A heartwarming tale of hospital fun!
This was recorded ages ago by some brave souls from Starfleet Dental, who listened as I got drunk at 0300 and told them the beautiful story of a man whose body overcame a terrible disease by sheer willpower alone. Or, wait, no, I think he actually died horribly while rotting. Either way, I'm sure this will lift your spirits.
Do not listen to it while eating.
Thursday, July 9, 2015
Diabetes 101, or Put Down the Fucking Candy
Edit: This page seems to be getting a lot of traffic, which is unexpected, and I wish now that I'd done a better job of explaining some things about diabetes, both Type I and Type II. I certainly never expected this to be passed around as a PSA!
For those of you just visiting, this blog is a meandering mess of rants and stories about my experiences as a nurse, and the health education aspects are intended to help readers understand a little more about what I handle at work and what it means when I say my pt is "in DKA" or "doesn't take their insulin." I initially made this blog for a pretty small audience of people who were already familiar with my forum posts, and nothing here has been edited or really even thought through. I'd say half of it was written after at least one round of gin & soda.
So what you'll find here may be useful if you're trying to grasp the very basics of hyperglycemia and what it does to the body, but I strongly suggest: if you find this interesting at all, go find some other sources and do more reading. There is SO much more to this topic, and this page-long rant barely begins to scratch the surface.
___________________
A colleague of mine related the tale of a pt, a young man with Type 1 diabetes, who went into diabetic ketoacidosis (DKA) and didn't get appropriate treatment. After a walk-in clinic failed to diagnose his impending health crisis, he went home and chugged sugar syrup-- the drink mix that's poured into soda machines, where it's diluted with carbonated water for serving-- until he lost consciousness. The next day he was delivered by ambulance to the hospital, where he died horribly.
So what the hell, you're thinking. If you know you have diabetes, why would you pound syrup like cheap beer? No, he wasn't just some stupid fuck who wanted a Darwin award. There's a genuine reason for this...
...so it’s pathophysiology time, motherfuckers. (That will be the title of my children’s network show someday.)
We kinda tend to think of insulin and sugar as polar opposites. Too much insulin and your sugar goes away and your brain tissues starve; too little insulin and your blood sugar goes up and, uh, this is bad. Somehow.
That’s really just part of the picture. Yes, the syrupy-thick blood is super bad. Sugar is corrosive to the blood vessels (just ask any nurse who’s pushed dextrose 50% into an IV and watched the vein blow) and over time even moderately high blood sugars rip and scar your arteries and veins. This is incredibly bad for things like your legs, which are the farthest from your heart and have a hard time getting blood back and forth to begin with. A few years of sticky scratchy sugar blood, and the nerves die from poor circulation, wounds stop healing because no blood is getting to them, and eventually your legs just rot off. The syrupy-sweet blood is just fudge sauce on the leg-flesh sundae that bacteria love to eat. This is why diabetics lose their legs. (The nerve damage is why diabetics go blind.)
Your kidneys, likewise, are almost entirely made of blood vessels. Too much sugar gouging out your kidneys = scarred up kidney circuits that are too damaged to let the water through. Bonus: when your blood sugar is insanely high, your kidneys can try to compensate by squeezing sugar directly out through your blood filters, which lets you piss away the dangerously gooey stuff… but rips holes in your filters, essentially. This is why diabetics have kidney failure and end up on dialysis.
On top of all that, your heart and brain blood vessels get shredded to boot, which is why diabetics have so many strokes and heart attacks. Diabetes is bad shit.
But there’s something even more dangerous than just having your blood turn into razor soup. Thick, dense blood is like a sponge, sucking water out of your tissues (read: organs and muscles). When your body enters a diabetic crisis, you become so thirsty you can’t fucking stand it. Undiagnosed diabetics are often spotted because they pack a couple gallon jugs of water to bed with them when they sleep at night. And as soon as their blood thins out a little, their kidneys dump all that new water in an attempt to flush out the sugar, further ripping themselves to shreds… which is why undiagnosed diabetics are also often spotted because they pee themselves in public or spend 2/3 of their day pissing away the gallons of water they’re chugging.
Soda-fountain guy was thirsty as fuck, and all his body’s instincts were telling him to slam a bunch of liquid. But why the fuck choose soda syrup? What the hell?
To answer that one, let’s get back to what insulin does. It doesn’t magically make sugar go away; your cells have their mouths locked shut to keep them from eating every damn thing that goes by, and insulin is the key that unlocks them. If your body doesn’t make insulin (because it destroyed all its own insulin cells), fuckin blows to be you, because your cells will starve surrounded by delicious food. If your body is fat as hell and all that fat is secreting endocrine shit to inform your body that you have enough fucking food to last you a month, your cells become insulin-resistant and it takes a lot more insulin to open those locks. (This part is the least-understood part of the whole fat ---> diabetes cascade, but while we don’t know exactly how it happens, we do know that excess fat leads almost inevitably to insulin resistance, and the ‘almost’ is generous.)
So now your cells can’t eat. Your blood is getting thicker because the onslaught of sugar isn’t slowing, but your cells are starving to death, being ripped apart by sludgy sugar sauce, and having all the water sucked out of them by your spongey thick blood. Insulin also allows your cells to eat the potassium they need to keep their internal pumps running, so now your potassium is backing up, causing your blood to become acidic, and making all your cell’s pumps run backward. In desperation, your cells start burning protein, which is a really poor energy source because it’s actually the cell’s furniture and tools. At this point, shit inside your cells is so bad that instead of putting food on the table, they’re chewing on the table legs in case the varnish is edible.
This is why that poor motherfucker was drinking sugar syrup. He was literally starving to death.
Many diabetics think they have low blood sugar right up until they realize their blood sugar is actually high—their cells just can’t eat any of it.
Broken-down proteins and fats produce ketones. Starving cells produce lactic acid. Between those two and all the extra potassium, your blood turns to acid in your veins. Over time, your kidneys might have been able to slowly compensate for that by secreting bicarbonate, but right now they’re busy squeezing sugar and potassium out through their battered assholes. The only other way your body can try to fix the whole ‘acid blood’ problem is by blowing off as much carbon dioxide as possible, since carbon dioxide is acidic when dissolved in blood. Soon you’re sobbing for air like you’ve been running a marathon (another situation in which stressed-out and starving cells dump tons of lactic acid), your body is so dehydrated you’re losing your mind and your organs are failing, your cells are so hungry they’re literally eating themselves, and so much potassium is backed up in your blood that your heart’s muscle-pumps get overwhelmed by the back-pressure and your heart just… stops.
If you're lucky. Massive organ failure due to combined starvation and shredding is your other, slower option.
DKA is a horrible way to die.
---
Addendum: Type 2 diabetics get a similar thing, hyperglycemic hyperosmolar nonketotic syndrome, which does basically the same thing as DKA, but with even higher blood sugars and a lower chance of survival.
For those of you just visiting, this blog is a meandering mess of rants and stories about my experiences as a nurse, and the health education aspects are intended to help readers understand a little more about what I handle at work and what it means when I say my pt is "in DKA" or "doesn't take their insulin." I initially made this blog for a pretty small audience of people who were already familiar with my forum posts, and nothing here has been edited or really even thought through. I'd say half of it was written after at least one round of gin & soda.
So what you'll find here may be useful if you're trying to grasp the very basics of hyperglycemia and what it does to the body, but I strongly suggest: if you find this interesting at all, go find some other sources and do more reading. There is SO much more to this topic, and this page-long rant barely begins to scratch the surface.
___________________
A colleague of mine related the tale of a pt, a young man with Type 1 diabetes, who went into diabetic ketoacidosis (DKA) and didn't get appropriate treatment. After a walk-in clinic failed to diagnose his impending health crisis, he went home and chugged sugar syrup-- the drink mix that's poured into soda machines, where it's diluted with carbonated water for serving-- until he lost consciousness. The next day he was delivered by ambulance to the hospital, where he died horribly.
So what the hell, you're thinking. If you know you have diabetes, why would you pound syrup like cheap beer? No, he wasn't just some stupid fuck who wanted a Darwin award. There's a genuine reason for this...
...so it’s pathophysiology time, motherfuckers. (That will be the title of my children’s network show someday.)
We kinda tend to think of insulin and sugar as polar opposites. Too much insulin and your sugar goes away and your brain tissues starve; too little insulin and your blood sugar goes up and, uh, this is bad. Somehow.
That’s really just part of the picture. Yes, the syrupy-thick blood is super bad. Sugar is corrosive to the blood vessels (just ask any nurse who’s pushed dextrose 50% into an IV and watched the vein blow) and over time even moderately high blood sugars rip and scar your arteries and veins. This is incredibly bad for things like your legs, which are the farthest from your heart and have a hard time getting blood back and forth to begin with. A few years of sticky scratchy sugar blood, and the nerves die from poor circulation, wounds stop healing because no blood is getting to them, and eventually your legs just rot off. The syrupy-sweet blood is just fudge sauce on the leg-flesh sundae that bacteria love to eat. This is why diabetics lose their legs. (The nerve damage is why diabetics go blind.)
Your kidneys, likewise, are almost entirely made of blood vessels. Too much sugar gouging out your kidneys = scarred up kidney circuits that are too damaged to let the water through. Bonus: when your blood sugar is insanely high, your kidneys can try to compensate by squeezing sugar directly out through your blood filters, which lets you piss away the dangerously gooey stuff… but rips holes in your filters, essentially. This is why diabetics have kidney failure and end up on dialysis.
On top of all that, your heart and brain blood vessels get shredded to boot, which is why diabetics have so many strokes and heart attacks. Diabetes is bad shit.
But there’s something even more dangerous than just having your blood turn into razor soup. Thick, dense blood is like a sponge, sucking water out of your tissues (read: organs and muscles). When your body enters a diabetic crisis, you become so thirsty you can’t fucking stand it. Undiagnosed diabetics are often spotted because they pack a couple gallon jugs of water to bed with them when they sleep at night. And as soon as their blood thins out a little, their kidneys dump all that new water in an attempt to flush out the sugar, further ripping themselves to shreds… which is why undiagnosed diabetics are also often spotted because they pee themselves in public or spend 2/3 of their day pissing away the gallons of water they’re chugging.
Soda-fountain guy was thirsty as fuck, and all his body’s instincts were telling him to slam a bunch of liquid. But why the fuck choose soda syrup? What the hell?
To answer that one, let’s get back to what insulin does. It doesn’t magically make sugar go away; your cells have their mouths locked shut to keep them from eating every damn thing that goes by, and insulin is the key that unlocks them. If your body doesn’t make insulin (because it destroyed all its own insulin cells), fuckin blows to be you, because your cells will starve surrounded by delicious food. If your body is fat as hell and all that fat is secreting endocrine shit to inform your body that you have enough fucking food to last you a month, your cells become insulin-resistant and it takes a lot more insulin to open those locks. (This part is the least-understood part of the whole fat ---> diabetes cascade, but while we don’t know exactly how it happens, we do know that excess fat leads almost inevitably to insulin resistance, and the ‘almost’ is generous.)
So now your cells can’t eat. Your blood is getting thicker because the onslaught of sugar isn’t slowing, but your cells are starving to death, being ripped apart by sludgy sugar sauce, and having all the water sucked out of them by your spongey thick blood. Insulin also allows your cells to eat the potassium they need to keep their internal pumps running, so now your potassium is backing up, causing your blood to become acidic, and making all your cell’s pumps run backward. In desperation, your cells start burning protein, which is a really poor energy source because it’s actually the cell’s furniture and tools. At this point, shit inside your cells is so bad that instead of putting food on the table, they’re chewing on the table legs in case the varnish is edible.
This is why that poor motherfucker was drinking sugar syrup. He was literally starving to death.
Many diabetics think they have low blood sugar right up until they realize their blood sugar is actually high—their cells just can’t eat any of it.
Broken-down proteins and fats produce ketones. Starving cells produce lactic acid. Between those two and all the extra potassium, your blood turns to acid in your veins. Over time, your kidneys might have been able to slowly compensate for that by secreting bicarbonate, but right now they’re busy squeezing sugar and potassium out through their battered assholes. The only other way your body can try to fix the whole ‘acid blood’ problem is by blowing off as much carbon dioxide as possible, since carbon dioxide is acidic when dissolved in blood. Soon you’re sobbing for air like you’ve been running a marathon (another situation in which stressed-out and starving cells dump tons of lactic acid), your body is so dehydrated you’re losing your mind and your organs are failing, your cells are so hungry they’re literally eating themselves, and so much potassium is backed up in your blood that your heart’s muscle-pumps get overwhelmed by the back-pressure and your heart just… stops.
If you're lucky. Massive organ failure due to combined starvation and shredding is your other, slower option.
DKA is a horrible way to die.
---
Addendum: Type 2 diabetics get a similar thing, hyperglycemic hyperosmolar nonketotic syndrome, which does basically the same thing as DKA, but with even higher blood sugars and a lower chance of survival.
Week 1 Shift 1 (technically five of seven)
Let me tell you about my days.
Today I took report initially on one pt, a man with a neurological disorder that has left him wheelchair-bound and epileptic. Recently he seized during a wheelchair transfer and broke his hip. Now, after hip surgery, he remains unable to swallow, massively incontinent of urine and stool, and extremely forgetful. He wants oral swabs soaked in water, because his mouth is dry-- we are giving him IV water and food, but this doesn't keep your stomach from growling or moisten your throat-- but he can't remember when he's had them, and he presses his call light every twenty seconds. I almost never take a call bell away from a pt, but I took this one away. I feel vague guilt, and also this increases my workload since I now have to ask him every fifteen minutes if he needs anything. The answer is always "swab." I can only give him one every thirty minutes; he chokes on even that little bit of water.
I attempted to start a feeding tube earlier but it just made his nose bleed, which kept me at the bedside suctioning him until the bleeding stopped so he wouldn't choke. That can take a while, since you can't put pressure on the bleed.
Meanwhile, took an admit from an urgent care clinic, a little old man whose heart is too slow (bradycardia). He will get a pacemaker today. However, the night doc was caught up in a Code Blue, and failed to put in ANY orders before staggering out of the hospital to (I'm guessing) die quietly in the parking lot of exhaustion. The day doc had no time to put in orders for a full 1.5 hours after admit. I just started dopamine and crossed my fingers, as the urgent care clinic had already tried atropine.
Paging the night doc got me written up. My initial response was not exactly polite, but hey, a thirty-six-hour shift will make any doc kind of cranky.
The rest of the shift was fairly uneventful. The old man's heart converted back to a more stable rhythm (sinus bradycardia is better than junctional bradycardia) so they're holding off on his pacemaker until tomorrow.
The neurological disorder guy just made me sadder and sadder. His brother brought in his dentures so he could chew food, even though he can't even swallow his spit. He constantly begged for water, but choked on even the few drops from the mouth swabs I gave him every thirty minutes.
A little investigation revealed that he's been on hydrocodone every six hours for the last thirteen years, but since admission hasn't received a single pill of it-- or any of his psych or anti-seizure meds-- because he couldn't swallow after surgery. Whether this is because of advancing neurodegenerative processes or because the intra-operative intubation process damaged his throat, he stil needs the damn drugs. Plus he had fucking surgery, he needs pain meds. I threw a fit and got IV morphine, then finally got it switched to a PCA (patient-controlled analgesia) pump so he could dose himself at need.
The dentures were time-consuming. They had to be cleaned and stored, the container labeled, their presence noted in the chart, etc etc. Paperwork.
Another nurse asked if I could do a sign-off with her. This facility requires sign-offs on all cardioactives, sedatives, and electrolytes, in addition to the universal two-RN blood sign-off. Her pt looked shitty, pale, drenched with cold sweat, and gray-mottled all over. I hovered for a few minutes while she listened to the pt's chest for some fucking reason, waiting for my chance to sign off on whatever drug or bag of blood she needed me for.
Then she nodded briskly, walked back to the computer, and entered all this into the "clinical death" flow sheet. Fuck, okay, no wonder the guy looked bad. Guess we were just hanging out with a dead body.
The reason I had to sign off on the pt's death is that apparently once an RN had a dying old person hauled off to the morgue before their heart was quiiiite done. This is easier than you might think, because the heart keeps slight electrical impulses for a while after death, and a weak pulse isn't always palpable. So two RNs are supposed to listen to any dead pt's chest for two minutes straight to make sure we can't hear any beats (ie valves closing). I mean, at the point where your heart beat is debatable, your brain is getting no perfusion and you are already brain-dead, but recent corpses do enough weird shit like breathing and farting that it's a bit much to risk em having a heartbeat as well.
Not that I actually listened, since I had no idea the guy was dead. If I had been reading off blood or checking a drip that had a chance of hurting a living pt, I would have had to go back and check the whole thing... but honestly, if I know you're a decent nurse and you tell me your pt is dead, and I've been standing there for five minutes and not seen them breathe at all and noticed that they look like three-day-old waterlogged ground beef, I'm probably going to trust your assessment.
Cleaned up, gave report, drove home, passed out. Tomorrow will be day six of seven, and I'm tired as shit.
Today I took report initially on one pt, a man with a neurological disorder that has left him wheelchair-bound and epileptic. Recently he seized during a wheelchair transfer and broke his hip. Now, after hip surgery, he remains unable to swallow, massively incontinent of urine and stool, and extremely forgetful. He wants oral swabs soaked in water, because his mouth is dry-- we are giving him IV water and food, but this doesn't keep your stomach from growling or moisten your throat-- but he can't remember when he's had them, and he presses his call light every twenty seconds. I almost never take a call bell away from a pt, but I took this one away. I feel vague guilt, and also this increases my workload since I now have to ask him every fifteen minutes if he needs anything. The answer is always "swab." I can only give him one every thirty minutes; he chokes on even that little bit of water.
I attempted to start a feeding tube earlier but it just made his nose bleed, which kept me at the bedside suctioning him until the bleeding stopped so he wouldn't choke. That can take a while, since you can't put pressure on the bleed.
Meanwhile, took an admit from an urgent care clinic, a little old man whose heart is too slow (bradycardia). He will get a pacemaker today. However, the night doc was caught up in a Code Blue, and failed to put in ANY orders before staggering out of the hospital to (I'm guessing) die quietly in the parking lot of exhaustion. The day doc had no time to put in orders for a full 1.5 hours after admit. I just started dopamine and crossed my fingers, as the urgent care clinic had already tried atropine.
Paging the night doc got me written up. My initial response was not exactly polite, but hey, a thirty-six-hour shift will make any doc kind of cranky.
The rest of the shift was fairly uneventful. The old man's heart converted back to a more stable rhythm (sinus bradycardia is better than junctional bradycardia) so they're holding off on his pacemaker until tomorrow.
The neurological disorder guy just made me sadder and sadder. His brother brought in his dentures so he could chew food, even though he can't even swallow his spit. He constantly begged for water, but choked on even the few drops from the mouth swabs I gave him every thirty minutes.
A little investigation revealed that he's been on hydrocodone every six hours for the last thirteen years, but since admission hasn't received a single pill of it-- or any of his psych or anti-seizure meds-- because he couldn't swallow after surgery. Whether this is because of advancing neurodegenerative processes or because the intra-operative intubation process damaged his throat, he stil needs the damn drugs. Plus he had fucking surgery, he needs pain meds. I threw a fit and got IV morphine, then finally got it switched to a PCA (patient-controlled analgesia) pump so he could dose himself at need.
The dentures were time-consuming. They had to be cleaned and stored, the container labeled, their presence noted in the chart, etc etc. Paperwork.
Another nurse asked if I could do a sign-off with her. This facility requires sign-offs on all cardioactives, sedatives, and electrolytes, in addition to the universal two-RN blood sign-off. Her pt looked shitty, pale, drenched with cold sweat, and gray-mottled all over. I hovered for a few minutes while she listened to the pt's chest for some fucking reason, waiting for my chance to sign off on whatever drug or bag of blood she needed me for.
Then she nodded briskly, walked back to the computer, and entered all this into the "clinical death" flow sheet. Fuck, okay, no wonder the guy looked bad. Guess we were just hanging out with a dead body.
The reason I had to sign off on the pt's death is that apparently once an RN had a dying old person hauled off to the morgue before their heart was quiiiite done. This is easier than you might think, because the heart keeps slight electrical impulses for a while after death, and a weak pulse isn't always palpable. So two RNs are supposed to listen to any dead pt's chest for two minutes straight to make sure we can't hear any beats (ie valves closing). I mean, at the point where your heart beat is debatable, your brain is getting no perfusion and you are already brain-dead, but recent corpses do enough weird shit like breathing and farting that it's a bit much to risk em having a heartbeat as well.
Not that I actually listened, since I had no idea the guy was dead. If I had been reading off blood or checking a drip that had a chance of hurting a living pt, I would have had to go back and check the whole thing... but honestly, if I know you're a decent nurse and you tell me your pt is dead, and I've been standing there for five minutes and not seen them breathe at all and noticed that they look like three-day-old waterlogged ground beef, I'm probably going to trust your assessment.
Cleaned up, gave report, drove home, passed out. Tomorrow will be day six of seven, and I'm tired as shit.
Introductory blatherings
My name is Elise. I am an ICU nurse, and I'm here to tell you what it's like in the disgusting, heartbreaking, obsessive, foul-smelling world of intensive care.
First off, I'm gonna come clean: sometimes I change details in my stories. Nothing to interfere with the mundane horror of the stories, of course, but you wouldn't be able to recognize any of these people from the info I give. Dates are altered; shift end reports are offset by varying times. I work in one main hospital, which is an amazing facility; I've also worked in six other hospitals in this city, and two others in a different state, which means that from time to time I will be dropping in tales from other facilities and past shifts when things are running dry.
If you really wanted to find my main workplace, you could, although I would appreciate it if you didn't. They might not understand.
If you wanted to find me, you probably could, although you're better off just dropping me a note.
If you wanted to find one of my pts, you shouldn't be able to.
If you are one of my pts, and you want a story removed, I will do so immediately-- just let me know. I will ask you for some verification, since with the identifying details stripped from my stories, it could very well be someone else's story you're recognizing.
---------
I will post anywhere from three to five shift stories per week, depending on how many shifts I work.
I will not embroider anything to make it more sensational or more dramatic. ICU work is dramatic enough without any yarn-spinning faffery to tidy up the edges. Where I change details, I will stay true to the spirit of the story; where those details are improbable, I will clarify whenever possible, so that you can trust what I write here.
I will respect my coworkers, my pts, and their families. Where I have a conflict with another person, I will not sugarcoat it-- but I will hide their identity even more thoroughly, and approach their story with empathy. I see people at their most vulnerable, at points of high stress, in moments of crisis and terror, in contexts of immediate tragedy or chronic suffering. I can't promise to like everyone, but I can promise to treat everyone with humanity, compassion, and dedicated care.
I will indulge in stupid derails, frothy diatribes about pathophysiology, and occasional rants about the things I like or hate. I will use clear language whenever possible, and clarify whenever I've been confusing. I will make disgusting metaphors about food and inappropriate jokes about death. I will mess up my details and fuck up my patho and drive everyone crazy with my profane explanations for basic medical matters. I will take requests. I will take criticism. I will not take bullshit.
See you guys at the end of shift.
First off, I'm gonna come clean: sometimes I change details in my stories. Nothing to interfere with the mundane horror of the stories, of course, but you wouldn't be able to recognize any of these people from the info I give. Dates are altered; shift end reports are offset by varying times. I work in one main hospital, which is an amazing facility; I've also worked in six other hospitals in this city, and two others in a different state, which means that from time to time I will be dropping in tales from other facilities and past shifts when things are running dry.
If you really wanted to find my main workplace, you could, although I would appreciate it if you didn't. They might not understand.
If you wanted to find me, you probably could, although you're better off just dropping me a note.
If you wanted to find one of my pts, you shouldn't be able to.
If you are one of my pts, and you want a story removed, I will do so immediately-- just let me know. I will ask you for some verification, since with the identifying details stripped from my stories, it could very well be someone else's story you're recognizing.
---------
I will post anywhere from three to five shift stories per week, depending on how many shifts I work.
I will not embroider anything to make it more sensational or more dramatic. ICU work is dramatic enough without any yarn-spinning faffery to tidy up the edges. Where I change details, I will stay true to the spirit of the story; where those details are improbable, I will clarify whenever possible, so that you can trust what I write here.
I will respect my coworkers, my pts, and their families. Where I have a conflict with another person, I will not sugarcoat it-- but I will hide their identity even more thoroughly, and approach their story with empathy. I see people at their most vulnerable, at points of high stress, in moments of crisis and terror, in contexts of immediate tragedy or chronic suffering. I can't promise to like everyone, but I can promise to treat everyone with humanity, compassion, and dedicated care.
I will indulge in stupid derails, frothy diatribes about pathophysiology, and occasional rants about the things I like or hate. I will use clear language whenever possible, and clarify whenever I've been confusing. I will make disgusting metaphors about food and inappropriate jokes about death. I will mess up my details and fuck up my patho and drive everyone crazy with my profane explanations for basic medical matters. I will take requests. I will take criticism. I will not take bullshit.
See you guys at the end of shift.
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