Tuesday, March 31, 2015

Thoughts, various.

I would really like to be in Seattle right now. From now until mid-October sounds about right; that means I would miss tornado season here. Tornados, strong thunderstorms, hail--it all sends me, shaking and swigging whatever alcohol is in the house, into my safe closet for hours, usually a couple times a week. I hate heavy weather. Call it a remnant of my days in Kansas, including living through the infamous Wichita/Haysville/Andover tornado of 1991.

Failing that, I would like to be up in the Blue River or over in the Comal for the next few days, not going back to work.

*** *** ***

An email arrived today from a woman who had a palatectomy on Friday.

This is comparable to a dodo sighting. In four years, with God only knows how many hits to this blog for "palatectomy," "obturator," and "palate cancer," I have only heard from one other person who'd had a palatectomy before now, and she was introduced to me by my uncle. Given how quickly oral cancer is becoming The Latest Thing, you'd think I'd have a coterie of fellow bionic-mouth wearers, but I don't. It seems that most oral CA people get nasty stuff at the base of their collective tongues, or on their tonsils, not in their minor salivary glands.

The emailer asked how long it would be before the hole closed up.

Honey, I said, that hole is never gonna close up. That's gonna be with you for life. How did nobody tell her that before? WTF?

Which took me back to the months after surgery, when my obturator was equal parts problem and blessing. I searched all over the Innerwebs for palatal reconstruction, eventually finding somebody in Alberta? Saskatchewan? Someplace in Canada, who would do palatal reconstruction in adults, with only poor-to-fair results.

It took a good three months before I accepted that I would indeed be wearing this Thing in my mouth until the day I keeled over. After that period of adjustment, I started experimenting. I discovered that having a removable mouth was actually superior, in many ways, to stock equipment.

For instance: I rarely have to pop my ears on an airplane, and almost never have pressure and pain with a sinus infection. (Of course, I can't wear my obturator when my sinuses are really inflamed, but you take what you can get. At least I can sleep without sitting up.) I am proof against pizza burns, Dorito stabs, and all but the most aggressive Cap'n Crunch bits. I have something cool to show the medical students and nurse interns, and I have won several bets on how much I can fit in my mouth at once. (The trick is breathing carefully, so as not to send stuff down your airway.) Nothing but poppyseed muffins cause me any trouble any more, and I never liked poppyseed muffins anyhow, so no great loss.

It's weird, how a simple email from a person can bring it all back. It's like I haven't come all that far after all. Then I remember: I saw Maricel, the tech at The Prosthodontic Elf's office, wax like the moon during her first pregnancy. The second pregnancy, I only knew about during the eighth month. I've missed the third one altogether. So that's something.

*** *** ***

Mongo comes home tomorrow. I have to bail him out first thing. I will be setting my alarm. I've had trouble sleeping without him curled up on my feet, or in the small of my back. The cats have been strangely needy this week; I think they miss him, though they'd never admit it. A seventy-pound dog leaves a huge hole when he's not where he's supposed to be.

*** *** ***

Can we please stop pillorying people for shit they tweeted five years ago? Tweets I would've made five years ago would've had me strung up by six or eight groups of people with whom I now identify. Jeez, people: personal growth. Look it up. It's a thing.

Monday, March 23, 2015

My Dog Is A Fugitive From Justice.

My dog is on the lam.

My dog is living under an assumed identity.

My dog is being shielded by others at great cost to themselves.

My dog is an asshole.

*** *** *** *** *** ***

While Boyfiend (formerly Brother In Beer) and I were spending a nice few days in the Pacific Northwest, watching Der Alter Jo get hitched, Mongo The Magnificent (aka ThugDog) was being dogsat by a very nice woman who keeps pups in her home and charges very reasonable rates.

He had a lovely time. I have more than sixty photographs of him running through the woods, swimming in the lake, chasing ducks (aka Water Squirrels), and sleeping on the nice woman's couch. In most of those pictures, he's side by side with her foster dog. Her foster dog is sweet, ancient, and tolerant.

The last day he was there, on his last outing, he got upset with Dogsitter's Dog and snapped at him. Dogsitter's Dog of course retaliated, because even at ninety years older than dirt, he still has some self-respect. Dogsitter tried to break up the fight. Using her hands. Near the dogs' heads.

And got bitten. Not intentionally, not badly, not in a mean-spirited way, but she had to go to the ED when her hands started to swell. And the ED, following the law, called the cops. All dog bites in this county have to be reported.

(Which brings up the following conundrum: if a burglar breaks into my house and Mongo bites him/her, and then said burglar is taken to the ED for treatment by the cops, does that count as a reportable incident? Or do the cops simply wave their hands and say "Eh"?)

Anyway, things started going Keystone Kops in the ED. The salient point in all of this is that I live in one city, the dogsitter lives in another, and the bite took place in a third, very small, city, just inside the city limits. The first cop--one from my town--showed up, decided it wasn't his jurisdiction, and left. The second cop showed up, the dogsitter refused to give him any information about me (more on this in a minute), and he left.

And the next day, in succession, the dogsitter had the police from four different cities show up at her door with animal control trucks, ropes, lassos, dart guns, and various other implements of distruction. They pounded, she said, on the door. In succession. And she refused to answer the door. (Here I have to credit her heart and cut her some slack for being flustered. If cops were pounding on my door, I would hesitate to answer it as well, for fear that the dogs in my care would be taken away in the paddy wagon, with nobody sorting the good dogs from the bad ones.) Anyway, she said squat until they showed up with a warrant.

(I don't know what the police from the fourth city were doing. Maybe it was a mistake? Maybe a show of moral support? Maybe they had to run to the store for a few things and just dropped in on their way? I dunno.)

When they showed up with a warrant, she called me. I had known she had gotten bitten, but had figured things would work themselves out in the noiseless-tenor way that they normally do. I mean, I had no idea she had bucked the police.

I had to get on the horn with three successive animal control and sheriff's divisions before I found the person who could deal with my problem, only she had left the office about ten minutes before.

So tomorrow, I am staying home from work. I will call my vet, explain the problem, and ask for a quarantine cage. It's the law here that any dog who bites a human has to, if its vaccinations are up to date, be quarantined for ten days. I can't quarantine Mongo at home, since it wasn't a family member who got bitten.

Then I will call the third city sheriff's office and say, "My dog is a fugitive from the law, and I am calling to turn him in." And we will go from there.

No, it doesn't feel quite fair that Mongo has to be quarantined because somebody got in the way of his teeth. On the other hand, I can see the dogsitter's problem: when you see two dogs going at it, the immediate instinct is to shut that shit down, any way any how.

And while it was accidental, I can see the reason for any-skin-break-is-reported. If I asked for an exception, they'd have to make exceptions for every blockhead with a truly dangerous asshole dog, and then where would we be?

So, the upshot is, Mongo gets another vacation. Not as much fun, and not as heavy on lakes and ducks, but another vacation.

And I have to figure out whether to outfit him in a striped outfit, an orange jumpsuit, or just put an ankle bracelet on him and write "LOVE" and "HATE" on his paws.

Saturday, February 28, 2015

Things got a little busy.

There was an ice storm. And Friend Abilene Rob and his lovely bride-to-be Alice moved closer (hooray!). And The Boyfiend started physical therapy, and finished it, and now doesn't think he had a failed back surgery. Which I had been telling him, but when does any Boyfiend ever listen? Never.

We're also ramping up for That Yearly Festival That Makes My Commute Hellish, aka South By Fuck You. And our supplies manager's son died of septicemia, which is something you really wouldn't imagine happens any more, but apparently it does, so we were out of supples for about six weeks. Like, no insulin syringes for two weeks out of supplies. Which is horrible, but not as horrible by a long shot as watching your only child die of septicemia.

Also Friend Lisa's husband died, which was scary. He's my age, and he had a sudden heart attack. Just. . .went to sleep, as my mother says, and woke up dead. I assured her, when she asked the other day, that he felt nothing. Just went to sleep and woke up saying "Dafuq?" at the Pearly Gates.

Then another bout of bad weather, although not as bad as the first. I got the stomach bug that was going around and lost nine pounds in six hours, all fluid. Then I got better.

And through all of that, I felt really burned out. Not just burned out on blogging, but burned out on nursing in general. I was looking for jobs outside of nursing. I was considering learning to code, even though dealing with computer scientists is the last thing on my list of Things I'll Do Someday Before I Die, and last on my list of Things I'd Do If The Alternative Were Being Stuck In The Eye With A Bamboo Sliver.

See, we've had some changes at Sunnydale. As a result, we've lost probably thirty-some nurses, the same number of nurses' aides, half a dozen doctors, and not enough Manglement. We've been so short lately that people are calling safe harbor every shift. Manglement's focus has been on getting us new monitors, new isolation gear, and new urine-sampling devices, so it's been. . .well, it's been a recipe for burnout.

It's bad when critical-care nurses call safe harbor. It's really bad when rehab nurses call safe harbor.

It's been really bad.

I started thinking: I deal with people every day who are in extremis. Most days, I can't go home and leave my job behind. Part of that has to do with the job itself; part of it is the fact that I've become the de facto manager of my unit and the de facto mentor for several new nurses. I took a couple of days off--literally two--and came back to people with their hair on fire, asking where I'd been, a stack of paperwork six inches high on a desk that I don't have, and a new nurse having a crisis of confidence.

And I thought, where is the benefit to me? What on earth am I getting from this, aside from a steady, if variable, paycheck? I used to feel a sense of accomplishment at the end of the day. No matter how bad things had been, I knew that there had been one person, at least, who felt less pain at the end of my shift than they had at the beginning. Now, it seemed like, I had so many people yanking me so many different directions that I couldn't even be sure of that one simple thing.

I went in stressed, I worked for twelve hours frazzled, and I left feeling guilty and like I simply wasn't enough.

Most people go to work, get a paycheck, get insurance, get vacation time, and that's enough. Those things are the benefits that they look for. Their work is a thing they do, not the thing that they are. They turn off at the end of the day, shuck the coder/garbage man/shoe salesman/flight attendant skin and reveal their Real Person skin.

It's not that way for nurses. It's not that way, I suspect, for teachers or ministers or doctors or God only knows what other professions. Maybe if you're born to be a garbage man, you never take off that skin. Who'm I to say? Point being, if you're one of those people who's in one of those professions, it's bound up in you to the extent that being a Good Whatever is the main benefit of your job.

So, for about a month and a half, I was burned. the fuck. OUT. Not only was I not wanting to be a nurse, I was not a nurse. I had no curiousity about nursing stuff. I didn't care about medicine. All I wanted to do, and all I did, was explore the wonderful world of Amazon Prime Bad Movies and rearrange my closet. I went to work depressed, left more depressed, and didn't sleep well that night.

Then something changed. I don't know what it was. I knew, going into the period of burnout, or brownout, or whatever you call it, that it was temporary: this has happened every year or two for as long as I've been nursing. Still, the thing that pulls my head out of Burnsville is always a mystery.

This time, it was maybe palliative care for a Mohawk woman. There are lots of tricky technical, cultural details to be aware of when somebody from the Confederation dies. Maybe it was the kid with Ehlers-Danlos type 4, who reminded me of another bright, driven person with the same disorder and the same prognosis. Maybe it was the birthday card my pal Abbs made for me. I don't know.

Six weeks ago I left my job feeling like I wasn't enough. It was a gaping wound. Yesterday I left my job knowing for sure that I hadn't been enough, but that I had done my best, and that I would be enough for some other person some other time. And that was okay.

Wednesday, January 14, 2015

Yeah. . . .no. I'm having some thoughts about BSNs.

I'm an ADN-prepared nurse. Those of you who've been here for a while know that I often refer to those two years (three, actually, counting prerequisites) as the Hardest Work I Ever Put In For An Extended Period of Time. It was like drinking from a firehose, like trying to cross a raging river while wearing combat boots, like riding a bull with no previous experience. And the instructors I had hammered one thing home over and over: that we, as front-line nurses, had the right and the responsibility to consider ourselves colleagues of our BSN or MD or PA coworkers, not as helpers or assistants.

Of course, that was in the days of The Nursing Shortage. ADNs like me were being fought over by multiple hospitals. Nobody in my class started work at a nursing home; we all got acute-care or better jobs right off the bat.

Now my facility is going for Magnet status, which means BSNs are the basic standard of nursing education. And I have some problems with that.

First, I've seen a massive drop-off in terms of the diversity of our nursing staff. Used to be, Manglement would hire people with ADNs, provided they had either a bachelor's degree in something--anything--or equivalent experience not related to nursing. As a result, I got hired with a man who'd worked as a hospital chaplain for ten years, a woman who'd been in the Navy for a decade, three people from three different African countries, and a guy who'd been a medic in the first Gulf War (1990's) and had worked as a mechanical engineer afterwards.

Now they hire BSNs. And since they hire only people with BSNs from colleges here in the US, we have a crop of new hires who are all white, middle-class, and in their twenties. All of them are native-born, all of them are young, and for all of them, this is their first job outside of, say, Sonic. They're also all female.

This is a problem. This utterly fails to reflect our patient population. Not that that's a necessity, but for Heaven's sake: you ought to have at least some employees who can connect on some level with the people they're caring for.

Second, the BSN programs in Texas seem to focus mainly on management and leadership. Which is all well and good, but you're getting folks who, at the end of their senior year, have absorbed a ton of nursing theory and still have no time-management skills. As a result, we've lengthened the preceptor period for new grads to sixteen weeks. The preceptor period for ADNs was twelve weeks. Why? Because, at the end of our last semester, we were providing care for five patients. The BSN-prepared nurses provide care for two.

And they don't catch up. I'm seeing BSNs who, after two years on the floor, are still having time-management issues severe enough to attract Manglement's attention. They're schooled in critical thinking, they're schooled in history, but they simply don't have the chops to handle more than two post-op admissions in a shift. (Oh, Lord, how I wish I were exaggerating.)

Third and finally, I'm working with a lot of new grads who don't have a good fund of general knowledge (to use the MD's term). I'mma be a snob here and suggest that a working knowledge of, say, how to Google effectively, or American history, or politics, might all be good things to have on a day-to-day basis while you're living your life and doing your job. I'm not getting that from the new grads I work with. I have the reputation of knowing everything there is to know about everything simply because I know how to look shit up. I can assess sources, decide which ones are bunk and which ones are decent, and move on from there in a winnowing process. The new nurses I work with (and by "new" I mean "anybody who's graduated in the last three years") do not have that ability. I don't know if it's a liberal arts education or maturity or what, but unless it comes to them from a textbook, they do not know how to analyze information.

Maybe it's a lack of curiosity. When I get a patient from Backobeyondistan, I try to find out everything I can about their culture and belief systems. I'm the only one who does that. *sigh*

ANYWAY. There is a place for BSNs, no doubt. I'm planning to start mine this year, so's I can continue to work somewhere other than assisted-living facilities. Some BSN degrees (though not the ones here, from what I can tell) give graduates an excellent foundation in pathophysiology, assessment, and basic sciences. (Ours tend to require two semesters of state history and a couple of classes on theory.) Some actually prepare students to be nurses, not just research-bots or management candidates.

Overall, though? I'd rather see more diversity in the graduates we get. I want to see middle-aged, fat women like myself who are on their second or third career. I'd like to get into a conversation about Buxtehude with a dude who got his BA in organ music, then went back to school when his carpal tunnel got too bad. I'd like to see the occasional Indian nurse, or Filipino/a nurse, who took the exact same courses for her or his degree but has been denied a job because his/her  diploma didn't have "US" on it.

I'd be interested to hear what you guys have to say.

Thursday, January 01, 2015

Wednesday, December 24, 2014

Tuesday, December 16, 2014

How I learned to stop worrying and stopped giving a shit--and became a better nurse.

It's the classic nursing moment: after you've spent uncounted minutes putting a gorgeously neat, clean dressing on a wound, a doctor walks in, takes the dressing down, and wanders off without a word.

(Which makes me wonder about the nurses who reference this moment: are their doctors that unpredictable? I always catch mine in the morning and ask when they plan to round; it's easier to work in a dressing change after six neurosurgery residents have looked at it. Maybe they don't have easily-cowed residents.)

That, at the very least, prompts an eye-roll and the exhalation of breath through gritted teeth. That's the bottom of the nurse-exasperation scale: the top is the shouted "What the FUCK do you think you're doing??" Somewhere in the middle is the terse conversation, either with a doctor or a family member, in the hallway, with a candlestick and Colonel Mustard.

Y'know what? I no longer have those conversations. Or, rather, I do, but they're not nearly as terse.

I no longer sigh heavily when a patient has explosive diarrhea right after I've rolled out a new pad.

I no longer roll my eyes when I hear that Manglement has opened a new critical-care unit and hasn't hired anybody to staff it.

I no longer, in short, give a shit. And it's made me a much better nurse.

See, there are things worth getting upset about. If I have a post-aneurysm-clipping patient whose blood pressure won't stay down, even with all the drips I can throw at them, *that's* worth flipping out about. If I have an acute ischemic stroke patient whose pressures won't stay up, even with ditto, *that's* worth a phone call or two. If the pharmacy forgets to send the super-special tubing with that bag of potassium phosphate, then yeah, I'mma get on the line to them.

But the usual, boring, irritating stuff, like dressings hurled flang-dang all over the bed? Not worth giving a shit over.

Likewise, every single corner must not be exactly perfect on the top sheet when the patient's up in a chair. I'll have a chance to fix it once they get back in the bed. Every single label doesn't have to be printed out on the in-room label printer if doing so means my labs will be delayed by twenty minutes; I can always send 'em down with a plain, pre-printed label. I can, if necessary, deal with too many patients in one assignment, because I have learned how not to give a shit. I have, in short, learned to prioritize.

More than prioritization, though, the art of Not Giving a Shit has helped preserve my mental health. I have a colleague who is brilliant, talented, very-very-very smart--the sort of nurse who walks around with a halo of golden light because she is just. So. Good.

She loses sleep over minor stuff: whether or not somebody will get mad at her because she missed charting the KVO rate on an IV for three hours, or didn't match the P&P exactly when she ran hot salt on somebody. It affects her personal life, it sometimes comes close to paralyzing her professionally, and it makes her miserable. She needs to learn not to give a shit.

I would say to her: First, is the patient safe? If so, excellent. Is the patient comfortable? Even better. Is the patient clean, fed, and neat-looking? You get a gold star. Is the patient calm in their mind about what's going on? Then you can sleep easy.

The fact that you might not've checked blood return every two hours on an IV, instead letting it go to two-and-a-quarter or two-and-a-half hours, is not worth worrying about. You'd kept a weather eye on that IV, you knew it was good; fifteen or twenty minutes will not make the world catch fire. Five cc's an hour is not a huge deal.

My Not-Give-A-Shit list goes something like this, in order of Not-Givingest to Most-Givingest:

1. Emails from anybody with extensive lettering after his or her name. If it comes from the president of the university, it gets deleted right away.

2. Emails from management that go out to everybody. Those get deleted, usually, without being read. If it's important, they'll cover it in a staff meeting.

3.  Emails from management that go out to my unit. I'll glance over them.

4. Orders from doctors that say things like "be sure patient is fed dinner" or "turn Q2 hours." Well, DUH.

5. Saline locks that don't work on patients with multiple saline locks. I'll take them out and may or may not start a new one, provided that person has at least one other working IV.

6. KVO orders that don't conform to unit policy. I'll run your IV at 5cc/hour; I may or may not get around to rewriting the order that the doc placed for "KVO fluids." (In my head is the Grecian chorus of They Ought To Know How To Order It By Now.)

7. No orders for Tylenol when the docs have already ordered Norco. They're cool about me stepping a patient down.

8. Patients not getting turned or fed appropriately. This raises my hackles.

9. OT or PT skiving off a patient who they feel is too much trouble. In truth, I only have one occupational therapist that I have to watch closely; he looks for reasons to shorten his patient list. Dude, "patient already up in chair" does not mean you don't have to see them. The PTs and OTs where I work are spectacular. Except for that one dude.

10. Not breathing. That will get me full-on, hair-on-fire, running down the hall, giving a shit.

And I will have time to care, because I have learned how not to, for lesser stuff.