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.

Wednesday, November 26, 2014

This is not Thug Kitchen.

However, I have a roll recipe for your motherfuckers that you are gonna love.

This is what I bring to every holiday gathering, and have brought since forever. It's a soft, white, not-too-sweet, not-too-salty, buttery bread that you can make into loaves, or into rolls, or into a braid. It is incredibly easy, even if you've never made bread before. It's also high in fat, totally devoid of nutritional value, and should therefore be eaten only once or twice a year.

Check it out: you will need. . .

one package of regular yeast, or quick-rise/bread-machine yeast, or a cake of yeast, if you roll that way. (For newbies: these packets come in threes in the US. You will need only one. It's about two US teaspoons of yeast.)

two and one-half cups (590 ml) of lukewarm milk. I use whole milk and zap it in the microwave for a minute, just to get the chill off.

one tablespoon (~15 grams) white sugar

one teaspoon (eyeball it) salt

one stick (half a cup, or 4 ounces, or 120 ml) of unsalted (very important!!) butter, melted and cooled slightly. (Salted butter will make the dough both too salty and make it brown unevenly.)

Mix all that stuff up. It'll make a nasty, semi-lumpy, unpromising mess.

Now stir in, about a cup at a time. . .

six (more or less) cups (~150 grams per cup) of plain white all-porpoise flour (not bread or cake or semolina flour)

. . . until you get a sort of sticky, shreddy dough.

Now dump some flour onto a clean surface. It doesn't matter if it's a bread board or a counter or what, as long as it's clean.

Begin to knead. If you've never kneaded bread before, this is a treat: the dough is such that it's not hard to manipulate, and you'll know when it's done by a foolproof method I'll lay on you in a minute.

To knead, take your lump of unpromising flour-goop in the middle of your floured surface. Grab the top edge and bring it toward you. Using the heels of your hands, shove the top edge gently into the middle of the lump. Give the whole shebang a quarter-turn and repeat.

It's not hard, I promise. The trick is to stretch, rather than tear, and tuck, rather than hammer, the dough. Although you really can't go wrong. Add more flour if you need to; it's really hard to fuck up.

The dough has been kneaded enough when it's smooth, relatively elastic, no longer lumpy, and --here's the secret trick-- no longer sticks to the surface, even without extra flour.

Now. Take that dough, butter it well all over (I soften a lump of butter in my hands) and stick it into a buttered bowl. Cover it with a damp dishtowel and stick it in a warm, out-of-the-way place, like the top of the fridge, and forget about it for an hour or so (less if you're using rapid-rise yeast).

Make a mental note of the volume of the dough when you pop it into the bowl, so you'll know when it's roughly doubled in size. When it's at that point, put it back on to your clean surface and shape it into whatever form you like. I make two-bite rolls, about an ounce to an ounce and a half each, and I think I got three dozen? today.

Once you've shaped your dough, stuff it into whatever container you'll bake it in. Strangely, butter will not work for greasing your baking pan. Use solid vegetable shortening instead, okay? Throw your damp towel back over the container(s) and stick it/them back into that warm place you used earlier.

Nota bene for first-time bakers: give your dough some room. You want it to be able to grow and expand and breathe, so use a pan a smidge bigger, or leave a bit more space than you'd expect between pieces of dough. Crowded dough can't rise properly and will make heavy, unhappy rolls that don't fulfill their potential.

Allow that shit to rise until it's doubled in size again. The beauty of this step is this: if you want to take a long nap, like I did today, you can leave the dough in a relatively-cool place to slow its rising. Hell, you could even stick it in the fridge overnight! The possibilities are endless. You do you.

When the dough is nice and puffy, preheat your oven to 425F/220C/gas mark7. If you're making rolls, they'll bake for about 20 minutes. If you're doing a loaf, you might want to turn the oven down to, say, 400F, and give it forty minutes or so.

The bread/rolls/carbohydrate portrait of Nathan Fillion is/are done when they're that golden brown that you only see on TV commercials about bread, and when it/they smell done. At that point, remove your product from the oven and turn it out onto a cooling rack. This is important. No cooling rack = sad soggy bread and disappointed eaters.

Americans love these. Canadians love these. Indians and Filipinos love these. Mexican-Americans from Laredo practically fucking riot over these rolls, since they're very close, apparently, to something served in the Laredo school system in the 1970's. Italians love these, but only for dessert. Nigerians love them, as do all the Egyptians and Lebanese and Moroccan people I've tried them on. I have yet, in short, to meet a single person who does not like these rolls. Even skinny white girls like them.

Starch: the Universal language of Peace. Do your part for understanding and tolerance today!

Thursday, November 13, 2014

This was my week:

On Monday, my Sonicare toothbrush bit the dust. I'd been limping it along for months, and it finally coded and couldn't be revived.

Today, I had a decision to make: I had money in the budget either for a new Sonicare or a bottle of Laphroiag.

I chose Scotch. Oral care, I am not up in you right now.

And this is why:

On Tuesday, I was minding my own business when I saw a coworker hurpling cheerfully down the hall with what looked like a liter suction container full of bile. I shook my head and blinked twice, and damned if it wasn't a liter suction container full of bile.

Now, normally when one is faced with a quart or more of straight-up digestive fluid that has to be removed from, say, a patient's room, one gets a bottle of this nifty fluid-solidifying stuff and takes it in to the room where the straight-up digestive fluid is. One then dumps the solidifying stuff into the container of SUDF, waits until it solidifies, and tosses it into a biohazard bag.

One does not bop down the hall, hugging the still-liquid, suctioned-out contents of a stranger's stomach.

So I stopped the coworker, and took her into the storage room, and grabbed a bottle of solidifying stuff. And then told her how to handle the liter of green corrosive goo, and what to wipe down, and where to throw it all away.

And she argued with me. She wanted to take it into the nurses' breakroom and deal with it there, because you can't deal with that stuff at the sink in the clean utility room. She argued, and continued arguing, until my hero the unit secretary came in and laid down the law.

Wednesday was a blur. I think it had something to do with more than one bottle of wine, consumed such that I maintained a happy glow throughout vacuuming and napping and cooking dinner. I know there was some Doctor Who involved. (Does anybody else get a creepy vibe from Danny Pink? I sure do.)

Today that same coworker, who is a nurse (well, a nurse who hasn't been a nurse in, like, twenty years) but who has a non-nursing job, approached me with a sunny smile. Here is what she said, verbatim, with no prelude:

"As soon as the car arrives, they can go to rehab!"

What car? I asked. And who, and where, and how?

Turns out she was talking about a patient she'd been rounding on and case-managing for *for a week.*

Dude has a dense hemiplegia and is globally aphasic. He's also incontinent, has no truncal control, and requires frequent suctioning. He's a max assist with two people to sit edge of bed and can't tolerate an hour in a geri-chair.

And she wanted to send him to a rehab four hours away in the family car, with only his wife and son (no suction, no help) to watch him.

And she argued when I said we needed an ambulance.

Unfortunately, the Hero Unit Secretary wasn't working today. I was forced to say, "You are out of your effing MIND" before she would stop arguing and call the ambulance company.

Why is bile green, anyhow? What, chemically, causes that to happen? I never learned that in school.

Anyway, tonight it's Scotch and muscle relaxants (don't try this at home, kids!) because I also threw my back out this week, and then bed. I'm hoping I don't get awakened by Playful Mongo at some ungodly hour of the morning.

Tuesday, November 11, 2014

We need our own goddamned poster.

Recently, the unit I work in won an award. It was one of those not-Press-Ganey awards; the kind of award that has to do with things that are nursing quality indicators. You know, the "you haven't had a central-line infection in two years; here's a cookie" kind, but bigger.

Much bigger.

And it was nurse-driven, nurse-implemented, and exacting. And national. So, kind of a big deal.

During the hootenanny surrounding the award, we were shown a slide of everybody (so said the CEO of the hospital) who'd had a hand in making Such A Great Thing possible.

There, front and center, was the CEO. Next to him was the director of nursing operations, a man who's been actively obstructionist and slashed staffing and resources, and who has visited our unit maaaaybe three times in as many years. Next to him was a woman I didn't recognize but who, I was told, was instrumental in something statistical.

Arranged behind those people were dozens--maybe as many as a hundred?--people, all in varying degrees of business attire.

No scrubs.

Not one nurse.

Not. One.

Especially not one from the unit, the unit I work on with some of the best nurses I've ever worked with, that won the award.

So, I'm thinking we need our own. Goddamned. Poster.


Saturday, November 01, 2014

So, finally, my patient died.

Once in a very long while you get somebody under your hands who ought to have been let go months before.

We had somebody like that the other month: multiple surgeries for a brain tumor that was not going to go away (grade IV glioblastoma), multiple rounds of chemo and radiation, and in the middle of all of that, a surgery for an abscess that led to wound-vac sponges all down one side of the poor sot's body.

The spouse didn't want to let them go. The mother didn't want to let them go. The brother didn't particularly say one way or the other.

Ever smell a person who is, quite literally, rotting from the inside out? It's not fun.

Because, see, a glioblastoma (that's the most common form of malignant brain tumor and is, thankfully, still very rare) slowly takes away your ability to think, speak, walk, control your bodily functions. Then it starts to take away your ability to breathe. And your brain's ability to control things like its temperature and blood pressure. And, eventually, it will invade the areas of your brain that register pain. At that point, you will be in pain all the time every day forever for as long as you last.


It sucked. For us, as well as for the patient.

The only reason I can think of that this person was kept alive was that they had a significant pension that would've ended upon their death.

So their spouse, the person who was supposed to keep their best interests in mind, kept them alive for two entire months in order to get money.

I very rarely get *existentially* angry at work. I get angry at the administration, or at Manglement's bad decisions. There's one house supervisor in particular that I suspect was put on this earth to make sure my lungs get a workout every three weeks or so. But I generally don't get to the point that I go in search of things to punch. Ask my coworkers: they'll tell you that I'm the sweetest-tempered, most cheerful, helpful person they work with.

Seriously. And I haven't drugged a one of 'em.

Anyway. When this person came to us (and I'm carefully not using gendered terms here, because it would probably surprise you), they were reasonably compos mentis. By "reasonably" I mean that they knew their name, they knew where they were and why, and they'd mostly follow simple commands.

Within two weeks, the leftover tumor in their brain had doubled in size. Glios do that. The things that cancer loves are space and glucose and a good blood supply, and the brain has all three. What makes glioblastoma particularly nasty is that it's a tumor of the structural cells of the brain, so it sends out little undetectable filaments all around the original site. You can never get rid of it entirely.

But you can resect, and irradiate, and chemotherapize, and that's what happened. And when the patient developed an abscess on the right side of the abdomen, it didn't heal. It kept filling up with pus and tissue kept dying, because all the things we were doing to kill their brain tumor kept the rest of their body from fixing itself.

So at the end of the day we had a patient who was not a DNR, who was not on palliative care, who could not have a feeding tube inserted into their stomach courtesy of the twenty-five centimeter wide wound in their belly that would not heal; who had been intubated and extubated and who, finally, had to be four-point restrained because the tumor had hit the pain centers in their brain.

The family didn't want continuous pain control because they felt the patient was still able to communicate. This, when the MRI showed that three-quarters of this person's brain was tumor.

All of this made me vent uncontrollably to my buddy Mark, the neurointensivist. It made me vent to Ginny The Inappropriate Chaplain, and to my coworkers, and once to the patient's spouse (in a controlled and therapeutic manner). Ethics came in, ethics bowed out, case management was crushed under the wheels of the Sustain Life At All Costs juggernaut, and we all started to have a bit of twitchy post-traumatic stress.

Finally we discharged the patient to an acute-care, long-term setting. And there they died, after multiple codes, a day ago.

.*** *** *** *** ***    *** *** *** *** ***   *** *** *** *** ***

What nobody tells you about nursing is how cases like this can haunt you. I've dreamed about that poor person at least once a week for two months, now; the news that they'd died has turned the nightmares into milder anxiety dreams.

There's something about changing and bathing and turning a person who begs to be left alone to die that scars you. I am supposed to be alleviating pain, not causing it. I have a personal rule to touch every patient in my care at least once a shift *without gloves,* no matter what they've got, in a way that doesn't cause pain. Because, frankly, a lot of people in the hospital don't get touched without at least discomfort, and that fucks a body up.

But what do you do when there's nothing you *can* do? We were barred from starting a morphine drip or giving IV pain meds. The poor patient's brain was working against them. Everything hurt. Everything was futile.

And through most of it, the patient asked, then begged, to be allowed to go home with Dad. Dad had been dead for some fifty years, but showed up at the bedside on a daily basis, trying to get our patient to go with him.

I do not often have to get angry about injustice and cruelty. I don't often cry over my patients any more.

This one, I'll do both.

Wednesday, October 15, 2014

An excellent op-ed from a Minion in lovely EnZedd. . .

This is what we all should be worried about.


Thanks to the Virally-Knowledgable Minion who pointed out that I made an error by referring to Ebola as EBV. That is Epstein-Barr virus, not Ebola. As you can see from her/his comment below, Ebola is referred to as EVD or EHF. That error's now been fixed. Thanks very much for that correction, VKM! I knew there was something off about my abbreviation, but I couldn't think of what and (of course) didn't bother to check. Der.

The whole EbolaPocalypse is wearing on everybody's nerves.

I have friends who work in Dallas. A couple work at Presbyterian there. And holy shit, are things bad there. Last I heard, surgeries had been cancelled and the ED was turning away ambulances. I don't know what's happened in the last twenty-four hours, but that's what I heard on Monday.

Here's what's happened at the hospital so far, for those of you who have either been under a rock, across the uncharted oceans, or simply hiding under the covers:

A symptomatic patient, Thomas Eric Duncan, showed up at Texas Health Presbyterian Hospital (Presby) in late September. He had a fever and abdominal cramps, and told the intake nurse that he'd come from Liberia, but was sent home with antibiotics. He was later readmitted with bloody diarrhea and projectile vomiting and put in isolation.

At first, Presby officials said that he had lied on his intake form; that he'd said he hadn't been in Liberia. That turned out not to be true.

Then, Presby officials said that the intake nurse had not communicated Mr. Duncan's travel history to anybody else on the health care team. That story stood for a couple of days until some bright person pointed out that travel history is right there in the electronic medical record for anybody to see, and obviously warn't nobody checkin' nohow.

Then they said that he'd been isolated immediately. That story stood until today, when a nurse at the Presby ER said no, he'd actually (during his second admission) been sitting in a common area for as long as seven hours.

Then he died. But not until after getting dialysis and being intubated, both of which the WHO says won't do shit to prolong life and *will* do a lot to spread aerosolized virus or increase the risk of bodily fluid exposure.

And, as it turns out, the nurses at Presby who cared for him spent two days in standard isolation gear (flimsy plastic gown to the knee, goggles and mask if you're lucky, gloves, booties if you can scrounge some up) and also had other patient assignments during the time that they cared for him.

Of course, the CDC said the minute the first nurse came down with the virus, that there must've been a breach in isolation protocol on her part.

But then it turned out that holy crap, the hospital had waited until final results of viral testing from the CDC had come back to get their workers into proper gear and limit their patient-care assignments. The preliminary positives apparently weren't enough, combined with the poor man's travel history, to alarm the administration. So it wasn't so much a breach of protocol on the RNs part as it was sending a nurse into a forest fire with a bladder full of piss and no backup. Nurses were cobbling together whatever they could in an attempt to replicate proper isolation gear. They were borrowing from other departments and MacGyvering stuff for two days.

Now a *second* nurse has come down with Ebola, and she travelled from Dallas to Cleveland and back in a state of as-yet-undetermined contagiousness. I got nothin' to say about that except holy shit what a . . . .wait, no. I can't judge. Because if she'd been told she wasn't contagious without symptoms, and her movements weren't restricted, then. . . .? I don't know what to think about this part of the story, because, if it's like the rest of the story, there's more and different facts to come.

So. What conclusions can we draw from this?

Conclusion the first: The first reaction on the part of everydamnbody has been to blame the nurses. From the first inkling that Mr. Duncan's diagnosis was missed to the news that a second nurse was infected, the director of the CDC and the administration of Presbyterian Dallas have pointed to the RNs as the weak links in a chain.

I'm sorry, guys (because they are all, frankly, guys, and NOT nurses): in order for a fuckup of this magnitude to happen, a number of links in your chain of failsafes have to break. It doesn't matter if you have a "health care team" if members of that team only see each other in the bathroom and when they're punching in. People have to communicate, yes, but they have to be given the opportunity to communicate, which means proper staffing levels and backup when it's needed.

For one, nobody noticed the travel history when it was submitted the first time. That means that the ER staff was either understaffed or slammed, or both, and/or that the intake nurse never got a chance to communicate face-to-face with the rest of "her team." So you had a team in name only, screenings in name only, and procedures in name only.

Conclusion the second: Whoever had the job of preparing the Dallas area (and my area, come to that) as a whole for Ebola did a piss-poor job. The nurses I work with have been talking about the probability of caring for an EVD-infected patient since July, when it became apparent that the outbreak was getting out of hand overseas. ER nurses I work with have been wondering what, exactly, to do for protective gear and isolation facilities, since not a lot of hospitals have more than curtained cubicles in the E R. We do not even have an international airport in this area. What must it have been like in the breakrooms in Dallas?

To give you some idea, one of my besties works at a large academic medical facility in the Dallas area. It's the sort of place you take gunshot victims or people who've been hit with a chemical contaminant or folks who've been bitten in half by a llama. She told me yesterday that her facility's prep for Ebola (and keep in mind that this place has a busy ER in a highly international area) has consisted of one streaming video and a lot of assurances from administration that they're working as fast as they can on a protocol.

Guess what, Administrators of the World? The CDC and WHO and MSF already have protocols in place. All you have to do is devote the time to learning them and the money to proper materials.

Conclusion the third: If you are a nurse anywhere in Texas, you are screwed to the wall. You might wonder why the nurses at Presby who spoke out are being protected by the largest nursing union in the US. It's because you're told, as a nurse, that if you say anything negative about something that happens at your facility, you will be fired. Period, full stop, do not pass go.

A couple of years ago, somebody got mugged in our parking garage. A nurse I worked with put it up on social media that she no longer felt safe in that garage, and wondered why we didn't have better lighting. Two weeks later, she was gone. Fired. For a med error that had happened months before, and for which she had received no prior counseling. All totally fine and legal in Texas, kids.

Imagine what it must be like for the Presby nurses who were sent home, day after day, to their families and dogs and cats and knew what they'd been in contact with. They can't say boo for fear of being fired and placed on the informal blacklist that exists in this state.

Conclusion the fourth: Texas nurses need a union. Yes, unions tend toward the bloated and bureaucratic. Yes, unions sometimes do more harm than good. Yes, yes, yes, I know all the arguments.

But right now? The nurses in this state are being hung out to dry by their bosses, and nobody's getting upset, except in a very low-key, please-don't-fire-me kind of way.

If I had to care for a patient with Ebola tomorrow, I would have no appropriate protective gear. I would also have no way to refuse the assignment (not that I would; I'd pull up my big-girl panties and pray like hell). I would have no way to protest that I was taking care of the patient without proper safeguards in place. The most I could do would be fill out an incident report after the fact and hope that it got to somebody who gave a good goddamn.

They say you can't be fired for calling safe harbor here, but I've seen it happen many times. And there's no way to register that you're nursing under duress. None.

Unions add a little muscle to the arguments that nurses make. It would be nice, for once, not to feel like I'm stepping out on a tightrope over a windy canyon full of hungry alligators, naked, with a bad case of chiggers on my ankles. I would like some fucking backup, please; a little bit of muscle that I could use to enforce the staffing ratios and protocols that my administrators brag about on promotional materials.

I have no problem at all taking care of somebody with Ebola. I don't think it's necessarily the best idea to have such a disseminated system of care; perhaps we should look into certain hospitals specializing the way Emory and Nebraska do.

However, if it comes down to it, I am more than happy to do it. I did not sign up for this job because I thought it would be glamorous or easy.

All I want is a little consideration, a little preparation, and a smidgen of concern for my safety. From what I've seen of how things have been handled up to this point, I doubt I'd get any of that.

**It occurs to me that this is the most bolded, italicized, and screeching post ever posted in the posting history of this here blog. Sorry 'bout that, y'all.

Sunday, October 12, 2014

In Which Jo Has Doubts About Her Floor.


Some of you longer-term minions might remember when I bought Casa DogHair and renovated the bathroom. The shortest version, for those of you who haven't sobered up yet, is this:

The people who owned CDH before me were both of some size. They were also not good with maintenance. This led to the bathroom being entirely rotted out in vital areas, which in turn led to Then Boyfriend and I redoing it.

I should mention here that Then Boyfriend had a weird work schedule and I was working all the time, so I had very little input into the construction. I helped with demo, tiled the floor, and that was it.

So when I stepped through the bathroom floor a few months ago, it came as a bit of a surprise. TB had told me he knew what he was doing; in fact, I knew he had worked construction in the past. So I trusted that he knew how to install a bathroom floor, make the shower water-tight, all that stuff.

Instead, what I found was un-taped cement board in the shower that had been waterproofed on the wrong side, weird joints that weren't water-tight, and a floor that. . . .well.

Normally when one installs a tile floor, one lays a sheet of plywood down and fastens it to the joists. This provides a stable surface for what's to come after. Then, one lays a quarter-inch-thick layer of thinset mortar down and uses that to bed cement board. It's important, when you're laying tile, to have a deflection-free (no bouncing), solid (won't shift laterally), independent (not screwed to the joists) surface for the whole shebang. Plywood screwed to joists is layer one. Mortar-bedded cement board, screwed to the plywood bur not to the joists, is layer two. Properly done, the resulting monolithic surface should last a lifetime.

He had laid half-inch cement board over a vapor barrier and nailed it to the joists. There is so, so much wrong with this that I can't even. I had to liberate a fair two gallons of water from under the floor, atop the vapor barrier, where the weird seams had leaked.

Here's the deal: demo of a properly-installed tile floor of this size ought to take a solid day or day and a half of work. It took me forty-five minutes, and I didn't even break a sweat.

After I demo'ed the floor, I began to get the willies about the shower, so I started peeling tile off of the walls with my bare hands, no joke no kidding, and the whole project got exponentially bigger in about ten minutes. Shower tile should not be removable with one's bare hands. 

But it was and it was and here we are, with a plywood floor barely tacked down and shower walls covered in plastic.

Which brings me to the floor. All of the preparation for laying tile will result in a floor that's at least 3/4 inch higher than the floor outside the bathroom door.

The Boyfiend, who actually *does* know how to do this, has done it before, and is doing it right this time, floated the idea of lowering the joists under the bathroom to give us sufficient clearance to have a seamless transition between the wood floors outside the bathroom and the future tile within. Over dinner last night, he and his brother The Psychopath debated the various ways this could be done, with The Psychopath insisting in a querulous voice that we'd have to pull the tub (find me four strong and patient men and a space warp, dear; that tub is wider than the doorway) and jack up various bits and bobs of the foundation.

Boyfiend insists this is not a big deal. I have my doubts about that. As I told him last night, when I hear a man say "It's no big deal; it'll work out fine" I know that I'm gonna need three hundred bucks and a course of antibiotics, stat.

So I started thinking of alternatives and came up with a roll of rubber flooring in a coin pattern. It's exactly the same thing that Daniel used over at Manhattan Nest a gazillion years ago. It's cheap, totally waterproof, and there will be no seams.

And it's thin enough that we won't have to lower any joists or do any other major structural work.

Boyfiend is still snoring away, but I plan to hit him with this idea once he's up and has had some coffee. And we shall see.