point that the RN's are threatening to get a collection together to pay me my call stipend to not take call and let out a universal groan at report yesterday morning when they hear I was on . We were doing slow correction/hydration when I went back to bed for a few hours, and likely has been shipped out by now (well hoping anyway).

I'm not sure what our low cut off is for the iStat...I'll tell you her EKG would have made a med student's case study wet dream...

Yo're not the only one...

Kinda wondering how low it was before we gave her the oral replacement...

My trial week up north had a lady come in with K unrecordably low on iStat - asked the RN to repeat it like I usually do, comes back the same. Hx T2DM, chronic diarrhea, some CHF...came in with Tachy-Brady stuff. Gave her 60 or 80mEq po stuff (have no liquid K on the Formularies . Flew them out, inital K was 1.2 at the ED.

Had a weird case the other day - came in presenting with syncope, complaining they couldn't breath...recent UTI, initial labs largely normal, HR in 130 range, sats 94%, BP 76/50 something...felt a bit better with O2, BP bumped a bit with fluid, but went down quickly. Nil really of note on exam other than diaphoretic/tachycardic, EKG was STach. Started aggressive fluids and Abx, because it was early morning, handed over to the day person awaiting airevac. Evacuated them either expecting a PE or Urosepsis...turned out to be an 8x10cm liver abscess, despite no abdominal tenderness on exam. Had someone yesterday that was likely having a crack cocaine crash (I didn't know anyone still did that anymore, what with the advent of meth around here) and had been hallucinating for 5 days or so, but also had a wicked HHS happening...bright side, with their sugar unrecordable high on the iStat, and a Hx of heart failure coupled with complete medication non-adherence, they were at least auto-diuresing...

This is becoming a huge issue in the communities I work in - nobody wants to spend their last 4 weeks until confinement away from home and family, so they show up in active labour with no prenatal care - "My body/My choice" is being bantered around a lot...which get's tossed back at them when we can't/won't give them the epidural they want, etc, that we're not equipped for. Thing that always freaks me out is that my first solo delivery in school was a shoulder dystocia and my last one was 5 weeks undercooked and showed up out of nowhere...and came flying out like a KY'd football...I'm on the phone if someone is remotely in labour when they show up - they get a PV right away and if they're less than 5cm we're on the horn for a plane. I'm sure my luck is going to run out soon that way, but here's hoping

I have what I call the "90/5/5 Rule" of Health Care Administrators...90% are there because they couldn't make it in some other profession, healthcare or otherwise. It's something I uncovered in the military - a lot of folks that failed out of combat arms officer training, crappy medics that took their commissions, that sort of thing. Oddly, a lot of the combat arms washouts were washouts for leadership reasons, as opposed to tactically useless...which is even worse as far as I'm concerned because if you can't lead as an officer - your actual job - then that should be a "3rd and Long" (or 4th for those south of the 49th) scenario. The next 5% were genuinely good at what they did, were good leaders and managers and were great bosses. The last 5% were senior Chief Warrant Officers that took their commissions to extend their pensions and were employed in specialist planning roles - again, most of those were very good at what they did. I find there isn't much difference in the civilian world...observational study over all of my adult life doing this stuff - 31 years Green and about 12 out in the real world. Had to laugh when I applied for the "head PA" position for the overarching Health Authority in my Province, I was told I didn't have enough management and leadership experience - I guess 18 years as a Junior and Senior NCO/WO (our PA's weren't commissioned until in the last 5 years or so) doesn't count .

Yeah, the ones that help Satan in Hell...

Of course, they won't do anything to mitigate that from happening in the first place though - likely the opposite would be my guess then drop the person like a live grenade. Yes, I hold health care admins in a high degree of disdain that they have to earn their way out of.

So have come off a wacked out 2 week rotation in 2 different little places - one that will be my new home away from home starting in January...first afternoon in community and 2 women in premature labour, no pre-natal care...one delivered at home, and another was labouring in our "ED" when the kidlet that was already out came in. 26ish weeks, though looked less cooked than that, we resuscitated to no avail - managed to intubate with a 2.5mm ETT; second kidlet was a little farther along, but neither made it...the lady with the second delivery had a PPH and the one that delivered at home was retaining the placenta - while someone was fishing around, they thought they felt a head - U/S confirmed a twin . A neonatal air transport team arrived not long after and thankfully had no choice but to stay due to a weather system. OB/Gyn on call in Winnipeg asked us to give Mag Sulf and some ABx, but she started labouring again anyway and delivered around 0Dark OMFG in the morning. Luckily there was me and 2 docs and an experienced NP in house...most surprised person there was me as the first 2 intubations I've done on a non dummy in over 7 years were 2 premies. Ironically just finished NRP about 6 weeks ago. The bright side, with the NNATT there, the second twin did and is still in NICU to best of my knowledge...however took forever to get the two moms out - the dispatch idiots cancelled the twin mother's plane as she'd delivered, but hadn't delivered the first placenta (the main reason we were sending her out) and the PPH mom was there for some time as well. That whole week was a story of stacked up medevacs due to "safety" - wasn't weather that's for sure, since for most of the week it was pretty clear - I'm thinking that the sole HEMS provider just didn't feel like flying after a certain point - they make enough money there that it can't be because they can't afford NVG's for the pilots - I personally believe it's a typical Canadian sole source contract issue where they're getting paid if they fly or don't, so they don't.