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.

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.