Happy Christmas!

What on earth are you doing here? Go drink some eggnog, or something.

Best wishes for a peaceful and happy Christmas.

Advancing the profession

I had a conversation about Advancing The Profession two days ago with a friend and colleague at work. Advancing The Profession is, for those of you who aren't nurses, a Big Thing in nursing circles. Nurses who bother to answer surveys report dissatisfaction with their careers, frustration with their practice limitations and paperwork, and anger at how they're perceived and treated by both the public and the other professionals they work with.

There are as many ideas for improvement as there are problems. Many nursing professionals want to change scope of or requirements for practice. Still others want to educate the public. Some want to raise the consciousness of those other professionals with whom nurses work.

Raising Conciousness was the focus of my colleague's and my conversation. I had spent a good part of the morning cleaning up the mess that a group of lazy, ignorant physicians had left and I was frustrated. Being sniped at by everybody and his dog is part of being a nurse, as is cleaning up loose ends that others (usually "too busy" residents) leave lying...but it gets old.

My colleague, who works ICU on the weekends and is an educator during the week, suggested that I devote a little time to Raising The Consciousness of the physicians I'd cleaned up after. And even though it was a good suggestion, I couldn't take it to heart.

Why? Because I was tired. I can see where conciousness-raising would be a brilliant idea: take a resident who's disrespectful aside and talk to him calmly about professionalism and hope for a change. But most of the time, we nurses are so frazzled, we simply don't have the energy to devote to educating the odd Neanderthal who comes in with a medical degree.

I'm lucky on a number of points. The floor where I work is well-staffed. The doctors are, for the most part, good colleagues. My specialty is such that I don't get a lot of jokes or flack about wearing short skirts and a cap. (Say "I'm in neurology" to even the most uncivilized bar patron and they back off.)

But still. Why is it *my* responsibility to educate/lecture/come down on like the crack of Doom somebody who just doesn't get it? If I have the time and the inclination, I will. Otherwise, watch out: if you're an attending physician who hasn't learned to be a decent human being by this time, I am not going to educate you. I'm gonna push back as hard as you push instead.

A group of interns made a video in our nurses' station about how to deal with sexual harassment. It wasn't focused on how to handle the nosy patient if you're a young female doctor, or how to deal with the predatory professor that occasionally crops up. It was on how to deal with a (female) predatory nurse if you're a (male) doctor.

When we (female) nurses all stopped laughing and wiped our eyes, we got into a serious discussion with the instructor of the group. Why, we asked, were the students not being taught lessons that would serve them in good stead? Sexual harassment is covered in our medical school. Being professional and working on a team is not. How not to yell at somebody simply because they're following the rules is not. I'm not implying here that sexual harassment is a chimera or overstated; it's not. What I'm saying is that the curriculum at our facility pays far too much attention to the one problem--often to the exclusion of the other.

I'm a feminist and childfree and a nurse; raising consciousness is not unfamiliar to me. What's unfamiliar is the unwillingness of other professionals with whom I work to police their own. It's left entirely to us to educate/train/police the people who technically are our superiors. At the same time, we're expected to provide good care for sick people and their families, act as gatekeepers and coordinators of care, and keep a smile on.

I once had to report a resident to his attending for being a jerk. I heard the tail end of the lecture the attending gave the resident. Just before Attending turned Resident loose to go back to work, he said, "...and don't let their hysteria get to you, okay? Most of them just aren't that tough." (Enter Crack of Doom Nurse hard on the heels of that statement.) Point being that I'm expected to Educate and Enlighten this person, but his boss will undermine me, then blame nurses for the lack of respect that his students show them.

Honestly, I have no solution for this particular problem. All I can do is keep practicing as professionally as I know how and deal with trouble when it happens. I just hope I'm not completely burned out by the time I retire.

Okay, okay, it's done.

Bidness

Whew. I got a number of new links up. My original idea was to parcel them all out nicely so that Gentle Readers would have some idea of what they were getting into (Medical? Humor? Other?), but not only do my HTML skills suck, I figured at the end of the day that I don't know what I'm getting into at any given moment; why should you?

Update the First

Coworker's Brother has had the last of four surgeries. The docs found the bleed that was giving him trouble, so he'll be medevac'ed to Europe in the next few days.

Update the Second

Troublesome Coworker is rapidly weaving rope.

Update the Third

Hemicorporectomy Guy (and don't feel bad if you've been humming "Eric the Half-A-Bee"; we all have) is doing fine.

End of Updates.

Any nurse can tell you that a number of folks will ask, when told that you're a nurse, how to improve their health, well-being, and general mood. In an attempt to head off those folks at Christmas parties this year, I present:

Nurse Jo's Tips On How To Live A Happy, Healthy Life

1. Don't be mean. That's number one for a reason. If you're mean, you make everyone around you miserable. You'll be lonely and sick and people will think you deserve it. So don't do it. Smile, smile, smile.

Or if you can't, at least fake it.

2. Shut your piehole and move. No great mystery here. The average person eats too much and moves too little. Get or borrow a dog and take it on runs. Play with your kids. Turn off the TV, or at least do crunches during the commercials.

3. Vegetables: the green things at one end of the grocery store. Vegetables are fun. Really. They're interesting. You should eat them occasionally.

4. Relax. There's nothing worth getting *that* upset over.

5. Drink if you like, smoke if you must. Just don't be a self-righteous twerp. See Point Number One. Self-righteous twerpiness goes right along with meanness in shortening your life. I don't care what you do as long as you're a reasonable human being. If your choices are smoke crack or be a twerp, let me get you a lighter.

6. Water. Your body is 70% water, not 70% Diet Coke.

7. Find what you like to do, then do it. This relates both to work and non-work situations. If you passion is basket-weaving, then by all means, weave baskets. The point is to have at least one thing in which you can lose yourself on a weekly if not daily basis. Which brings me to:

8. Get out of your own head. It ain't all about you, so find something that helps you remember that.

9. Act. Whatever gods are running the Universe don't care what you *think*, they care what you *do*.

10. Recognize that life really *is* that funny and ridiculous.

I have hinty bazillion links to put up

And will do it on Wednesday or Thursday, I promise.

Too close to home

A coworker's brother was shot halfway to hell in Fallujah today. (Yesterday? I don't know the time difference.)

His squad was marching down the street when a car bomb was detonated next to them. The guy behind him died, but in doing so, sprayed my coworker's brother with bullets. He (the brother) also has some nasty shrapnel wounds.

Thanks be to the Army medics who got there first. They're still working on him in a field hospital in Iraq, trying to find the internal bleeding that's keeping him in critical condition. After they do, he'll be airlifted to Europe for further surgery.

When the Red Cross called her as she was on her way to work, all the person could tell her was that her brother'd been shot. They had no details. Wouldn't you hate to have that job?

Any prayers on her behalf, on behalf of her brother, and on behalf of her two siblings--also in the Army, also near or in Fallujah--would be gratefully accepted.

Any political emails will be tossed back to the senders so hard that the electrons bounce. I'm too upset by her upset-ness to be rational.

Odds and Ends and Drama

From Correspondent Tim, somewhere out there in the Worldwideinternetwebland, comes this very funny list of do's and don'ts for patients. Tim says "all of these would've come in handy had I known to tell my patients beforehand."

Some generalized advice for patients

Dos
1) ...ask if the large puddle of blood pooling under your disconnected IV is normal.
2) ...ask for help reinserting foley catheters if you pull them out.
3) ...use short chairs instead of tall barstools if you drink too much and have osteoporosis.
4) ...ask for help if you wish to amputate a body part BEFORE you start cutting.

Don'ts
1) ... tell the hospital policeman that you need to go get your gun.
2) ... steal the laptop computer I use to sign out your medications.
3) ... slam the Pleurevac in the door of the cab as you leave AMA.
4) ... barf on the nurse. (the biggie)

*snork*

It finally happened

"It" being Nurse Jo coming down on another nurse like the crack of doom. "Goddammit" was probably an ill-advised thing to say. "Fuck" was certainly unprofessional. The screaming will surely be discussed and embellished in rumor for weeks to come...but the only thing I feel bad about is the fact that I'll have a whopping big meeting with the floor manager on Thursday.

There's something about being a nurse that makes other people think they can yell at you. I got yelled at yesterday seven times before noon--that's more than once an hour if you're keeping track, which I certainly was after Yell Number Three. The reason I was getting yelled at and complained to was the attitude and shoddy people skills of the nurse whose patients I got yesterday morning.

A very nice paraplegic guy was upset because he wasn't given enough in-and-out catheters to use all night. Given that he gets dysreflexic if there's more than about 200 ccs of urine in his bladder, catheters are important. He also didn't get antispasmodic medication (very important for spinal-cord-injury patients; the limbs don't just lie there, they spasm) or pain medication for most of the night. There were other problems too minor to go into here...but they add up.

Another patient's husband was upset about the lack of communication on the nurse's part vis a vis what was happening with his wife. The doctor on the case was upset by her lack of help. The doctors on the consulting team were unhappy that the patient had gotten a large enough dose of sedative to leave her obtunded for hours and still zonked the next afternoon.

And all this came down on me. I ran around for several hours making nice, trying to wake my patient up, and generally picking up the pieces. The nurse who left me with this basket of rabid weasels is a technically excellent nurse. She's the shit when it comes to starting IVs and doing paperwork, but her attitude toward any patient who doesn't sleep peacefully all night sucks.

I'd finally had it. After she'd started complaining once again about how big a pain in her ass the obtunded patient had been, I went into Screaming Harpy Mode and yelled. For about ten seconds, at which time I realized it was pointless. Any nurse who responds to the suggestion that she might've oversedated a patient just a *leeeetle* bit with the words "I have to give what the doctor orders, that's my job" is a nincompoop.

I should've used the word "nincompoop" rather than "idiot". I should've moderated my tone and spoken to her in a calm, professional manner outside of the tension of the report room. I should've taken into account what had happened to her that night to make her personality even more wretched than usual.

I should've ripped her arm off and beaten her to death with it there on the spot.

Addendum: I came home to find a message on my machine from this same nurse, asking me to call her so she could clarify something with me. "If you can't, it's no big deal" she said. So I didn't. It's three a.m. If anybody says word uno to me about my not calling back, I'll point out that I too have been dragged into the 20th century and own a cell phone. Call me on that.

Ooooooohhhh, I am *so* not looking forward to Thursday.

Blog O' The Mornin' To Ye!

I love this woman. She writes and thinks the way I want to.

Mouse Words

All I want for Christmas

The tree is up, the frost is on the goose, the pumpkin is getting fat.

Or something like that. The tree (a nice Fraser fir) is indeed up, all six feet of Seuss-inspired silliness of it. I went to a local Walgetmartorama to look at artificial trees and came away unutterably depressed, so I broke all the apartment complex's rules today with my Fresh Cut Tree! Hooray!

The cat is disturbed by the presence of a tree in the living room, but she'll live.

What I want for Christmas, the non-commercial version:

1. To be listed under "Nursing Staff" on Cut to Cure.

2. To get a submission accepted for Grand Rounds. Note that I haven't actually submitted anything yet, primarily because the people who are listed are, like, geniuses. And I feel like an idiot. A neurologically-focused idiot, but a moe-ron nonetheless.

3. Three or four days off in a row with nobody calling me to see if I want an extra shift, or if I'd be willing to be on call. Everybody's been sick lately, what with induced labors and broken backs and the flu.

4. A comic strip that is as unironic and simply beautiful as the old "Peanuts" was.

5. Six more residents like Dario, Mia, Christos, and Jay. Another attending like Kevin: "I went to the Kellogg School of Management so I could manage cornflakes more effectively." Another surgeon like Duke or Bruce.

6. Failing that, no more like Dr. Chucklehead.

Wired, tired, and done, oh my.

I am finished wrapping Christmas presents. That is, I'm done wrapping the ones I have to mail to my family. I'm not done wrapping the ones I bought for The Boy, nor have I even finished assembling the present for a Secret Pal I have through an online forum. But the majority of Christmas present-wrapping is done, which gives me great pride. Even more than that, none of the presents look as though they've been wrapped by a mentally-deficient orangutan with Tourette's. This is unusual for me.

Yesterday was one of those days that every nurse dreads. Nobody coded; nobody had intractable pain...but nothing happened all day.

Nothing, that is, until about an hour and a half before the shift ended, at which point we got eight admissions. That sort of day will make you crazy: You start out well, get into your groove of planning and assessing and running around, then hit a wall. You sit for eight hours with absolutely nada to do, and then all hell breaks loose in the middle of your nap.

I got home so wired I didn't get to bed until after midnight. That's twenty hours out of twenty-four that I was up. It's no surprise I took a two-hour nap today.

Following is an opinion I sent to a pal via email today, included because I'm too damned lazy to think of anything new to write:


I have a BA in music and sociology (double major) and an ADN myself.
Unless you want to teach, research, or be an NP, don't get an MSN. MSNs
are highly specialized and focus on management (ugh) or specific areas
of practice like oncology or family practice or women's health etc.
MSNs are a waste of time for the average floor nurse (which is what I
am) and not a great idea for anybody who wants to stop at, say,
midlevel management. Even for upper-level management in a hospital or
community health setting, an MBA would be a better choice.

BSNs are fine and dandy, but I think they're overrated by the nursing
establishment. The amount of clinical experience you get with a BSN
compared with an ADN is about the same; the major difference is (again)
in the focus on management and decision-making skills. What the
proponents of BSN over ADN fail to recognize in my experience, though,
is that the majority of people getting ADNs are doing so because
they've either already got a degree or three in something else or
because they're 45 and changing careers. Both of those things reduce
the need for extra courses on prioritization, law, and management. We
been there, done that.

My advice, which costs what it's worth, is this: get the ADN. It'll
come near to killing you if you pick a good program, but you'll get
more knowledge in less time than you would if you did it any other way.
After that, work in a clinical setting of some sort for a year or two.
(Everybody says that and I've become a believer myself; there's just
something about knowing what works in real life versus what the books
say.) After *that*, make a decision on what to do with the rest of your
brain. You might decide that eine kleine floor nurse is what you want
to be, or you might have found some specialty that sparks a need to go
further in school.

A word about specialties: everybody ("everybody" being nursing
professors, nursing consultants, and others who haven't worked in the
field for years) says to work med-surg for a couple of years to "build
your skills" before you specialize. Bullshit, in a word. People coming
into hospitals are so sick now, and have so much going on in terms of
different systemic involvements, that even a specialty is broad enough
in practice to learn things. I deal every day with cardiac involvement,
diabetes, arthritis, women of reproductive age...you name it. And I
work in an environment that I lot of people would consider progressive
care rather than an acute care floor.

That, in long, is my sermon to anybody considering starting a nursing career after doing something else.

Can't Do Better Than This 'Un...

Courtesy of Geena.

Rock/Suck

The occasional Rock/Suck list returns.

Rock:

1. Hamilton-Beach's version of an electric grilling machine. I just made no-added-fat salmon with garlic and pepper in under eight minutes. And mushrooms. And asparagus. Next up, portabello mushrooms. Plus, you can flatten the darned thing out and put on flat grill plates and make pancakes for your sweetie!

2. Glad Corn. For the love of Mike, stay away from this stuff. It's salty, crunchy, a cross between Corn-Nuts and popcorn, and I think they dust it with crack. The cat even ate some while my back was turned. You can find it at any good organic food store, right under the sign that says "I'd Turn Back If I Were You."

3. Land's End flannel sheets. I have a set that Beloved Sister sent after she was done with them, and they're still the softest, warmest things I own. No frays, either, on the hems.

Suck:

1. Garnier Fructis Revitalizing Shampoo. I'm sure it's wonderful for some folks, and gee it smells terrific, but it turns my hair brown. My hair is red.

2. Any generic brand "guacamole-style" dip. Just...don't.

3. Dropping a Christmas present on your feet. Especially if it's a Christmas present your folks sent you. Especially if it's a 19-kilogram (41 lb) folding butcher-block table with a stainless steel frame. Again, just...don't.

What I do when I'm not working.

Truly kickass pasta salad

Normally I hate pasta salad. I don't hate this one. Warning: it will make all vampires in your neighborhood very scarce.

Boil 1/2 pound of pasta, preferably something twisty or round-y or ridged.

While the pasta is cooking to the al dente stage, combine:

3/4 cup olive oil
1/4 cup red balsamic vinegar
2 tablespoons capers
about a teaspoon of anchovy paste
about a teaspoon of black pepper
5 big cloves of garlic

In a blender and whirrrrrr until it's all unlumpy and creamy.

Drain cooked pasta and dump in bowl. Follow with enough of the dressing to coat--you may not need all of it. Let it cool down a bit.

Add:

*1 cucumber, peeled, seeded, and diced
*1 diced red pepper
*2 cans quartered artichoke hearts, torn up with your hands while you giggle
*1 pint of quartered or halved cherry tomatoes--the really sweet sort you have to stop snacking on as you cook
*enough black olives to make you hum under your breath. Kalamatas are good.
*some cheese, cubed. Mozzerella is yummy, though I'm partial to a nice mild Muenster.

You want something that's mostly veggies, with pasta as a filler. Sometimes I add tiny whole broiled mushrooms or chunks of cooked chicken. Sometimes I add bits of ham or salami. Sometimes I don't add anything extra and simply sit on the floor, eating the salad out of the bowl with my big wooden mixing spoon.

Back in the saddle again...

A couple of folks have mentioned that my blog isn't the Laff Riot lately that they're accustomed to. I therefore present...

Tips for Folks.

1. If grandma is frail, confused, and 90 years old, put her bedroom on the *first* floor. That way she won't fall down the stairs and break all sorts of things.

2. Turn on the fucking light before you go to the damned bathroom. You won't break an ankle in 14 places.

3. I am the new sheriff, here to clean up the town. Deal with it.

4. You *will* get up. Doctor's orders are *orders*, not suggestions.

Don't make me tell you this again, people.

Have I mentioned lately how crazy I am about my boyfriend? I got to meet his sister in law, a woman with whom I'd love to have a couple of cups of coffee, over Thanksgiving weekend. It's rare that I approach somebody with the catlike caution that means I might make a friend, but I did her.

Also, his brother rocks my world. He mentioned casually during the evening that, as far as he was concerned, I was his new sister-in-law. Brother was rewarded with seeing me gape like a goldfish for a good five seconds.

But best of all is the way the day suddenly improves when he calls.

Enough mush. Off to the fridge for a beer; Nurse Jo is done for the day.

This one is for John.

I've been corresponding off-and-on with a nursing student in Arizona named John. He's married with kids and works full-time in addition to going to nursing school. That makes my jaw drop: anybody who's done nursing school, especially an accelerated program, knows that it invades your sleep, your dinner table conversation, and your showers. Working while you do it is crazy. Raising a family is nearly impossible.

So I asked him how he's managed it. In return, he sent an explanation that included a mention of his recent surgery.

John weighed 500 pounds last year. He had gastric bypass surgery three months ago, in an effort to live long enough to see his kids grow up.

People, 500 pounds is no laughing matter. At that size, as John points out, breathing is hard work. You can be smothered, literally, by your own weight as you sleep--for that reason, many really obese folks have little machines that push air into their lungs as they snooze. Walking is difficult. Your knees, hips, and back start to give out. You live with chronic pain and skin infections, as the skin folds you've got trap bacteria and fungi. Going out to a movie is out of the question, as is sitting comfortably--or at all--on the average toilet seat. Furniture breaks, beds sag, cars need struts far more often than those driven by those of us who are a measly 30 pounds overweight.

Imagine for a moment being so large that you can't have laparascopic surgery--the instruments aren't long enough. Imagine being told that for the rest of your life, a half-cup of food at a time will be a lot. Imagine having to pay more attention to food--now an unattainable addiction--than you've ever had to before in your life...and not being able to eat until you're full without vomiting immediately.

Now put all that in context with working for a living, going to nursing school, raising three kids, and trying to be a decent husband.

John, man, I salute you. You've taken on one of the toughest challenges a person can face: one that'll change your life, hopefully for the better, but that'll take time. It'll necessitate your changing your long-held beliefs and your perspectives, it'll require that you develop emotional reserves you didn't think you could.

And I'm not talking about the surgery. To do what you've done is brave and impressive and I'm sitting here, admiring the hell out of you for it.

What would you do?

We were discussing (not on my regular floor) the Hemicorporectomy Guy yesterday. One of the nurses asked if he had a family and kids and grandkids and so on, because she "couldn't imagine living like that if I didn't have something else to live for."

Wow.

I replied that I hoped I'd never have to make the choice, but that there was still an awful lot I wanted to do and see and learn, and that maybe I could manage with half a body.

"But you'd only be half a person" she protested.

Double wow. And this from a rehabilitation nurse. Who works with amputees and paras and quads all the time.

There's a difference between being half a person and being a whole person in half a body. Obviously. As far as I can recall, I've never met a half-person. I mean, I've never met anybody so stunted or handicapped emotionally or mentally that they weren't able to appreciate, at least on some level, the same things that the rest of us do. People who are persistently vegetative or profoundly mentally handicapped respond well to touch and music and other sorts of stimulation; just because they can't talk politics doesn't make them a half a person.

Likewise, losing the bottom half of your body doesn't make you a half a person. You still have a brain, a mind, and the technology to get around physically. You can still roll around the middle of Seattle or Paris or wherever you'd like. You can still type, write the Great American Novel, or compose music. It would take determination and imagination and a hell of a lot of help, but you're not half a person without your legs.

Living only for your kids and grandkids in that sort of situation strikes me as unfair, both for them and for you. Maybe your kids and grandkids would feel terribly guilty, knowing that you didn't want to be alive, really, except for them. And what sort of barriers are you setting up to your own growth if you say, "The only reason I'm alive today is for you"?

Hell of a burden to bind on anybody else's shoulders, I say.

In other news

You'll notice a new link on this page. The link goes to Ivo Drury's medical blog, which is part of his physician career consulting site. I'd mentioned some weeks ago that I was considering taking advertising here, and this is it. I feel okay about imploring readers to click his links because I click them myself. Ivo is a concise, entertaining writer. He expresses the humanity necessary in medicine in ways that anyone can understand. He's not afraid to expose his own vulnerabilities or talk about his own mistakes.

So click the damned link, already.

Nota bene: I am being paid for hosting his ad, yes. The monies that come in from that are going to charity: half to pay for an annual exam at Planned Parenthood for some person with no money and half to pay for shots and a check-up for some puppy or kitty-cat with no dough at my vet's office. So not only are you helping out Ivo by reading his stuff, but you're helping the poor and downtrodden mammals of my town.

Suddenly/I'm not half the man I used to be...

There is a man, currently on a different floor of the hospital, who will be coming to us after his next surgery. His previous surgeries have been to debride decubitus ulcers (pressure or bed sores) and to create an ileostomy and urinary diversion in his abdomen.

His next surgery will be a hemicorporectomy.

Think about that word. "Ectomy" is a suffix meaning "to remove." "Hemi" means "half," while "corpo-" means "body."

This man will have half his body removed, a la the magician's trick of sawing the lovely assistant in half. Only for him, it'll be real. And dangerous; there's a strong chance that he won't survive the surgery. Even a high amputation of one leg is tricky; taking a person's lower half off is bound to be a stinker.

He was sent home to die by several other hospitals. He has chronic infected bedsores (he's paraplegic), has become septic, and was seen as a non-starter by surgeons. He's also in his early forties and is intact save that his legs don't work and have turned against him with gangrene. So he decided to take the chance of dying during surgery for the opportunity to live a whole life in half a body.

If I sound lighthearted, it's because the thought of this surgery scares the bejeezus out of me. Imagine waking up after surgery with your lower spine, your buttocks and genetalia, your legs...gone. On purpose. It sounds like something out of a bad horror movie, doesn't it? But it's an option that this man discovered on his own, researched, and then convinced one of our doctors to consider. She did, and now he's scheduled to be sawed in half (in a measured, careful way) so that he doesn't die of various infections.

After which he'll come to our floor for recovery, then move on to rehabilitation. Most nurses might see one or two hemipelvectomies (those are amputations that remove a leg and half the pelvis, usually for cancer) in a lifetime; the chances of seeing somebody with a hemicorporectomy are quite slim. For that reason we've all been researching and reading articles and discussing this case for the last two days. It's a way to prepare; the nursing care is sure to be challenging.

So will the emotional aspects, and not just for the patient. When you see somebody who's shy an arm or two or a leg or two, you don't automatically assume that that person is thereby less of a person. The idea of losing so much of your body, though, makes you question whether or not the person's person-ness will be adversely affected. It also makes me face my fears of traumatic amputation (or planned amputation, for that matter) and the fears I have of something so uncontrollable, so horrible happening that I would consider such a thing.

On to lighter topics

My Culinary Institute of America-trained, three-star chef boyfriend asked me today how to roast a turkey. "Bake at 325 or so until the thigh registers 180 on a meat thermometer...wait. You don't know how to roast a turkey? You've never roasted a turkey??" Turns out he doesn't like turkey and never bothered to learn how to roast one. If he gets any compliments on the turkey at La Schwankienne Restaurante today, I'm taking credit.

Which might just balance out the fact that the rolls I made for his family dinner tonight, to his instructions and with his recipe, suck. Maybe they're supposed to be that way. All I know is that if he'd've let me make my own damn rolls, we'd be chomping our way through mounds of doughy goodness tonight rather than breaking teeth on hockey pucks the way Grandma used to bake 'em.

Speaking of, I have just over an hour to shower and dress for The Big Family Dinner. Yes, Mom, I am bringing a hostess gift. Hope everybody has a happy Thanksgiving, no matter what bits of you may or may not still be attached.

*sigh*

Employee reviews were yesterday. Everyone on the floor was rated a 3 on a scale of 1 to 5, three being "meets expectations". Ones are apparently reserved for nurses who, you know, actually kill patients, while fives are reserved for the Holy Ghost Incarnate types who work immense amounts of overtime, spend hundreds of hours each year on clinical ladder work, and generally overachieve.

For what it's worth, I got two fives--one for "talks to her patients as though they're human beings" and "takes time to explain the niggly shit that nobody else does".

Still, there are things that bother me about this. Why, for instance, would a manager simply mark everybody at "meets expectations"? There are a couple of folks on the floor who most decidedly do *not* meet expectations. I was always under the impression that reviews were supposed to give you something to work on as well as kudos. And why would a manager who spends most days on a different unit bother to rate our practice at all? Why not leave that to the sub-managers, the people who actually see us practice? Why not give us something useful rather than simply playing it safe?

It's an interesting sidelight to this that the manager has specific goals for all of the nurses on the floor: Everybody Has To Do Everything. We have three "special" programs on the floor: clinical ladder, preceptoring, and COU.

The close observation unit is something I've written about before, so I won't go over that again. Preceptoring is, basically, taking on a new nurse or a new-to-us nurse and training them in the procedures and patients that they're likely to run into on a neuro floor.

Preceptoring takes a person with a lot of patience and a well-organized mind. I have a well-organized mind but a shitty memory and zero patience with students. Realizing that, I told Manager yesterday that I will not precept. Period. "But you're good with the nursing students" Manager protested. Yeah, for five minutes at a stretch. Give me the same person for six or eight weeks and I'll turn into a snappish martinet. There's no need to traumatize a new nurse in order to prove that I'm not good at teaching; I've done it before and know my limitations.

The other bugaboo is Clinical Ladder. This is a hospital-wide program designed to make nurses more competent in their specialty, as well as to introduce them to the wide world of volunteer work and training other nurses. We do get paid more if we complete the clinical ladder program, so there are compensations besides being a Champeen Form-Filler-Outer.

At the end of the day, all CL proves is that somebody is willing to copy articles, post them, and cram for a cert. exam once a year. There's no standard formula that tests whether a nurse on the ladder is actually becoming more competent. Those who invest the time in CL are generally those who 1. live in the city and don't have to commute, 2. work three-quarter time or only on weekends, or 3. are generally recognized as being such strange people that it's inconceivable that they'd have a life. Petty but true, that last one.

I'm pretty damned competent, as are most of my colleagues. We see no reason why, as a group, we should be expected to conform to a standard set apparently at random by someone who isn't competent in our field (Manager is a cardiac nurse, not a neuro nurse) and who doesn't live in our unit.

I guess what bothers me about this whole culture of standardization is this: We work with patients who have weird brain things going on. Every patient is different, as is every nurse. Yes, there are some similarities among people who have subarachnoid hemorrhages, as there are among people who specialize in neurology...but you can't expect total uniformity inside either group.

If you hired me because I'm unique, then let me *be* unique. Don't pressure me to do things that I'm just plain not good at, like preceptoring, or expect me to produce the outward flourishes that signify competence instead of demonstrating competence. If you want good nurses, let us be good nurses. Let us spend time with our patients rather than pressuring us to copy yet another article from JAMA.

I probably have more esoteric crap stuffed into my brain than almost anyone else in the unit. I read compulsively and widely. My talent is Translating Medicalese Into English For The Benefit of Civilians. I'm good at what I do. I'm as intelligent as almost anybody else and more so than a number of people...but the current standard, as it's been put into place by Manager, doesn't allow me to demonstrate that.

Nor does it allow other nurses with different talents to demonstrate those talents. It's the standardization that bugs me. We're a tight group of loose cannons. We demonstrate our strengths every day. Watch us instead of asking us to fill out yet more forms. You might learn something.

Channelling Andy Rooney

Grump, grump, grump.

There's nothing like being awakened three times during the night by someone else's child, then treated to the sound and sight of repeated temper tantrums at 0630 in the morning on your day off. This is why I do not have children. This is also why I left The Boyfriend's house this morning without coffee or a shower.

Please explain to me why people can drive like bats out of Hades when it's raining and pissing and visibility is what you'd see in, say, the middle of a tar pit, yet slow down in the same construction zones on perfectly clear nights. There are two construction zones--the sort with no shoulder, where three lanes of traffic zoom between concrete barriers--between me and work. Every clear, lovely night people slow down and we crawl through at 25 miles an hour. On nights like Saturday night, when it's raining cats and dogs, they blast through the flooded areas going 80. Riddle me that.

If you tell me that you're friends with the hospital board president, it will not make me treat you any better. Especially if you're obnoxious. Let's face it: unless Mister Bigshot is in the room with you, holding your hand, you're just another patient.

My hospital hobbyist is now in isolation. Unfortunately that means little or nothing to HH's spouse, who insists upon heating up dinner in the communal microwave and removing equipment from the room. Given that these are the same people who think that empty rooms are good for taking naps or entertaining the kids, I'm not surprised...

Goodness. In my current mood, the only thing to do is scrub the shower. That'll make me feel less grouchy, and I'll end with a sparkly clean bathtub.

Never, ever, evereverever....

Drink with a fireman.

Especially a fireman who's just gotten off his 24 hours. An English fireman (that is, an Englishman who's here fighting fires) at that. Perhaps especially, never ever drink with an English fireman from Islington, a place that apparently endows its children with heart of oak and liver of stainless steel.

If you do decide to drink with a fireman, do not trade stories about work. If you do decide to trade stories about work, do it somewhere other than a quiet pub. Otherwise, people might start to look at you funny.

At least I know that my job, whatever its adventures, is not so bad. "What's the hardest thing you've done lately? Trauma?" I asked. "Oh, no" he replied. "Trauma is easy. CPR on a 400 pound corpse is hard." "How corpsey?" "Very, very corpsey."

In other news

We have four ICU overflow beds on our floor. That is, when the intensive care unit is tippy-top full, the Powers That Be send the extra neuro ICU folks to us. I worked a shift this weekend in the overflow unit, with--thank you, God--only one patient, and her with only one drip.

Having ICU overflow beds on a regular floor is a bad idea. The number and type of monitors, drips, and tubes your neuro ICU person has wired into his head or heart requires that the room be set up differently and that it be out of the way, in a place surrounded by signs warning of the Dangers of Cellphone Use. That means that the only practical place to put overflow patients on our floor is in a suite of rooms off in the boonies where nobody can hear you scream.

More importantly, we are not ICU nurses. Hand me a patient with a nicardipine drip (used to control blood pressure) and I can handle it without too much trouble...but I don't like it. I'm not in practice for it. Telemetry, while not a completely closed book, is not something I do every day. I can bumble along, true--but bumbling along is not something you want for a person who's sick enough for the ICU.

It was lucky for everyone involved that my patient was stable.

How to be an addict

If you're poor, you'll have to get your hits from the street or a series of ERs. If you're rich, you can milk a few months out of various hospitals with a series of ever-more-complex problems that require Demerol and Phenergan to treat. If you're rich and well-connected, you can find a doctor who will diagnose you with a rare disorder, one that requires diagnosis by exclusion, and you can run with the Dilaudid for years on end.

One of our pet Hospital Hobbyists came in three weeks ago and is still with us. This patient is still getting various fun narcotics to control pain that's caused by a rare disorder--one that allows a significant amount of activity in the hospital but apparently renders one inable to go home to perform the same activities. Dilaudid every two hours, nausea medications every four, and a tea-time dose of some sort of tranquilizer is helping the Hospital Hobbyist get through the day, see friends and relatives, and take a little vacation from real life.

I had another of the Hobbyists a few months ago, with the same attending physician, and got into an argument with said physician over my unwillingness to push 50 milligrams of Phenergan and 8 milligrams of Dilaudid every two hours. For those non-nurses in the audience, these are drugs at doses that would knock down a small hippopotamus for several hours. Yet the Hobbyist in question was still happy and conversant, completely sane, and relieved that the withdrawal symptoms had stopped for a bit. Not that any Hobbyist would ever admit that, of course. Nor would a Hobbyist appreciate the observation that their hospitalizations tend to come over holidays and other high-stress times in their lives.

Don't ask me why people do this. Don't ask me to speculate on how they get this way or why their physicians allow the behavior to continue. I swear that when my liver decides to cut out the middleman and hop out of my body to find a bar on its own, it won't have to go past hospital security to do it.

Finally, a political post.

This gentleman is the reason I'm a liberal.

"Comfort women." Nice. Just...well, I'll be honest with you. I understand that a blog's a blog; that people can be just as sweet or as nasty or as purposefully inflammatory as they want, and that a lot of folks are inflammatory for fun. We'll take that as read; I'm not naive enough to believe that everything written in the NetWorldBlogOSphere is meant to be taken seriously.

But "comfort women"? Uh...do the thousands of Korean women who were tagged with that name originally not mean anything to you?

Curb stomping and comfort women. Amazing. Makes me wonder if somebody like Joe Lieberman is, in this guy's eyes, a Comfort Heeb. You know, not too bright, but good with the deli meats and bagels.

Holy shit. This is the reason I'm not moving to Canada. Specifically, the likes of Ann Coulter and William Bennet are the reason I'm not moving to Canada. *Somebody* intelligent has to stay and enunciate the other side's views.

For the record, the above link came from Pinko Feminist Hellcat's blog.

Ethical noodlings, or, Friends Don't Let Friends Treat Friends. Or Family.

Geena at Code Blog has a story that every nurse can echo: the conundrum of the patient whose doctor is unwilling to let him die the way he'd like. When something like what she describes starts to go down, everyone around gets involved--the family, the nurses, the residents. Sometimes it works out. Sometimes it doesn't. Here, from my own experience, two stories that came swimming back to the top of my head after I read Geena's post. Note that these are even more heavily fictionalized than usual.

Case #1: Bill W.

Bill W. was a high-powered executive with a large national company based in our town. He was well-liked, considered by friends and coworkers to be a highly ethical, stand-up kind of man. He had a large supportive family. He was diagnosed with lung cancer at 45 and, with extensive treatment, went into remission.

His remission lasted twelve years, at which point he ended up with brain, liver, and spinal metastases. The prognosis was quite poor; you rarely end up beating back a disease as aggressive as lung cancer more than once. He ended up in my care on the medical floor. The first day he was communicative but disoriented. The second day he was responding to touch but not making any sense. The third day he stopped responding at all.

He and his family agreed that he should be no-coded (ie, a "DNR," or "do not resuscitate") and that treatment should be palliative. His doctor, on the other hand, was unwilling to let his patient die. On the third day I had Bill in my care, his doctor wrote orders for IV fluids at 125 ccs per hour (about half a cup; much more than is necessary for palliative care), every-six-hour fingersticks for blood glucose, insulin injections, and three different IV antibiotics.

The man was comatose. His kidneys had failed; he was producing about three tablespoons of urine in an hour. What his kidneys couldn't get rid of had settled in his legs, his scrotum, and his lungs. His hands and arms were swollen and bruised from repeated IV sticks and lab draws. His breathing was harsh and slow, with long periods of apnea.

The resident and I got into a very polite shouting match about his treatment. I told her that it went against my grain to go against his and his family's wishes for his death; she told me that her boss (his attending physician) felt he had to "try everything" for the man and the family he'd known since childhood.

Eventually, the family's and my viewpoint carried the day and Bill was put on an IV morphine drip. Palliative care was all we gave; we stopped the insulin injections and the antibiotics. He died the next afternoon with his family in the room with him; I bathed his body and walked it to the morgue.

Who was right? Who knows? Who can say that a person at the edge of death, unable to talk or make his wishes known, might not experience a change of heart and want others to do whatever's necessary to bring him back? Is it cruel to run IV fluids and antibiotics and stick somebody with needles when they most likely can't feel it, or at least can't translate the pain into anything meaningful? And would the person in the bed want to go through all that, if it meant that his wife and kids could sleep better at night?

Case #2: Kelly G.

Kelly was involved in a one-car accident that left her in a persistent vegetative state. The trauma of her accident had led to one of her arms being amputated below the elbow and one leg being amputated above the knee. She had a tube going into her stomach for feedings, a trach to breathe through, and a tube coming out of her belly just above her pubic bone to drain urine. She came to our floor without purposeful response to anything including pain, with only basic brainstem reflexes, and with very sluggish pupillary reflexes.

She also, because of the sort of trauma she'd had, had seizures. In order to relax her rigid muscles and prevent the seizures, she was on a number of medications, all of them sedating.

By the time I saw her the first time, she'd been like this for four years. She'd endured seven bouts of pneumonia, uncountable urinary tract infections, bedsores, and her limbs were contracted from lack of use. Her parents had bankrupted themselves to care for her. They were convinced that she would someday wake up and begin to respond to them in a meaningful way.

Shortly after her last hospitalization with us, her parents began to wean her off of all sedating medications, including the ones that were preventing her seizures. Their theory was that the medications were delaying or derailing any chance she had of getting better. Within six months she'd had six tonic-clonic ("grand mal") seizures. One had lasted three and a half minutes, a long time for a seizure. Her spasticity had gotten worse, and she'd begun to vomit tube feeding and inhale it, thus setting herself up for more bouts of pneumonia.

But her parents persisted, thinking that at some point she would, in the words of one of my more blunt colleagues, "Sit up and ask for a Pepsi."

Again, who's right? I can't imagine what her parents went through, having a bright and talented 16-year-old who came so close to dying and returned to them far from intact. Was it cruelty to keep her alive on life support in the first place? What about each successive case of pneumonia? Should one of them have gone untreated? And is it ethical to subject a person, no matter how unable to think or feel or respond, to repeated seizures in an attempt to bring them out of the shell that brain injury creates?

And the question comes up again: would the patient have wanted to go through this in order to spare her family the late-night what-ifs?

At the end of the day, I guess it's just not up to us, as caregivers, to have the definitive answers to those questions. The best you can do is to have some sense of when things are crossing the line for you, personally, and when you have to get somebody else to provide care. Sometimes it's hard like this; most of the time things are easier. Thank God.

I'll get to it, I swear.

Sorry, kids. I just don't have the energy today to deal with The Types of Nursing Student. Maybe next week.

Beekeeping, or odds and ends cleared up

GruntDoc has noticed that I don't have a description of ED docs in my guide to specialists. As I told him, I'm depraved on account of I'm deprived--our hospital, being referral-only, has no ED.

However, I'm sure that ED guys and gals are uniformly the most attractive, most talented, most charming, and most tasteful doctors of them all.

I've not written lately because my arm is acting up. I have an old case of ulnar neuropathy that doesn't take kindly to typing, though it'll handle cooking just fine. The result is that I've made a huge salad to last the week and baked some apples today.

The rash is better, thanks for asking. Not gone, but not as leprous as it was.

Head Nurse: Now With More Poop

I got a request via email for more poop and mucus stories. (You know who you are.) Therefore, I present to you the Worst Poop Story of Them All:

A young man with a high cervical injury was admitted to our floor by the PM&R doc that sees him most often. His diagnosis was fecal impaction: not unusual in spinal-cord-injury patients, as nothing below the level of the injury really works as it ought to. Even daily bowel programs don't always do the trick.

This kid was scheduled for a colostomy to reduce the need for occasional admissions for disimpaction. Problem was, he hadn't had a normal bowel movement in something like six weeks. He'd been having *daily* bowel movements, but not enough to keep him from....well, from backing up.

On assessment, the guy had a distended belly. Let me rephrase that: He looked like he was ten months gone with quadruplets. Bowel sounds were almost normal all over except in the lower-left quadrant. He complained of a lack of appetite and difficulty breathing; not surprising considering what he was dealing with. His belly was tympanic to percussion. (In English, that means it went "bomp bomp bomp" like a drum when I whacked it gently.)

His doc decided to try the gentle stuff first: a couple of doses of Sennakot over a few hours, digital stimulation, and see what happened.

Nothing.

So she went to two bottles of magnesium citrate and digital stim.

Nothing.

Enemas. Nothing. More mag citrate. Nothing. Further doses of laxative. Nothing.

Finally, I called her just before shift change and asked permission to coordinate with another nurse who worked nights and simply do our worst.

So James and I went to work in tandem, him on nights and me on days. Our poor distended patient got a couple of Triple-H enemas (high, hot, and a hell of a lot) and a gallon of Go-Lytely, given in a dose of fifty cc's every ten minutes. (In a case like this, you want to work from both ends and not dose the person too hard with Go-Lytely, lest something bust open.) In the morning, he got yet another enema and some more mag citrate, drunk slowly and carefully.

About two o'clock in the afternoon things started to happen. By four his belly was soft and nontender, its normal size, and we'd all had three changes of clothes. It ended up being easiest simply to hold him up while he sat on the regular toilet--not the bedside commode--and flush every thirty seconds or so as he sat.

Some medications dissolve through their capsule, leaving their shells--the actual tablet or capsule part that you see--intact. He had literally hundreds of those backed up in his colon. That should give you some idea of what our day was like.

If the government is ever looking for a cheap, easy way to put people into low-earth orbit without a spacecraft, I recommend magnesium citrate and a hose.

Taking care of business

A few updates:

1. My rash is slowly improving. On the offchance that this could be pellagra, the plague, or alien invasion, I'm upping my vitamins and doubling up the Clarinex. Maybe I'll see the doctor; maybe not.

2. Faithful reader Mark has suggested that I do something called an RSS feed on this blog. Watch this space for technical foul-ups and broken links as I attempt that very thing.

3. You may soonish be seeing an ad on this very blog. Please attend:

It was my original intention to make this site something that maybe one or two people would read three or four times a year, after heavy doses of antiemetics and Immodium. Unfortunately, as with so many other things in my life, I failed miserably in the attempt. So much so that some very nice but probably not-too-bright person in Cyberland wants to link a site he manages to this one.

I didn't want to go commercial (as it were) at first, but damn, I can really get behind the site in question. I like the writing, I like the premise, and the folks there seem to be doing good work. When the link goes up, you'll see what I mean. I've no idea when that might happen; the person in charge of such things is just as laissez-faire about deadlines as I am.

I really wish I felt inspired.

Sorry, folks. The guide to nursing students will have to wait. Right now I feel rather like an old car that suddenly has things going wrong with it all over.

The count so far is:

1. One left ankle that's still complaining when I try to put weight on it in a certain way

2. One right arm that's having a flare-up of ulnar neuropathy

3. One left deltoid that's developed an odd, itchy reaction to the flu shot I (miraculously) managed to get yesterday

4. Several square feet of skin that's now covered, not just with an itchy bumpy rash, but also with hives in weird spots (back of one thigh, front of one shoulder).

The plan for today, therefore, is to stick my check in the bank, swing by the early-voting place and vote, and then hit the drug store for things I avoid, like Benadryl. I wouldn't normally touch that stuff, but being goofy and sleepy and weird for twelve hours, even with the attendant hallucinations, beats looking like something that ought to be sitting in rags, bowl held out beseechingly, on the street of a medieval walled city.

Once many years ago, when I still worked in a large college bookstore, I had an interesting Benadryl reaction. Actually, all of us had interesting Benadryl reactions.

It was during the fall rush, the busiest time of year for textbook departments. Those of us who normally worked in the front office placing orders were drafted to help unpack wholesale order after wholesale order of used textbooks. Those damned things come in by the freightload and are in all sorts of shape--from soaked in perfume and god-knows-what to pristine and lovely.

Fall here is bad for allergies. Fall in a dusty warehouse with only fans to cool the place is worse. Fall in a dusty, fan-cooled warehouse with several tons of textbooks is one circle of Hell.

So we all--eight of us--had been pumping the Benadryl for several days as we cleaned books, priced 'em, and tried to get 'em into the hands of the students. If 25 milligrams of diphenhydramine works well, 50 must work better...and if you've built up such a tolerance that 50 will still let you sniffle and sneeze, go on up to 75. At which point you'll begin hallucinating.

And if you're working with seven other people who've also been snacking on antihistamines, you'll soon find that *all* of you are hallucinating. What's more, you're all hallucinating roughly the same things. For us, this meant ten- and twelve-hour days lifting literally two tons apiece while small fuzzy black things scuttled at the edge of our vision.

Lather and rinse that bad boy for ten days, no time off, and see how you're doing at the end. You lose your ability to gibber on about day 5 and become irretrievably punchy on day 8.

And *that*, my chickens, is why I'm going to hide all the sharp things, make sure there's plenty of farina in the house, and lock all the doors before I take my first antihistamine today. If I start dreaming I'm back at the bookstore, at least I won't be moving other peoples' books around.

Growl.

How many nurses does it take to change a lightbulb?
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ONE, to call the intern!

Oh, fuck you.

In case you hadn't noticed, I'm the person that calls you to let you know when you've fucked something up. If your patient has a critically-high potassium level because you've been supplementing them out the wazoo without requesting more levels, I am the person who catches it.

I'm the person who wakes you up, sweetie, before your attending walks into the station and justifiably fries your ass.

I'm the person who holds your patient's hand while she dies, then spends thirty minutes trying to locate you because your department can't get the call schedules right. When you do finally show up, I'm the person who shows you how to fill out the paperwork you should've been familliar with months ago.

I'm the person your attending yells at when *you* fuck up. If you write an order that doesn't comply with our chemo protocol, and forget to have your attending clarify it and cosign it, I am the one who will have to endure thirty seconds of blasting in the nurses' station from your overfed, undercivilized boss.

I'm the person who, just last week, paged you a total of forty-eight times over the course of eight hours about a patient who was hemorrhaging from an incision. I had, of course, already contacted your attending and had the problem dealt with by somebody else...because you had slept through your beeper on your on-call weekend.

I do an amazing amount of scutwork, from running to get you lumbar drain kits to holding your hand when you're doing a procedure you've never done before. I'm the one who keeps that patient with the undiagnosed tremors and dyskinsesia still in my arms while you do a lumbar puncture. I catch your errors more than once a day, thus saving both your license and mine. I change your dressings for you when you don't have time and correct your orders when you don't know that a) Xanax doesn't come IV or b) the dosage of phenytoin for a loading dose. Your patients weep and vent and rage to me so that they can keep a calm face to you, and maybe you won't then think less of them.

I am, in short, a nurse.

I may need you to change a lightbulb, but you apparently need somebody else to wipe your ass.

So why do it?

For starters, it's better than being shot at.

Seriously, if I get my back up at a stupid-nurse joke, why do what I do? Why not take one of those six-week miracle courses that will turn me into a legal nurse expert, or work in case management, or become an NP?

Here are some reasons:

The time I called Mario, one of the neurology residents, with what was an idiotic question. I realized that before he called back and apologized for paging him, remarking that I'd been hired for my looks, not my brains. Mario, with a total lack of irony and his usual sweetness, said, "Jo, I've been trying to tell you that for months, but was afraid it would land me a charge of sexual harassment." (To get the full effect, you need a heavy Brazillian accent on that last bit.)

Hearing a patient or a patient's family member say that they've never been in a hospital with such caring staff or such good care.

Improving one patient's mood or symptoms, or just leaving them better/cleaner/more comfortable than I found them.

The time that the Ice Queen, a brilliant and unapproachable internal med specialist, broke down and confided her worries about her elderly and ill dog. I teared up too; we ended by drinking cups of very hot and very strong tea in the family room.

Watching a total dickhead of a resident turn into a real human being and begin to be good for his patients. Sometimes this takes a while.

Being able to translate what a patient needs into language even the most inhuman doctor will understand, and being able to translate back into English what he says for even the most overwhelmed patient.

The science of neurology and neurosurgery. The joy of learning something new and incredibly neat. The fun of trading jokes with the orthopedics staff or setting aside brownies for the constantly-hungry hem/onc fellow. Seeing the aforementioned dickhead resident melt and grin and stammer when I ask him about his newborn son.

Knowing that somebody was with that person who died. If a patient doesn't have family around, we arrange assignments so somebody can be with him or her when he or she dies. Nobody should have to die alone, without another human being's smells and sounds in the room. Once in a while, I'm that other human being. That's a privilege and an important job.

I'm better at this than I've been at anything else in my entire life. Nursing is a calling, as much as medicine is, or more so--we're belittled and underpaid in a way that doctors aren't once they leave residency. "Just a nurse" is a common refrain among patients and doctors and even some nurses. (Yes, I've said it. Once. And kicked myself silly afterward.)

We don't do this because we want to lean on other people or depend on them for answers. The majority of us have a passion for the science and a fierce pride in our work. We appreciate being given room to practice and independence to make our own decisions. If we fuck up, we admit it and fix it (well...most of us do, at least).

I get cynical. I get angry. There are days when I come home exhausted, sore, covered in puke and shit and blood and less-savory substances, and fall into bed too tired to cry. There are times when I've lost a patient or had to deliver bad news or made a stupid mistake when I berate myself endlessly.

But if you offered me any other job in the world, I wouldn't take it. If I won the lottery tomorrow, I'd keep working. And there's never a morning that I don't secretly look forward to going in to work, no matter how much I might grumble over that first cup of coffee.

Blog O' The Mornin' to Ye!

Michelle Au

Be sure to check out the "Scutmonkey" cartoons. They're among the funniest things I've ever read.

Resident Wife

Love it, love it. *AND* she uses the word "schadenfreude" (spelled correctly, of course) as part of her subtitle.

Jasper Dog

James Lileks, the guy who did The Gallery of Regrettable Food, takes pictures of his dog. Many of them. Many of them are beautiful. It's your dog-fix for the week.

Damn, my ankle hurts.

I was leaving a patient's room today and somehow torqued my left ankle in such a way that it made a little teeeeeny "pop" noise and started to hurt. This was at 0900, of course, so I hobbled around on the ankle for the rest of the day, too busy to ice it or wrap it.

It wouldn't be considered a work injury, ironically enough, because though I was in a patient's room, I wasn't actually *doing anything with the patient* when the injury happened. I guess if you sprain a wrist while holding a pillow over a patient's face, that's workmen's comp for you.

It ain't broken, it's not bleeding, and it's not much swollen. Tonight I'll ice it and elevate it and compress it and all that and see if it's better by Monday.

Dark dread and horror

Monday is the rassumfrassum EKG test I've been simultaneously dreading and not studying for. I can recognize a lethal rhythm on a strip and I know what drugs to give, but some of the trickier, non-lethal rhythms are gone out of my brain. They need to git up on in here by Monday morning so I can keep my job until the next round of testing.

A lack of med blogs?

I read somewhere that medical types are less likely to blog than English majors or law folks. A Chance To Cut Is A Chance To Cure gives the lie to that.

There are some excellent nursing student blogs in there, which surprises me. I don't remember having a lot of time to breathe in nursing school, let alone write funny and perceptive blog entries. These people may well be smarter than me, though. That's usually a safe bet.

And finally, it is officially fall.

I say that because I have my Annual Weird Rash again this year. I get this same Weird Rash every year during the fall, about the same time that other people are being socked with cases of hay fever. My personal opinion is that my body can only produce so much mucus. After attempts to break the Mucus Record, my immune system gives up and focuses on rashes. Itchy ones. Itchy, bumpy ones.

Please send nail clippers and back scratchers. And a three-inch ACE bandage, if you have one. Thanks.

"Use of alcohol on call may merit expulsion!"

(Noah Wyle sighs heavily; cut to Ford commercial.)

Probably a good thing I wasn't on call tonight, then.

Tonight I went to get a nice, peaceful burger at the local bar. It was, instead of a nice, peaceful burger, Pariahs of The Medical World Night.

There was Karen, the woman who trained me at the abortion clinic. There was Julie, who used to escort there. Lisa, who did HIV outreach for the local health department and later moved to the capital city to do the same thing, was dining with Julie.

Goodness. All that the night lacked was a couple of old patients from my Planned Parenthood days.

All went well until Julie, who worked with a woman who worked with my ex-husband, brought up the ex-hub thing. Then everybody got very quiet as I struggled to put into words what the last year has taught me:

1. My marriage sucked from day one.

2. We were both too dumb to notice.

3. Regardless, I'm glad I was married to the man, and retain many happy memories of that decade.

4. He's better off now with the woman he's with, and I'm happy for them both; nay, thrilled, that they could be this content.

5. I'd rather not talk about it any more, thanks.

Perhaps I need to move to a bigger--0r a smaller--town. One where either nobody knows me and my history, or one where *everybody* knows it, but the town's so small nobody wants to talk about it.

If I stay here, my liver is going to cut out the middleman. It's going to hop out of my body, a la Lenny's brother on the "X-files," and go looking for a bar on its own.

Christ...

This is funny...

Completely off-topic

I finished Christmas shopping today

I can't talk about what I got my sister or David, since they both read this blog. But Mom and Dad have nifty things coming: alpaca sweater, horned lizard jewelry, many fine pieces of duck-shaped things for the bathroom. We have a long-running duck joke in our family, and I've used that to best advantage.

What did you say?

David made the comment yesterday that if the funding comes through for his B & B (he wants to buy one south of here, in a touristy area known for its wine) he'll get me a MINI for Christmas. Not likely, but I can dream.

Extremely touching

One of the nurse techs at work told us how he proposed to his wife. She was flying to LA, at the other end of the state, and he had the gate attendant wipe all the flight information off one of the boards and replace it with the words, "Maria, will you marry me?" The gate attendant then announced the proposal over the airport intercom, and everybody around them applauded. Cynical me got a tear in her eye over that one.

Straw what?

I've recently developed a fascination with straw-bale construction. It's termite- and rodent-proof, earthquake- and tornado-proof, damned near fireproof, and cheap cheap cheap to build. A per-square-foot cost of $10 is about all I'll probably be able to afford, ever, and most existing houses are far too big for me. I'm looking at two bedrooms, two baths, and right at 1,000 square feet. Preferably passively-solar-heated, with in-floor hot water heating in the bathrooms (I found I loved that in Denmark) and solar panels on the roof. I don't want to go totally off-grid or sell back energy to the utility folks, but it would be nice to have a system that would make things cheaper, as well as act as a backup.

The neatest thing about straw-bale construction is, for me, the "truth window". That's a little bit of un-plastered wall you leave in the interior part of the house, covered with glass, to show the structure of the house.

They say that hemp bale construction is even better than straw in terms of insulation (straw has an R-50 value on its own), but I hear that hemp dulls chainsaw blades, is a bitch to work with, and is hard to pierce with the rebar that allows it to be load-bearing. Plus, you can't get it anywhere but Canada.

The Nurse's Guide To Specialists

Internal Medicine:

Fit, well-dressed, with a cholesterol of 130 and the oddest prescribing habits you've ever seen. If you need electrolytes repleted or your INR brought to its proper level (that's a measure of clotting time that's influenced by coumadin), the internal med specialist is your gal. Or guy. If you're a nurse, having an internal med consult means that you'll be cutting tablets into quarters and giving 7.5 milligrams of something that comes in a 25-mg dosage, but only on alternate Thursdays during the dark of the moon.

Neurosurgery:

Brilliant, with a necessary arrogance. Would you want somebody suffering pangs of self-doubt while their fingers are in your brain? Didn't think so. Usually underfed and underslept. Will eat anything that's moving slowly or standing still. Very nice people, overall, since they have to deal with people who can't talk, walk, or make a lot of sense. (Those are the nurses, not the patients.)

Neurology:

Sweet, but from Mars. Odd senses of humor. Usually strange facial hair (on the men, not the women). Sometimes they have a fascination with Bach or zebras or rowing. Older neurologists tend to be courtly in the extreme and wear bow ties.

Orthopedics:

The jocks of the medical world. They are carpenters and craftsmen--and I mean that as praise. A good orthopedist working on your hip will leave you with the equivalent of really good Art Deco woodwork: functional and beautiful, with nothing extra added. If you see a muscular young man or woman of few words striding down the hallway with a tiny box containing magnifying eyeglasses in his or her hand, that's your orthopedist.

They also have very strange senses of humor. A few months ago the C group at our facility had "Talk Like A Pirate Day." "Shiver me timbers! Swab the deck with that dressing, matey! AAARRR!"

Cardiothoracic Surgeons:

I do not work with any of those folks and so have no clue what they're like.

Plastic Surgery:

Artistic, with the emotional lability that comes with artistry. I'm personally uncomfortable with plastic surgeons, as I wonder if they're casting a covetous eye on my double chin.

Urology:

How much does that suck? Proctologists are probably the only people with a more-misunderstood specialty. Urologists, however, have the benefit of access to the scariest-looking pieces of medical equipment in the entire hospital.

General Surgeons:

If you see a resident asleep in a chair at the nurses' station, chances are it's a general surgery resident. They're horribly underslept but have a solid working knowledge of where everything ought to go in the body. If you're a general surgeon, you can take people apart and put them back together with no bits left over. I've gotten speech of a few of them that's beyond "mmmmrrrppphhhh" as I wake them up, but not many.

Endocrinology:

Your average endocrinologist has a second brain somewhere in his body, in which he stores minute bits of important information that came from some obscure study in Backobeyondistan five years ago. They will speak to you as equals, even if their conversation about a complex patient eventually sounds to you like "Grobble grobblescrink mmmmREEEE! ppphhhhbt!"

Psychiatry:

Well-dressed, with a fondness for expensive shoes and dangling pendants (men and women respectively). Pleasant but strange. Psych nurses are nice as well, but strange. You *have* to be a little odd to work psych and be good at it.

The best illustration of a typical non-psych-nurse and psych-nurse exchange I can come up with is this:

Me: (trying to reach a med on a high shelf) "Sometimes I wish I were taller, dammit!"

Psych nurse: "Oh...do you have body image issues?"

Next week: The Nurse's Guide to Nursing Students

A cool circle of Hell, with nice silverware.

Today I had lunch with my boyfriend's family.

They are really very nice people. His brother wasn't there, having had car trouble on the way, but his sister was, with her husband and their three kids. His mom was there as well--the reason for the lunch was her birthday.

Let me preface this tale by repeating that I like these people. They're intelligent, polite, funny, pleasant folks.

The trouble was not them; nor was it their children. It was the lunch itself, or maybe the way events conspired against the lunch.

Background: Boyfriend runs the kitchen at an exclusive little lunch-and-dinner place that's attached to a bed-and-breakfast. Fifty-five people is about as many as get served on a typical night; reservations are strongly recommended for dinner. We went to that restaurant for lunch. David came out wearing his chef gear, taking a break from preparing food for a wedding, and ate with us.

"Us" being a four year old, a two year old, a seven week old baby, Mom and Dad, Grandmother, and me.

I'm childfree for a reason. I have little to no interest in children. They don't bug or delight me; they just don't register. Mostly. Unfortunately, one of the things that I hate is adults bringing small children to exclusive eateries that have nothing to entertain kids.

I was one of those people I hate today. The poor kids were trying their best to amuse themselves quietly and politely, but the bread-basket is only going to last so long and forks hold only so much interest. Babies tend to get fussy and have to be fed. Adults tend to try to have conversations that don't have much to do with kids' interests. And no matter how you try, any meal that involves children is going to revolve around those children. Adult conversation is impossible while you're trying to keep one child or another from amputating bits of itself with a knife or tipping over backwards in a chair.

Add to that Hayseed and Hayseedette, our two "servers". I put "server" in quotes because it took us four tries to get teaspoons and three requests to get lemons for tea. "Serve from the left, remove from the right" apparently means (at least to Hayseedette) "Reach across the person who's eating to drop a spoon with a clank on the table in front of the person to her right." Water refills took two or three requests. Coffee got cold. It was bad enough that David sat vibrating with rage next to me, getting more and more humiliated by the minute. As executive chef, he's not responsible for training the wait staff, but still...it's his kitchen and his pidgin.

At least the food was good. Though I did manage to dip my breast into some red pepper puree (a common problem for the busty, Beloved Sister assures me). Nobody noticed. I think.

The brother-in-law faced the menu with trepidation: Unfussy Foodie greets Schwanky Menu. He ordered a beer with a quiet desperation that made me love him and want to take him down the street for a burger. Sister was busy with Baby, whom I tried to calm down at one point but signally failed to un-fuss, beings as I didn't smell like family. And through it all sat Grandmother, being calm and gracious and keeping the two year old from killing herself with cutlery.

All in all, it wasn't bad--except for Hayseed and Hayseedette. I want to train Hayseedette, since she looks like there might be enough synapses in her vacuous eighteen-year-old head to someday make a half-decent waitress. Hayseed I want to kick in the face. Had I known I'd see him today, I'd've worn heavier boots.

This day started with David and me bent over a power snake, unclogging his sewer line. I would've gladly done that all day.

Fat and a quarter tit*

Yesterday was Holy Mary Mother of Gawd Revelation Day. Out of curiosity, I measured myself and typed the numbers into the website for bra fitting I provided the other day, only to find that I'd moved from Cute Lacy Numbers to Three Hooks and Minimizer Size. I am now, judging from the numbers, fully a quarter tit.

John in Phoenix is a snookum-wookum who has complimentary things to say about this blog. In response, since he's a nursing student, I've decided to edit and publish my Ten Rules For Nursing Students, originally compiled some time during my third semester. To wit:

1. Type everything. Instructors prefer typed documents.

It's easier, of course, to jimmy handwriting so that you take up the requisite five pages, which is why instructors prefer typing. It's also nice to be able to read what somebody wrote without having to decipher hieroglyphics for hours. Contrary to popular belief, most nurses have handwriting just as bad as that of most doctors.

2. Handwrite everything. Instructors prefer to see your handwriting.

Or, as one particularly flaky instructor told me, "I like to get a *feeeeel* for what you're doing."

3. Concentrate on textbook learning; you'll learn skills in your graduate internship.

Not a bad piece of advice, especially if you have an internship like mine: heavy on tests for the first three weeks.

4. Concentrate on skills; you won't have time to learn them at your first job.

Foleys and IVs are all you really need to know. A trained monkey can do a dressing change. Really.

5. You will always have one instructor who is totally, completely, inarguably from Mars. Deal with it.

My From Mars moment came in a classroom discussion of ethics and the nursing shortage in our last semester, when one of the instructors on the team told us that the reason for the nursing shortage was that "we've aborted a third of our population since 1973." Everybody, for some reason, turned and looked right at me. I said nothing, preferring to marvel at the clear transmission she achieved even while orbiting somewhere outside the Van Allen Belt.

6. One in ten of your female classmates is looking to meet a doctor. One in ten of your male classmates might be, too. Deal with it.

Not much you can do about that one, unfortunately. The most you can hope for is that she'll leave the plum job she gets as soon as she meets a likely resident, leaving the position open for you.

Before anybody accuses me of stereotyping or downing young female nurses, may I present the following evidence? Out of 19 female classmates, one was in nursing school so her husband would "get off her back" about getting a job. She was pregnant at the beginning of our last semester. Another two were self-professed doctor-hunters. A fourth was admittedly in it for the money, and took a job at a pediatric clinic with the expectation that it would be low work/high pay (heh). A fifth was "drifting", in her own words, and didn't know if she'd actually use the degree or take up crystal healing.

Is it any wonder I was valedictorian of my class?

7. You will have no life for two to four years. Don't worry. It'll still be there when you get back.

I swear. Really. Honest. You'll be able to sleep and get haircuts and go dancing and everything.

8. Everybody thinks they flunked the NCLEX. Few people actually do. Go ahead and get blasted anyhow.

9. Yes, you do look dorky in those whites.

10. No matter how bad things are now, they will end. You will eventually be a nurse, subject to redefining hell. Of course, you'll also redefine happiness.

I can't tell you how much weight I lost the last six weeks of nursing school. The speculation on class ranking had really ramped up, and as immune as I tried to stay, I still felt the pressure to come in first. I think the under on me was something like 10 points.

But it ended. Valedictorian means shit in the world, except that older nurses will expect you to be able to recite the latest information on Disease X without pausing, like a computer.

And you know what? Being a nurse is infinitely easier than being a student. For one thing, being pushed out of the nest means not only the freedom to screw up, it means the freedom to make judgements. You're not really allowed to do that as a student. For another, you're finally done with those fucking care plans. For a third, you're able to sleep without dreaming that you've missed a test or three. Instead, you dream of beeping IV pumps.

To all those poor sots out there who have three, or two, or just one semester to go before the NCLEX, I raise a toast. Nursing is *not* the hardest job in the world. Being a nursing student is.

Oh, I forgot one thing:

11. Comfortable shoes. Comfortable shoes. Comfortable shoes. Comfortable shoes. Comfortable shoes, fer Godssake!!

***

*Carl Bennett, quoted by Oliver Sacks in An Anthropologist on Mars

Looks like it's time to call in the professionals.

Fair warning: girlyness ahead.

One thing nobody ever tells you when you enter nursing school is this: your hands and feet, after four years of schooling and practice, will be practically unrecognizable.

It's not just washing your hands every ten minutes or less or using alcohol foams on them. It's not just wearing heavy protective leather clogs all day long or running from place to place like a chicken. It's a combination of those things and lifting heavy patients and equipment, as well as not having the time or energy most days to fuss with cuticle remover or foot files.

My feet have grown a half-size since I started school. What was once a nice average 8 1/2 medium pair of feet is now a 9 wide. David said, as gently as possible the other night, "When did you decide to try to grow hooves?" I have calluses between my toes; that's how bad it is.

So I'm thinking that it may be time to enlist the services of a professional pedicurist and manicurist twice a month or so. Pal Joey took me for my first pedicure last summer. My shoes fit differently after the poor woman had finished sanding down my calluses. Not that I'm obsessed with my calluses, or that I'm afraid I'll injure my bed partner (although one callus, on my left small toe, left a scratch on his shin), I'm just sayin'.

Taking care of one's hands--which I do actually do--is a matter of self-interest in the nursing profession. A torn cuticle or a hangnail opens up an avenue for infection, no matter how careful you are with gloves. Long nails (ie, anything past the end of your finger) tear gloves and are a perfect habitat for bugs. I am therefore aggressive about keeping my nails short-short, using a good cuticle remover every other night, and slathering on lotion when I get home from work. As a result, my paws look workmanlike but not abused. It's my feet that resemble something from the Russian Ballet.

I guess I'll call my hairdresser, a patient woman who cuts my hair twice a month, tomorrow. I'll see if her partner has any openings on Wednesday. Her partner has horses and a fascination with straw-bale construction, as I do, so will be open to not putting pink nailpolish on my toes.

We'll see.

What's that blue stuff on the weather map?

Oh. It's a flood warning. Lovely.

Chuckleheads on Parade, Part Two

The chucklehead situation I wrote about the other day became so bad on Saturday that I could only sit back and stare with my mouth slightly open. Not only did the patient who got screwed as an inpatient get screwed as an outpatient, but I had another one of Doctor Chucklehead's patients who's going to be in just as bad of shape this morning. Thank God I'm not there to see the rivets pop out of the case manager's skull.

One quick tip for any medico who might be reading: If you write an order at 1700 on Sunday for rehab placement on Monday morning, it's *probably not going to happen*. Case managers have weekends, you know.

I don't want to go into details on the Previous Chucklehead Victim. Suffice to say that the level of arrogance, laziness, and outright disrespect I've seen from The Chucklehead Twins (attending and resident) is unmatched in my experience. Except maybe by the protesters who used to work outside the clinic where I worked. They walked the sidewalk with a baby every day for five years and got paid $38,000 a year by a local anti-choice group for their efforts.

Anyway. The case manager, a slender woman who drinks more coffee than I do, and I will have to figure out a way to do end-runs around Dr. Chucklehead and Friends. The normal routine of explaining, very patiently, why X and Y and Z orders won't work, or why one actually has to *write* an order for what one wants, rather than expecting it to be transmitted telepathically to one or more colleagues, is not going to be enough here. Punishment won't work. A good dope slap would probably be really satisfying, but it won't accomplish much in the long run.

In other news

It's been raining off and on for a week and a half now. This is wonderful for the crops and the grass and all the little birdies, but bad for the people who (like me) have to commute through construction areas. Remind me sometime to tell you what it's like to be slogging along in a Honda Civic when allofasudden the world goes away and you're covered with water.

My car also needs new tires. *sigh*

A Handy Site for Women

More than likely, you're wearing the wrong size bra. I know I am. Check this
out and learn how to fit a bra. As soon as I'm done here I'm getting out the tape measure.

Testing, testing

This week we have a series of tests at work to requalify us for whatever work we're doing. It's a hospital-based version of the ACLS or BLS or COC or whatever tests are national. In other words, we test three times a year for what normally only gets tested once. The biggie for me will be EKG stuff; I'm not a cardiac nurse for a reason. EKG strips have never made the slightest lick of sense to me. I passed that part of nursing school by taxing my short-term memory to the fullest and then promptly forgot everything I'd learned. Since David will be at a food show tonight and tomorrow, that'll be my time to cram QT intervals and P waves back into my noggin.

And so to bed

It's back to beddy-bye for me. The one drawback of working three days in a row (aside from the punchiness that hits on day 3) is that your body wants to get going at 3 am on day 4. I've been up long enough to get sleepy again. The cat will teach me how to nap.

It's schaDENfreude, asshole!

Confidential to Denise: I really, really do know how to spell 'schadenfreude'. It's just that I can barely type in English most of the time, let alone German.

Some nice person sent me an email asking "What's a typical day like for you?" Herewith, A Typical Day In The Life:

0420: Awaken to the dulcet tones of a BBC announcer soothingly reporting the latest casualties from the Gaza Strip.

0423: Pour first cup of coffee.

0424-0440: Mindless circumambulation with said cup of coffee gripped tightly in paws.

0440-0520: Shower, try to apply eye makeup without ending up in traction, dress, decide on lunch. Leave for work.

0610: Arrive at work. Eat yogurt while sitting in car, listening to the dulcet tones of Carl Kasell totalling up the latest casualties in Iraq.

0625: Stumble in to the breakroom with another cup of coffee, prepare for report.

0640: Report until 0700. Pee if possible.

0700: Start waking up patients. Most of them are grumpy, since they've been awakened every two to four hours for days on end. Check lab results from earlier in the morning. Inform the neurosurgery nurse liason if there's anything amiss. Send people to surgery, CT scan, and echo.

0800: Start charting. Morning assessments are done; all that remains is putting them on paper and hoping that I haven't charted Patient X's assessment on Patient Y's chart.

0803: Think longingly of eggs and bacon in the cafeteria downstairs, then remember latest scale numbers and cholesterol results.

0825: Five minutes for bran muffin.

0830: Begin passing morning medications. Deal with, at a minimum, six new orders and four new crises. Receive patient from ICU.

0915: Finish passing medications. Start calling residents, consults, specialists, the housekeeping people, the guest services staff, family members, and wound care/ostomy care/urology people for help or with information.

1006: Morning routine of physical therapy, bowel programs, and incoming phone calls begins. Take time to pee if possible. Change dressings, check ins and outs, empty drains. Retrieve six new orders from box. Discharge two patients home. Charting.

1128: Begin passing noon medications, hanging antibiotics, giving Decadron, and checking blood sugars and every-six-hour lab reports. Do noon assessments on neurology/neurosurgery patients. Call report on patient going to rehabilitation unit. Chart.

1230: Finish above. Begin to think longingly about sandwich. Retrieve six new orders from box. Send patient to rehab.

1240-1315: Various crises, lunch preparations, and phone calls.

1315: Sit down with sandwich. Take first lustful bite, be called away for lift help or because Patient Y has just had explosive diarrhea that covers the entire back wall of the bathroom.

1330: Return to lunch, if fortunate. If *extremely fortunate*, have time for another cup of coffee and a quick pee break.

1400: IV flushes, any dressings I didn't get to in the morning, afternoon rounds of tests start. Assess non-neurology patients again. Catch up with respiratory therapists for progress reports. Check box for new orders. Find new order written by chucklehead from any one of several services and call for clarifications. Hang new bags of tube feeding. Check ins and outs, empty drains, calculate total IV drips for the last seven hours. Check box for new orders. Hang potassium, magnesium, or calcium drips. Chart.

(Optional: four new crises.)

1530: Look at clock, realize there are only three-and-a-half more hours in the day. Fail to mourn this realization. Start 1600 assessments on neurology/neurosurgery patients. Get two new admits from surgery. Discharge late-home patient. Plow through group of new residents taking tour of unit. Be almost rude to hospital administrator taking group of investors through unit and thus blocking the entire damn hallway so I can't get a bed through. Field call bells from patients with problems ranging from inability to breathe to their fruit basket not containing enough grapes.

1700: Neurosurgery rounds start. Stare dully at wall, wishing I worked a ten-hour shift rather than a twelve-hour. Wonder what to have for dinner.

1745: Neuro rounds end. Reassess patients. Retrieve six new orders from box. Direct men who are impersonating Birnam Wood to various rooms for flowers/potted plant deliveries.

1800: Last push of the day. Hang evening medications, pass evening medications, check IV bags. Long for strong drink. Fill out report sheets. Do quick rounds of rooms, picking up dirty linens and trash, changing water in vases (yes, we really still do that). Check to see that evening labs have been sent. Sometimes, if very fortunate, practice French with Cajun patient or discuss politics with Political Heavyweight Patient over dinner. Chart.

1845: Report to night shift. Give up beeper. Hope I haven't forgotten anything.

1908: Punch out. Go home. Fall over.