I Pity The Fool: A Team versus B Team

Movin' Meat has a post up from a week or so ago about what it's like to work with the B Team of nurses.

It got me thinking about the differences between the B and A teams. I've been travelling a lot this past month to different units as staffing gets and stays wonky, and I've definitely had to adjust to the B teams on my own and other units. (Everybody thinks they're on the A team, but I think perhaps I'm not too far off-base with my thinking.) Some of the differences I've noticed:

1. With the B Team, shit simply does not get done.

Illustration: Two weeks ago I floated to another unit. Two hours prior to shift change, one of the day nurses had called in, and the night charge had not called anyone else to try to fill the spot. That's the charge's responsibility, working in tandem with staffing, at our facility. So I showed up, the floor was short-staffed as hell, and we all started with eight high-acuity med/surg patients.

Illustration Numero Dos: While on yet another unit, I got report on a postop patient who had a hemoglobin of 6 and a crit of 24, a blood pressure of 80/48, and a temp of 94.3F. The reporting nurse said, "You'll have to run two units of blood, stat." Uh, no, I replied, since the patient doesn't meet transfer criteria; you'll have to be the one running the blood. "But this guy's been down here four hours already, and I have two more patients coming in!" was the reply. (crickets...crickets) Quick cluebat: If you're postopping a patient for four hours, and he's your only patient during that time, and he's not stable, you have time to run blood. No, really. You do. Trust me.

Illustration Number C, or How It Should Be Done (The A Team): One week postop, a guy who'd had a radical prostatectomy showed up on the floor hemorrhaging from his penis, sweaty, with a temp of 95, HR 126, BP 90/50. By the time the resident had been able to cut out of surgery (half an hour later), I had drawn a rainbow of labs, typed and crossed two units of blood, started a saline bolus, administered a total of twelve milligrams of morphine for his excruciating pain, and started two large-bore IVs. I had a coudet cath set and urinometer at the bedside, along with dilators and lidocaine jelly and Versed.

I could not have done this all myself; the other nurses on the floor did things like start one IV while I did another, called the blood bank to give 'em the heads-up on the patient, and ran supplies back to the room. *That's* the A Team for you.

2. Attitude is everything. With the B Team, the attitudes suck.

Illustration: B Team tech/unit secretary/charge/staff nurse comes in, snaps the heads off co-workers, throws tantrums at the lab and radiology staff, belittles the respiratory therapists, and refuses to provide lift help. She or he spends most of the day on personal phone calls and surfing the Web. There's always a personal crisis that either takes up hours of the workday or necessitates the person leaving early. Best example? A secretary I'm fortunate enough not to work with all that often walked in and announced she'd have to leave mid-morning to attend the funeral of a relative, shot during a bungled drug deal.

How It Should Be Done (The A Team): Everybody on the unit shows up on time, clean, not hung over. Perhaps without the shiny-happy attitude that characterizes Disney employees who are still on the clock, true, but with coffee in hand and ready to work. Personal disputes are relegated to the back burner for twelve hours and cell phones are on vibrate. "Cute Overload" is checked for therapeutic reasons only. This is, thank God, where I work.

3. That certain indefinable something: The B Team Ain't Got It.

I don't know if it's experience (though newbies can certainly be A-Teamers) or perceptiveness or initiative or what, but the A-Team has something the B-Team ain't got. You'll notice that there are some nurses who rarely have patients go bad, unless circumstances are extreme. Some nurses seem always to be a step ahead of the docs when it comes to changes in their patients' conditions. Some nurses rarely if ever have patients who end up with decubitus ulcers or constipated. Those are A team nurses.

4. Humility and the ability to admit when you're in the weeds: See Above.

I work with really, really good people. Therefore, when I'm totally rag-assed and overwhelmed, I can ask for help. When any one of us doesn't remember what the hell a lipase value means or what a particular surgery involves, we ask about it, and nobody laughs. If somebody's in a bind with some procedure or other, or doesn't remember exactly how to level a ventriculostomy, we all are willing to help. And we're not afraid, any of us, to admit that there's somebody better at starting IVs or running NG tubes or putting in a catheter.

God help the nurse who works with the B team: she's on her own.

5. Finally, professionalism and calm: Not To Be Found on the B Floor.

Illustration: Fed-up attending throws temper tantrum at nurses' station. Charge nurse responds by getting in his face. Situation escalates. Nasty words fly. People start waving their arms around. Security is called to de-escalate the fight. (Yes, I've had a fun month, thanks for asking.)

How It's Done On the A Team: Fed-up attending throws tantrum at nurses' station. All the nurses stand around watching until he runs out of steam, then charge nurse remarks calmly that she's glad Attending feels the same way we all do, and why doesn't he write an email to the Carpeted People about it, since our complaints haven't made any difference? She then shows him how to operate the email system and thanks him for his concern. No longer fed-up, the Now Abashed Attending apologizes for his behavior. We accept the apology as a group and all go on taking care of business.

No screaming, no freaking out, no security, and everybody involved understands how professionalism was breached, how it was restored, and where we all stand individually and as a group. We're working together rather than at odds with each other.

Even A teams have B days, for sure. Sometimes everybody's a mess, or getting sick, or a mess *and* getting sick. The A teams, though, pull out of the weeds and keep going, while the B team floors fall to hell. I'm lucky enough to have landed on the A-est of the A-teams at our facility, and fortunate to be able to keep up with my coworkers. After the last few weeks, I am not going anywhere else. Ever. Period.

That's the kind of loyalty the A team inspires.

Change O' Shift is up!

Here.

'Twas the day after Xmas; all over the yard

A lone dog was chewing his prime rib bone hard.

He didn't believe when I gave him the bone;
He thought he'd spend Christmas night cold and alone.

But I came home at seven and gave him his treat,
Something better than kibble and raw egg to eat.
What a sight! Big brown dog-eyes with all the white all around,
As he went off to bury his bone in the ground.

Now it's the day after. His joy undiminished,
He searches for bits of the bone that aren't finished.
I have a surprise for him, here in the kitchen;
Two other prime-rib bones. Max's Christmas is *bitchin'*.

A Chrissolstikah Story

We were sitting around, doing nothing except trading stories of Irritating Family Christmas Traditions.

Munoz and Galindo had nothing to contribute, as Christmas Eve in Miami is celebrated (at least in their families) with huge pitchers of sangria and a slightly tipsy midnight Mass. Porchevsky likewise spent thirty years in the USSR keeping his Christmas traditions under wraps--and Possible Detention By The KGB is past irritating and on into scary. The one Jew in the room, a neurological oncology resident from Israel, was ignoring us and reading the paper. That left only the American nominal Christians to complain.

Becka started: "My mother makes us watch 'A Christmas Story' every year on Christmas Eve. I hate that movie. It annoys me. The business about 'You'll shoot your eye out' makes me pray every year that the kid actually does have some horrible accident and has to spend the rest of the movie in the hospital."

"You think that's bad?" responded James. "My family refuses to acknowledge that I'm gay, and I keep getting books on how to meet women, and free subscriptions to online dating services." He slumped in his chair. "The worst was when the family brought three different girls to meet me at Christmas dinner. They probably hoped I'd marry one of them by New Year's."

I knew I had the ace in the hole, so I waited until everyone else was finished, then cleared my throat.

"My father," I began, "has collected over thirty different singing, dancing, light- and motion-sensitive Christmas decorations."

The room was silent except for the scrape of the neuro resident turning pages.

"Every room in the house, and some of the closets, are fucking deathtraps. If you go into the bathroom on the ground floor, there's a wreath that sings to you. The kitchen is inhabited by a plastic Christmas tree that sings and dances and *tells jokes*. You can't cross the living room without something starting to whirr, click, and recite 'A Visit From Saint Nicholas.'"

"The only thing they lack is a dancing Menorah that sings 'Dreidel, Dreidel, Dreidel.'" I finished.

The neuro resident looked up from his paper and fixed me with a stern eye. "That is *not* Kosher," he said. "Hannukah is for making donuts and lighting candles. It is not about dancing Menorahs. Besides," he finished with a wail, "I HATE THAT SONG!!"

"No disrespect meant," I said, "But you have to admit that a toy fat guy in a red suit kicking his feet as he hangs out of the chimney isn't exactly embodying the spirit of Christmas, either."

"In fact," I said, struck by a sudden thought, "The only thing my folks lack, besides a dancing Menorah, is a Nativity scene in which the Virgin sings 'Papa, Don't Preach.'"*

That did it. Everybody, including the neuro resident, collapsed laughing, and then we all had some donuts.

Happy Holidays, everybody. Whether you spend it drinking sangria, praying in an onion-domed church, dancing around a fire, or eating potatoes in various forms, I hope it's a good one.



*I post this thought with some trepidation. I'm sure Dad will start looking for a singing Nativity now.

Blue

A bouquet of roses on the thigh of a woman who'd been a whore in Paris during the second world war.

A shirt and shorts of Japanese history on a pierced guy about my age in for back surgery. "Will the incision mess up my art?"

The names of three children arranged in a biohazard sign on the bicep of a Marine.

Tiny parachuting stick figures and a crudely-rendered plane on the upper arm of a man who'd been a Russian paratrooper during WWII.

Four dots on the foot of a woman with a huge brain injury.

A teardrop on the left cheek of a man who'd been shot in the head.

Two, in the same week: one on the inside of the left forearm, from Monowitz. One, upper left chest, tattooed all at once earlier in the war, from Auschwitz I.

Umpteeen trails of barbed wire around biceps.

A dragon over a mastectomy scar.

The names of four children, all born dead, winding around an ankle.

One very well-padded woman on the chest of a Korean war veteran. He was embarrassed to let me see it, thinking I'd be offended.

I wish I could take a camera to work.

When it hurts, I cuss.

Prodigally. Fluently. Creatively.

When it hurts a lot, I just make a sort of "Ehnnnggaaaahhh" noise

Today, because I know how to have fun, I stepped on a needle. It was large, but there's no such thing as a small needle when it's going through your foot.

It went straight through the ball of my foot, between two bones (thank FSM for that), and tented the skin on top of my foot, just north of the second and third toe space.

The going-through wasn't as bad as the tenting, and the tenting wasn't as bad as the pulling-out. Like babies and bad oysters, that sonofabitch hurt more coming out than going in. But, after I'd made the requisite "Ehnnnggaaahh" noise and sat down heavily on the side of the bed, there was nothing for it but to pull the damned thing out.

[My earliest memory is of looking through the French doors into the dining room of The Old House at my father as my mother rushed me upstairs. Seems I'd stepped on a needle at whatever age it was (two? Three?) and the needle had gone into the bone of my heel. I have vague memories of watching her pull it out as I sat on her lap in the rocking chair, but the strongest memory is of Dad looking up from his desk in the dining room (which was then his study) and seeing his face go slack.]

This was not that bad. In fact, the worst part of it was momentarily feeling the lump in my skin where the needle eye wanted to break through (because I had, of course, stepped on the thing wrong-end-up). Chef Boy was right there, grabbing my arm and keeping me from becoming hysterical. Bravo, Chef Boy.

So, after a moment for contemplation of the possibilities, off I went to see my friendly neighborhood Doc-In-A-Box. The MD entered the room with the words, "How's the seamstress today?"

Everybody's a comedian.

I have a tetanus shot in my left shoulder and 500 milligrams of Keflex to put in my belly thrice daily, as it would be a bad thing (as the MD pointed out) to get an abscess in my foot just before Christmas. Silly me, I thought an abscess was a bad thing at any time.

I also have about 300 ml. of Pommery POP champagne in my belly. Yes, it's only 13:24. Yes, it's a weekday. But dammit, I finished my Christmas shopping after getting a tetanus shot and stepping on a needle; I'll be damned if I face the rest of the day without help.

So I'm weird. What's it to you?

I find plumbworld.co.uk the most fascinating site on the Internet.

Macerators? Power showers? Bathrooms en suite? It's a whole new world.

Things I have learned on my winter vacation:

1. I am a cheap-ass S.O.B. Instead of dropping twenty-eight smackers on an in-drawer knife holder from Williams-Sonoma, I cut off part of the cardboard center from a roll of shelf liner and cut slits into it. Insta-knife-holder, for free, which not only keeps the knives from getting dull, but also prevents unwitting finger amputation! (I also use magazine subscription cards and those "Have You Seen Me?" things as coasters. Yes, I suck.)

2. I am a clumsy mother(shutyomouth) as well. Friend Pens the Lotion Slut and I were exiting the local shop-n-snack when I tripped and fell. Spectacularly. On dry, flat pavement. That was probably the highlight of Pens's trip, sadly.

3. I am not as good a cook as I thought. Friend Pens and I visited another friend of ours, who made such wonderful food I felt thoroughly spoiled in less than 12 hours. Of course, any recipe that starts with butternut squash and 3.5 cups of half-and-half will be good, but still. Plus, Bek and her husband live in a pastoral setting just up the hill from the Brazos and have a firepit. It was a perfect visit. Perfect.

4. Lane Bryant *rocks*. I went there just a few days ago for the first time and was amazed. I'm technically (in Big-Girl Speak) a "tweener"--somebody who can wear a 10, 12, or 14 depending on the cut. LB specializes in Big Girl clothes, and man, does their stuff *fit*. Every shirt I put on fit my lats and shoulders. Every pair of pants and skirt I tried fit my weightlifter's thighs and butt--*and*! you can buy pants with smaller or larger waists, so those of us with a size 10 waist and size 14 butt won't go naked! They're having a huge sale right now, so go. Seriously. I'm still not mentally over not being a size 6 any more, but the staff and clothes at LB made me feel normal and sexy and stylish.

5. My dog rocks more than I ever thought possible. Hanging out with Max for two weeks uninterrupted made me so grateful to have him around. He's smarter than most people I meet and better-lookin' than all of 'em.

6. I am capable of heretofore-unimagined feats of laziness. The first five days of vacation? Couch. Chair. Eat. Sleep. Beer at noon, with pizza. Couch again. The only time my metabolism got off baseline was when Atilla the Cheerleader showed up to make me run and lift weights. I have no memory of my first week off, and it was heaven.

7. I don't miss having a TV.

8. Not working is highly underrated. The most I did regarding work was to visit my work email and read the occasional, short email, then delete it.

9. If they'd pay me regular wages for staying home, I'd consider it.

10. I am going to be very sad to go back to work. Very sad. Especially when the alarm goes off at oh-dear-thirty on Monday.

11. But I still have two more days!

(Insert clever title here)

Change of Shift is up at Doctor Anonymous's place right now. Yes, yes, I'm a couple of days late. What's new?

Announcement:

I am going on vacation for two weeks. That means I may or may not be blogging. So if I'm not here, don't panic; it's just that I'm napping or walking the dog or something.

It's about damn time, too. I think this is the first real (read: no plans) vacation I've had since before I started nursing school. I didn't have ten full days off during those two years, let alone two weeks without homework. The last time I took time off was for Beloved Sister's wedding, which was lovely, but a house full of my family is not exactly relaxing.

So. I'm going to paint my nails. I'm going to wear my hair *down* for a couple of weeks, rather than *up*, and possibly wear high heels during the day, just for fun. I plan to un-stick the drawers in the kitchen and scrub the house top to bottom and rake leaves. Friend Pens the Lotion Slut is coming to visit for a few days, so that'll be a nice interlude. I might even go shopping. And, of course, drink champagne for no reason, eat artichoke hearts, and do silly crafty things with paint and glue.

I'll see you guys in a few days to a couple of weeks. If I remember something that happened that I simply have to talk about, I'll talk about it...but otherwise, Head Nurse will be Nap Nurse until mid-December.

You must immediately click the following link...

To Digital Cuttlefish.

Immediately.

I don't know how I lived without the Cuttlefish's blog for so long.

(Be certain to read the poem linked as Cute-Cute-Cute.)

Woo doggies.

I do brains. Brains and spines. It's what I do. It's why I titled my blog "Head Nurse." Because I do brains. And spines.

Except lately I've been doing a lot more than brains and spines. Kidneys, for instance, and intestines. And weird plastic surgery dealios that involve, like, seven incisions in somebody's head, all intended to rebuild bits that have been lost to gunshots or cancer or accident.

So I've found myself having to do things that I'm not exactly comfortable with lately, and I've come up with some new tips and tricks. They're old news for those of you who handle a lot of bizarre surgery patients ("bizarre" in this case modifying "surgery"), but they're new to me.

Tip the First: Label IV drips in more than two places.

The rule is to label your pump and your IV line if you're running, say, chemotherapy or total parenteral nutrition, two things that should not be combined with anything else. Normally those lines are labelled on the IV pump itself and then below the IV pump in one spot, using fabric tape and permanent marker or a pre-printed label in yellow or red.

I've found over the last couple of months that that is not enough labelling for somebody like me. I now label TPN and Weird NonMixable Drips in four or five places, running those labels straight down the line. It's not such a big deal if you're infusing, say, normal saline and IV immunoglobulin, but if you've got a four-channel pump with four fluids plus piggybacks, it helps.

Tip the Second: Label the drains coming out of your patient.

Again, I'm used to three or four drains at the most, and those well-spaced: maybe one at the head, one in the belly, and one coming out of the person's lumbar spine. I was confronted late last month with a patient who had ten (10) drains coming out of her belly alone. I'm not counting the ones coming out of her back, or the ones attached to the Wound-Vac.

None of the drains were labelled, yet there was an order that said, "Flush PAD with 30 ccs NS q 8 hrs, dwell for one hr, drain." Um. Lessee...three PADs there and no clue which one to flush. Flush 'em all? Flush one every eight hours? Or ask the resident? I went with door number three, then labelled the drain we were supposed to be flushing. I also labelled the lines with where they went (JP, Jvac, Hemovac, Wound-Vac) so there'd be less tracing back. It also helped differentiate the two drains that had exactly the same tubing but different uses when the only distinguishing marks were covered by tape and connectors.

Tip the Third: Warn the next shift about that abscess.

If you know your opposite number on the night shift will have to irrigate and re-dress an abscess or undermining decubitus, have the Vicks Vaporub right there at the door when they walk in. This is one of those "do unto others" things I wish somebody had done for me. There's nothing quite like encountering a fist-sized hole in somebody's belly or a stage IV undermining bedsore without proper preparation.

Tip the Fourth: Warn the next shift about that resident.

We have our residents trained well. The same can't be said for the residents who are, for our unit, off-service. It's only politic to warn the oncoming shift about the resident who's paranoid, suspicious, and has a God complex. I was the first person to encounter him and thought he was being ironic. Wups.

And, finally, Tip the Fifth: Iodoform, Aquacel, and various other specialty dressings never go as far as you think they will.

Let's say you've got a wound that's just about big enough to swing a cat in. Let's further assume you have to pack that sucker with some sort of wound-packing material. If you already have three containers of that packing in the room, take in a fourth. If there are already four in there, take in a fifth. Have an extra in your pocket just in case. This is especially important if your patient has a live flap from, say, their shoulder to where an ear used to be that has to be wrapped with petrolatum gauze, as that stuff's a beast to work with.

It's been an interesting couple of months. Things'll probably start getting back to normal soon, as the construction that's sent Bizarre Surgery Patients to our unit is almost done. I'll miss the variety. I think I've grown a third hand through dealing with all this new stuff, and I'm hoping that sticks around. What I *won't* miss is seeing patients with half a face, or faces that are attached to arms or shoulders or chests.

Who knew that a subtotal lobotomy patient could seem so peaceful and normal?

With regards to Jill Sobule

I once saw a photo of a poster, somewhere online, that showed a large Malamute and the words "LOOK AT THIS DOG."

The text below read like your typical Lost Dog advertisement, except that it consisted of things like "Isn't this a MAGNIFICENT FUCKING DOG?? I love this dog. He is so damn cool. Last seen being COOL in my huge-ass backyard, which is what he does EVERY DAY."

I am totes in love with my dog.

He grumbles. He dances. He makes "hmmmMMMMmmmrrrgh" noises when I rub his ears. Sometimes he invites me outside to play by bringing every single damn chew toy and rubber ball and bone and bull penis (dried) and stick and rock in the back yard up to the door and dropping it, then looking hopeful. "Herd Ball? Can we play Herd Ball, please? Pleeeeeeez?" (Thanks to Kris for the name of that game.)

He has enormous shoulders, big brown eyes, and blond hair. What more could I want in a male that takes up most of my bed? Yeah, he's got a hairy back, but hey. He only eats once a day and that's dry kibble, so I know he won't drink the last beer.

And he likes me to scratch his belly. There's nothing better after a long day than coming home and letting him in and having him roll over with one paw up, asking for Belly Rubs. Rub Mah Belly, Human!

He has a magnificent bark. I love to hear him bark, unless it's at 2 am. And we're having a problem with the "bark when people come to the door" thing, as he normally barks as they're driving away. Yeah, the Mansons could come in and he wouldn't mind, provided he got Belly Rubs, but he's learning.

He doesn't chase the cat. He doesn't chase squirrels. So far, he has not peed once in the house (we'll see how that goes once I get a Christmas tree). He's nice to strangers, unless they're skeevy. If they're skeevy, he stares at them with his ears pricked. If they're not skeevy, or if they're friends, he lets his right ear flop over or to the side. He's completely smitten with the pug next door. He licks my face when I'm feeling bad.

I am totally, *totally* in love with my dog.

LOOK at my dog. Isn't he magnificent? He is. Yes, he is.

Holiday recipe #1: Stuffing for Residents

Chop two white onions and five stalks of celery. Sweat in half a stick of butter until soft.

Dump into a large bowl. Refill the saute pan with a pound of chopped mushrooms and melt them into a stick of unsalted butter.

Boil six cups of chicken stock. Add one stick of unsalted butter.

Toast one pound of chopped pecans at the same time you cook one pound of lean bacon in the oven.

Open two of the largest bags of Pepperidge Farm stuffing mix you can find. Use the homestyle stuff, not the cornbread stuffing, which is too sweet.

Dump them into the bowl on top of the onions and celery.

When the bacon is crisp, drain it. Add bacon, mushrooms, and pecans to the bowl of stuffing. Be glad you got the largest mixing bowl Target sells.

Pour chicken broth mixture over your stuffing and mix well. Bake for an hour or so in a casserole pan or six, until the top is crispy and the house smells marvelous.

Will feed sixteen nurses, twenty normal people, or three and a half residents.

Burnt. Out.

It's that time of year again. I'm feeling burned out about my job.

What do you do when you feel burned out?

The eleventh hour of the eleventh day of the eleventh month.

Wilfred Owen

Dulce Et Decorum Est

Bent double, like old beggars under sacks,
Knock-kneed, coughing like hags, we cursed through sludge,
Till on the haunting flares we turned our backs
And towards our distant rest began to trudge.
Men marched asleep. Many had lost their boots
But limped on, blood-shod. All went lame; all blind;
Drunk with fatigue; deaf even to the hoots
Of disappointed shells that dropped behind.

GAS! Gas! Quick, boys!-- An ecstasy of fumbling,
Fitting the clumsy helmets just in time;
But someone still was yelling out and stumbling
And floundering like a man in fire or lime.--
Dim, through the misty panes and thick green light
As under a green sea, I saw him drowning.

In all my dreams, before my helpless sight,
He plunges at me, guttering, choking, drowning.

If in some smothering dreams you too could pace
Behind the wagon that we flung him in,
And watch the white eyes writhing in his face,
His hanging face, like a devil's sick of sin;
If you could hear, at every jolt, the blood
Come gargling from the froth-corrupted lungs,
Obscene as cancer, bitter as the cud
Of vile, incurable sores on innocent tongues,--
My friend, you would not tell with such high zest
To children ardent for some desperate glory,
The old Lie: Dulce et decorum est
Pro patria mori.

White girl, white rice, white wine edition: I threw away my TV, so...

...I can't watch Grey's Anatomy any more. Therefore, a list of things I do when I'm sick and tired of being a nurse.

Surf YouTube for Harry Potter tribute videos. Love that song. Love it.

My jeans are falling off of me, thanks to weeks of getting the yard in shape, so I might not qualify for Manolo for the Big Girl any more...but it's still a good read. You might see someone you know in the postings.

Gala Darling. Still my 3 a.m. fix for things to make me cheerful.

I own one bag for work, one for not-work, and one for play. Why, then, do I read Bag Snob? For the writing, friends.

No, you can't wear most of the makeup to work, and the latest mailer is silly beyond belief. Still, Sephora has the best deals on good soap guaranteed to get the smell of formalin/blood/poop off'a ya.

No, you can't wear these clothes to work, but when is a girl's life ever all work? StyleBites.

Dumb Little Man is not.

Canned goods are always a good investment: the story of my life! Frugal Fag has the lowdown. Or the down-low.

Food. Or not. The Food Whore is always a good read.

She's like me. Except she's a doctor, and all.

And this is what I do when I'm not at work. Or walking Max, or washing the car, or making salmon with cream-garlic sauce.

Change O' Shift!

Right here.

Nursing Students: A Love Letter

It's that time of year again. We're getting three days a week of nursing students. Some are experienced, some are not. Some are sure of their vocation, some are not. Some look like they're going to vomit on my shoes, some...wait. They all look like they're going to vomit. Or pass out.

Nursing students, take heart: that nauseated, faint feeling does not last past the second year of nursing. At least, not consistently.

I love nursing students. The longer I'm out of school, the more I love them. I love that they're willing to put up with two to four years of unmitigated hell in order to enter a profession that is, mostly, rarely-mitigated hell.

I love that they think they know nothing, when in reality, they know quite a lot. The students who overcome their terror long enough to open their mouths always end up asking some interesting, baffling questions. The ones who advance theories are more often right than wrong, and even the wrong theories are logical.

I love how hard they work. With one exception in five years, every class of students we've had has kicked ass on the floor. They come early and stay late, even after a night of doing care plans. Nothing is too dirty, too boring, or not-nursey enough for them to do. They know their theoretical stuff backwards and pick up on the real-world stuff fast.

I love how they keep me on my toes. When I have two or three (or more; word's gotten around) students following me, I am extra-careful to explain everything, both to them and to the patient. I triple-check rather than just double-checking. I wash my hands longer.

I love that they're enthusiastic. We have very few nurses working at Big Bob's Brain Barn that don't love what they do, but we do have a few. Working with them is poison to the soul. Working with a nursing student is the antidote: everything is new and fun and exciting.

I love that they make me see the patients in a whole new way. You get so used to people who've had horrible disfiguring things happen that you often don't think of how little things could make their lives harder or easier. Case in point: One of my patients last week was a dwarf (not horrible or disfiguring, but wait...). I hadn't thought of how, without a step-stool, the guy couldn't adjust the shower head to hit him and would therefore be bathing in backsplash. The nursing student shadowing me picked up on that right away and fixed the problem before it became a problem.

I love how they make me see the profession in a new light. Some nurses get ground down and start referring to themselves as waiters. The students I encounter are more often than not active in student nurse associations, volunteer work, and political stuff. They see the profession of nursing as not just a service profession, but also as a scientific and activist calling. I am heartened and impressed by how much thought they've put into their choice of careers.

Thanks, guys. You can round with me any time.

PS: Don't steal my pen.

What Not To Do, Part Eleventy-Seven.

1. 55 in the left lane. Never a good idea.

2. Disconnecting yourself from your insulin drip.

3. Disconnecting yourself from your D-10 drip after you've come in with a blood sugar of 17. Yes, seventeen.

4. Saying to the patient's family member, after said family member has suggested that a chest X-ray might be a good idea, as patient is choking on his own lung goop, "You're not a doctor! *I'm* the doctor here!" (Which led family member to retort, "Really? Gosh. Learn somethin' new every day, I guess.")

5. Suggesting, because *you* can't add, that *I* have made an error in recording the ingo and outpee of a patient with a continuous bladder irrigation. Or, rather, suggesting that loudly and abusively in the middle of the nurses' station. (See: Never a Good Idea.)

What To Do, Always and Forever:

1. If you are a nursing student, ask questions. I had three sets of students in three weeks, all of whom asked really intelligent questions. One woman asked me a question (this happens at least once a semester) that made me say, "Uh...buh...uh...I dunno..." which leads to many fun hours spent with books and Google and the unit educator. I love that.

2. Let me know if you're taking your family member off-unit in a wheelchair. That way I won't alert security when I can't find or reach any of you. Boy, were our collective faces red.

3. Bring an extra set of scrubs to work. I learned that lesson the hard way--for only about the fourth time--last week.

4. If you're a patient or a family member, ask questions. I don't care if they have nothing to do with the subject at hand; just ask. It is what I am here for.

5. Please check with me before you get out of bed. This holds true especially if you've just had a femoral artery puncture and are supposed to stay flat for six hours. That way, I won't be so surprised when I walk into the bathroom to find you sitting on the john, spurting blood like a fountain from your puncture site. (See #3 above; also see What Not To Do At Shift Change.)

What I wish I'd said.

The woman waved me down as I was heading to the hardware store. She was pushing one of those brightly-colored plastic toy cars and had a Chihuahua following her, so I figured she was looking for the dog's owner.

I stopped and rolled down the window. She came over. She was neatly and appropriately dressed and seemed friendly enough.

"Hi," she said, "I'm Sheri. I was wondering: do you live around here? Have you seen any unusual cars in the neighborhood, cruising?"

I allowed that, having lived in the neighborhood for only a few weeks, I hadn't noticed which cars were usual and which weren't.

"Oh. Okay." She looked over her shoulder. "I've been noticing a lot of strange cars lately, and I was wondering where they were from."

Crack houses and meth houses have a way of springing up here and there in this town, but I hadn't noticed any weird smells or late-night activity, and said so.

"I didn't mean that," she said, "I think it's the FBI looking for me."

Uh...

"I'm a paranoid schizophrenic, but I've been on my meds, and my symptoms are controlled, and I really think the FBI is following me. See that Audi? That car doesn't belong in this neighborhood. I think it's FBI."

I did not point out that with the volume of college students in the neighborhood, at least one would come from a family capable of affording an Audi.

"See, I've been working on this research on diseases, and I think the FBI knows about it. Al Gore and I are working on visceral leishmaniasis. I picked up some larvae in my back yard, and I kept them in a petri dish--except it wasn't a petri dish, it was an old pitcher--and they turned into black flies. I'm trying to get the university entomologists to take a look at them, but I can never get through. Anyway, I'm losing the sight in this one eye, and I think it's connected. And then there's that respiratory infection that's been going around--I think there's more to that, too. I'm giving a talk on it next Saturday at the library. It's invitation-only. It's for the children, you know, this awareness of coming plagues."

*boggle*

Just then, a car drove around us and honked. She flipped them off casually and, turning back to me, said with a laugh, "You don't want to mess with me. I'm a direct descendant of Genghis Khan."

I made some noncommittal remark.

She asked then, "What do you do for a living?"

I told the truth.

I wish I'd said "I work for the government."

Why, yes, it *is* 2:15. Funny you should mention that.

I am awake at 2:plus because of Max, the best dog ever.

Max had a lump on his foot. I took him to the vet today because the lump, which had stayed the same for two years, had suddenly changed. Dr. Vet Guy decided to put Max under right then and take the thing off, along with a teeth cleaning and nail-trimming. Max came home a few hours later shy one lump and with pearly whites and a vet-special pedicure.

The Greyhound I used to have got flipped out by anesthetic and would wander, tachypneic and tachycardic, in circles until you gave him Valium and he fell over. This is apparently a Greyhound thing. Max, on the other hand, stared fixedly into the middle distance for a few minutes when he got home, drank a whole bunch of water and peed (carefully, being drunk), and then laid down and went to sleep. I slept on the couch, wanting to be nearby in case he needed me in the middle of the night.

Which it is now, and he doesn't. He's fine. I, on the other hand, am sore from being crunched up on what could be described as a couch only with the greatest charity. I woke up from a dream in which I was helping redecorate Hogwarts, pointing my wand at things and yelling "Accio 'Sixties!", attempting to remove all the bad mid-century design from the place. When the huge chandelier in my dream started to swing toward me, I said "Wait. Not you." Then I woke up.

Pathology on the lump should be back about the time Max needs his stitches out. The vet hazarded that it looked like a pericytoma, something humans don't get (as far as I know). Pericytomas are benign but locally invasive, rather like Max himself, and can regrow if not removed with clean margins. Near as I can tell from the shape of the Coban covering Max's foot, they managed to save the toe the thing was growing on. We'll see later on when I take off the bandage.

So here I am. Wide awake. At 2:plus a.m. At least I don't have to work today. And at least I'm not really responsible for decorating Hogwarts.

It's all about the Ow.

Flu shot, 24 hours later: Ow.

Hiccups that won't go away (a reaction to anesthetic): Ow.

Hiccups that won't go away (symptom of brain tumor): Ow.

MCL strain: Ow.

Thoraco-lumbar reconstruction to alleviate "flat back" syndrome: Ow.

Urological reconstruction to correct multiple fistulae between bladder and outside world: Ow.

Getting hit by a bus: Ow.

Getting hit by a bus outside a hospital and watching several dozen people pass by without reaction: Ow, ow.

Baby delivered in breezeway between hospitals: Ow.

Landing on head after falling off drydock wall: Ow.

Slamming your head into the sharp corner of a metal cabinet: Oweeee.

Having two tonic-clonic seizures that land you, intubated, in the MICU: Ow, ow, ow, but not like you'd notice.

115-lb dog stepping on your foot in excitement when you come home at night: Ow, sort of.

Carotid artery dissection: Ow.

And my personal favorite: Laying your bike down on the road to avoid hitting a rabbit: Owie, owie, doh, ow.

More chicken-stapling and a simple wish for Christmas

Santa, Baby, hurry to the unit tonight....

All I want for Christmas is total and complete immunity, starting now, from all derangements of the nervous system for myself, my family, and all my friends. That's all I want.

Because, frankly, when you say to a coworker "I've seen one too goddamn many cases of brain cancer this week", you have to stop and reconsider what you're doing for a living.

Sarcoma. Lymphoma. Glioma (high and low-grade both, inoperable and semi-operable both). More sarcoma. Metastases. Astrocytoma. Every-darn-thing-oma you can think of. And, of course, the worst cases were in the most pleasant and productive people. One of my favorite patients in a long time showed back up due to complications of his particular -oma, and he'd lost 40 pounds in two weeks.

Dayum.

So it was with relief that I took report on a patient who'd had the misfortune to catch some sort of weird necrotizing disease. It wasn't that flesh-eating bacteria, nor anything you can get from, say, a bug bite--it was something I'd never heard of and couldn't spell, and promptly forgot the name of as soon as the shift was over. At any rate, it was a nasty case of face-eating whatever.

You know the mask the Phantom wears in the Lloyd Webber musical? Imagine the lines of that mask, but including the entire nose, covering your face. Now imagine that everything inside the outlines of that mask is gone. Eyelid, nose, cheek, mouth--down to the bone, including muscle and fat. That's what happened to this dude. He'd gone on vacation to somewhere lovely and quiet (Belize, maybe?) and come home rested and tanned. Three weeks later, his face had rotted off.

So he came to us and we rebuilt him in a series of surgeries. I got him after the second-to-last one. He'd already had all the nasty infected stuff cut and scraped away, and his eyelid and cheek and lip rebuilt (and the surgeons did a hell of a job, I have to say). This last surgery was the basic structure of his nose, and used rib bone and grafts from various tender places like his thigh. (Query for those more experienced with flaps than I am: if you take a flap from the upper thigh and build a nose out of it, won't it...uh...grow hair like it would if it were on the leg?)

Here's the really shocking thing: Two weeks after his last surgery, the eyelid-and-mouth rebuilding one, his eyelid and mouth looked essentially normal. I mean, give him another month to heal up and you wouldn't know anything was ever wrong with the guy. Plastic surgeons don't get nearly enough credit for doing really good work.

In other news, the war sucks. So does the Gubmint.

Take a 23-year-old kid. Put him in a tank in Iraq. Hit that tank with a shoulder-launched rocket. Make sure that a piece of shrapnel takes out a chunk of his right temporal lobe and a bit of one of his frontal lobes.

Medivac him to the nearest mobile unit so they can save his life. Then send him off to Germany, where he will get comprehensive, high-quality care. Once he's stable, send him home without a plate in his head. They can always replace the plate at the VA, right?

Right.

And in so doing, they can totally fuck him up.

I'm not exaggerating when I say this: our local Veteran's Administration hospital is the sort of place you wouldn't send your worst enemy. One of the residents I trust implicitly came back from there with stories of dirty surgical instruments--packets of stuff for brain surgeries coming from Central Sterile with blood and Cheetos inside. Nurses I've worked with tell stories of coding patients who are cold and stiff. It's bad. There are rats in the bathrooms.

So Army Boy ended up there. And underwent a total of twenty-eight surgeries to clear infections that would never have happened had he gone to a facility that took basic pride in, you know, keeping wounds clean and administering antibiotics. Eventually, as it will, something bad happened: he ended up in septic crisis and stroked.

So now he's 25, permanently and severely disabled, addicted to Demerol (a pain medication that no sane person ever uses for neurosurgery patients, as it's neurotoxic in large doses), and is rated at 40% disabled by The Gubmint.

Which means, essentially, that he's going to be living on 40% of his already crappy private's pay for the rest of his (probably shortened) life.

I am not usually political on this blog, but I have to say this here: Of all the harebrained, poorly conceived, abysmally managed, and based-on-bullshit things I've ever seen in my life, this current war is the worst. It's competing neck-and-neck for disdain with the way the VA here treats its patients.

We do get veterans from time to time, usually with some problem that the VA can't fix. I had one guy early on in the Iraq war who'd had half his face blown off by an IED. I had a woman with a tricky trio of amputations that had to be revised--she'd gotten hit by enemy fire while serving in a "support" role. 'Cause women aren't allowed in combat, don't'cha know.

Every time I see one of these guys or girls, it breaks my heart. It's one thing to take care of a 70-year-old with CNS lymphoma...it's another to care for a 19-year-old girl who's missing both legs and an arm, and to know that that condition arose from the lies and grandstanding of someone who never saw combat.

And now I will stop. Nurses believe in God, I think, primarily to have somebody to blame. All I can say is, when God and I meet up at the end of my life, we are gonna have one Hell of a Come-to-Jesus meeting.

Things I love Thursday, with apologies to Gala Darling

Baby Giraffes.

Chefboy and I went to the State Fair yesterday. (That simple sentence fails to convey the driving....driving....driving we did.) The petting zoo had a baby giraffe, about ten feet high, who decided that *my* five-dollar cup of critter feed was the *best* five-dollar cup of critter feed. He lowered his head, stuck his insanely narrow muzzle into the cup, and licked up feed with his huge black tongue. I was totally smitten. I was also intimidated by the size of his feet.

Mosquito Barcoding

Wahoo! Look it up. It's cool.

TIGI Oatmeal Cookie body wash

I know I've written about this before, but I just snagged the last two bottles at the grocery store. It's like bathing in brown sugar without the stickies, but then it resolves to a deep, rich sandalwood.

Postsecret.

My dog

He grumps and growls and barks and howls and raises his paw for belly-rubs. What could be better?

The new Wusthof knife Chefboy got for me

It makes insanely quick work of chopping. I didn't even feel it when I sliced my finger the other night (just a little slice; no worries).

Total Fangirl.

What do I do when I'm not working or blogging about work?

Well, when I'm done cleaning house, Furminating the animals, paying bills, grocery shopping, dancing on tables, scaling K2, and remodeling antique biplanes, I hop online and waste time at these non-medical sites:

Jezebel

Pop-culture snark for people with brains. Especially since Snarkywood went into hiatus, I love the comment section here.

xkcd

The single best Web-only comic for the money. Someday Randall Munroe and I will run off to a tropical island with good connectivity. He'll draw his comics and post them while I crack coconuts and mop his feverish brow. Call me, Randall!

Gala Darling

She's young. She's from New Zealand. She lives in Melbourne. She has bright pink hair. She's the go-to girl for fashion, relationship, and life advice for the young-twenties set. I'm about *mmph* years older than the target demographic, but I love her beyond reason anyhow. How could you not, when somebody signs off "Super love and cupcakes"?

Modern Mechanix

I fell in love with this site when I saw a layout from Popular Mechanics (I think it was) on "A Kitchen Built To Fit Your Wife". Ironically, the same ideas the authors thought were good in 1952 were ones Martha Stewart incorporated into some recent kitchen design or other. Paleo Future is another good one for the tech-heads.

Manolo's Shoe Blog

Not *that* Manolo. Better.

And, of course....Dogblog.

'Nuff said.

*mmmph* *rrr* *yawn* ...chickens...

Yeah. I don't know why I woke up a full hour early, either.

Spent yesterday on the Complex and Terrifying Incisions Unit, where it's par for the course to take care of two patients who've had their jaws recreated with bits of bone from their legs or ribcage, another with something in the middle of her belly you could put your head into, and a fourth with a series of flaps that go from shoulder to cheek, from collarbone to chin, and from cheek to nose. Some of those are flesh bridges, with the donor end still attached.

Maybe that's why I dreamed of stapling chickens to people overnight.

It's amazing what we can do with a few sutures and some extra meat. Since good ol' what's-his-name in 4th century Byzantium (Google sez: Oribasius!), we've been fixing facial and bodily defects with varying degrees of success. To wit:

Let's say you want to get a nice, cheap gastric bypass surgery. Let's say you decide to go to a surgeon who does business in a converted storage warehouse (oh, Frog, I wish I were making this up). Let's say said surgeon mis-connects something that leaves you with a sizeable necrotic area in your tummy. And let's say this necrotic area eats its way to the outside of your body over a period of months. Got a huge hole in your midsection? We can fix you up with less of a scar than a Star-Bellied Sneech has after his star-removal.

Or, to take another for instance, there was the patient with valid identification, no criminal record, enough money, and a poor understanding of ballistics. Note to those who would play Russian Roulette: If you're going to try to shoot yourself in the head, be sure, if you place the gun below your chin, that you angle up and *back*, rather than just up. Also, use a nice big bullet. Otherwise, you'll just end up with a fibula reconstruction of your jaw, several flaps rotated from your shoulders to fix your cheek, something weird connecting from your right chest to where your upper lip used to be, and a brand-new nose.

Or the guy who tried to take care of his skin cancer himself. The surgeons took out one eye, the sinus behind and below it, the bone around the eye, and a few other bits for good measure, and grafted a big chunk of meat on from his thigh.

On my usual unit, I nurse people who've gotten the crappy end of the stick from Fate. On this unit, I nursed people who had temporary and disastrous or extended and inexplicable lapses in good judgement. Either way, it's interesting and awful in equal proportion.

And it ends with me desperately trying, in my dreams, to staple frozen chickens to a bunch of people in an old-fashioned hospital ward.

The Mental Health Day: A Guide For The Overworked

When To Do It

Use Mental Health Days sparingly. If you text-message your boss with the words, "Call me back or I'll jump" and you mean it, then that's the time to take one.

Don't plan them in advance. The best Mental Health Days are those arranged at 4 pm the previous day, when you feel like you'll have a stroke if you have to come in the next day.

Don't worry about how busy it is at work.

How To Manage It

Keep a mental list of those people you work with who've got either an ARM they're struggling to pay off or a taste for Stickley furniture. Those are the work whores who are always happy for some extra hours.

Call them at 3:50 pm and leave a message on their voice mail: "If you hurry, you can pick up some extra hours tomorrow!" Make it sound like a great opportunity.

When they call back three minutes later, act like they've gotten really lucky. Then call your boss back and tell her you've got coverage for the next day.

How To Do It

First, don't set your alarm. You'll wake up at your usual time anyhow, at which point you can either go back to sleep or make a larger pot of coffee than usual.

Second, don't shower right away. Save your shower for the afternoon or early evening, when no normal people would ever shower. You may, however, brush your teeth on your usual schedule. When you do shower, make it sudsy, hot, and take a long, long time.

Third, have a stash of good MHD stuff laid up. My stash includes at least one fashion magazine, some Filipino potato chips, and British chocolate. Ramen is good, as are eggs or frozen pizza. The trick is to have fairly caloric food easily available that doesn't take a lot of effort to prepare. (Note: things which alter your level of consciousness are entirely optional, but might not be a bad idea. There's something nice about ending a big Scottish breakfast with a small nip of Scotch or a half-pint of brown ale.)

Fourth, make a space on the couch. If, for your own sanity, you have to sweep and dust the room first, do that as soon as you get up. Then you can park yourself on the couch the rest of the day with no worries.

Fifth, do nothing that is not fun. If the recycling bins are overflowing, ignore them. If the cat needs to be flossed, put it off. Bills that arrive in the mail on your MHD should be filed immediately and not paid until the next day. If your idea of fun is going for a four-mile hike with the dogs, do it. If it's lying on the couch eating V-Cuts and Flake bars and reading Elle, then by all means, feel free.

How To Recover From It

There's nothing better than following an MHD with a day in which you get a lot done through other people's labor. Get your car washed. Get its oil changed or the inspection done. Get your hair cut. Take things to the dry cleaner's. At the end of the day, you can look at your neatly-checked-off list with a feeling of accomplishment totally unsullied by exhaustion.

In case you couldn't guess, yesterday was my Mental Health Day. I filed my nails, modeled a new pair of shoes for myself, then went out and had a steak. Today I had my oil changed, inspection done, and hair cut.

Now I think it's time for lunch and a nap.

The most important thing about MHDs is to ease yourself back into life slowly, of course.

So, um? If you're in Central Texas? And you're not doing anything at the moment?

Could you please, please come over and get this enormous wolf spider out of my Everything Room?

We set up the washer and dryer today (it involved taking down a wall, which is what took so damn long) and while we were doing that, I saw something move out of the corner of my eye.

Now, I am a big spider fan. I love spiders. They fascinate and charm me.

But this spider? She's bigger than my palm.

I wear a size 7 surgical glove.

She is so large that the jelly-jar pint glasses I use for water won't go over her legs.

She moves quickly. Like a hairy Cuisinart. Disturbing.

I know, at least, that I won't have any palmetto bugs or roaches in that room. I might not have any Texas Red frogs or geckos, either.

Or a cat. I think she could take Max on and give him a run for his money.

Is there anybody out there with a really big clear-glass bowl or jar they'd be willing to bring over?

I'll just be hiding in bed, several feet off the floor. Wide-awake. Watchful.

Today has been a good day.

I had one patient go south about ten o'clock. I had another call late in the day because of a prescription screwup. I got three admissions in an hour.

But when I got home, Max leapt up from his spot behind the fence and greeted me at the back door. We spent half an hour on the floor of the kitchen discussing our days. He put his enormous paw over my hand (his paw, toe-tip to dewclaw, is as long as my hand from fingertip to wrist) and gazed at me soulfully, making subterranean rrowling noises when I got to the good parts. Then he told me about his day, via snifflings and snufflings and lots of grooming my arms.

We traded ear-scratches and belly-rubs and chin-licks, and then I checked my email. I found a reply to a piece of fanmail I sent another blogger. It was funny and kind and encouraging. I was a total fangirl before, but now I'm a double-total fangirl.

The cat is being reasonable. Given that she takes disapproval of everything to a whole new level, this is a good thing.

It has been a good day.

These big clumps of hair? Oh, they're nothing.

Take a tetraplegic. (That's the Medical Term for "quadriplegic", now fallen out of vogue because everybody knows what it means.) Give that tetraplegic person a rollicking urinary tract infection, dehydrate them significantly, add some weird heartbeats to the mix, and give her something called autonomic dysreflexia, which means "Nothing works right after you break your neck."

Admit that person to my floor with a blood pressure of 60 over 20. For those of you non-medical types, 100 over 70 or so is considered normal. 60/20 is a sign that something is wrong. Make sure her oxygen saturation level is somewhere in the high 70's (again, not good in a big way), and see that she's running a fever of 104.9 F.

Did I mention she's not producing urine? At all?

All the time I was running my twelve liters of fluid into her, to bring her to a grand total of nineteen liters of fluid, I was fighting with the attending who'd admitted her to our floor. She should've gone to the ICU straight off.

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

Take a person with a significant medical history, including multiple cardiac catheterizations, liver problems, and several heart attacks. Put them through a very minor--as in out-fucking-patient, for God's sake--surgery. Make sure they lose something like 3 liters of blood during that surgery. (No, I'm not exaggerating. You can't make shit like this up.) Lose her once during the surgery and bring her back to life.

Send her to the post-op unit for four hours while you run five liters of blood into her. Make sure you're running huge amounts of IV fluid at the same time. Warm her up, dose her on fast-acting narcotic pain medication, and send her up to my floor.

The whole time she was there, from the time she arrived until I sent her to the ICU after she coded (too much fluid, most of it going to the lungs), I was fighting with the attending who sent her to us. She should've gone to the unit straight off.

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

Here's a nice little old man who's recovering from a nasty bout of pneumonia. He's not dehydrated, his electrolytes are fine, and he's not feverish. But for some reason, he keeps throwing these bizarre heart rhythms on the monitor. They don't look good, and they're starting to look worse.

For eight hours, from the time he showed up to us until he coded and was pronounced dead, one of my coworkers fought the attending who sent him to us. He should've...but you get the idea.

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

This is why I love the neurosurgeons I work with. If I say, "Hey. Something is Not Right here," they'll snap to and take a look at the patient, even if all I have to go on is a gut instinct.

And it's also why I hate every other service pretty much all of the time. The first patient had been admitted the night before, and all three nurses who had worked with him had agitated to send him to the unit. There's such a thing as having too much going on to be well cared-for by a nurse who has five or six other patients to manage.

The second patient was transferred to us over the objections of the manager of the post-op unit. The third came in okay, but should've been sent to the unit the minute he started manifesting tombstone T's. There are drips we can't run and tricks we can't pull on the floor that they can in the ICU.

I do not know what to do. In both the cases that were my patients, I worked my way up the chain of command, finally culminating in repeated phone discussions with the attending physicians. I kept everybody updated, shoved my other patients off on other nurses and the charge nurse, and chewed new assholes right and left for every resident I could reach. Every nurse I spoke with about those two patients, from the clinical manager to the ICU charge nurse, asked the same question right off: "Why is this patient not in the unit?"

Yet the attendings, either through sheer laziness or disrespect for nurses (the first, I suspect, in the latter case; the second reason in the first case), ignored that my hair was on fire and their patient was tanking. The residents went along with the attendings, with the added joy of being snarky to boot.

I can handle almost anything within reason. Nearly losing two patients in two weeks is hard, especially since one of them will have a lifelong anoxic brain injury courtesy of her stupid surgeon. The nurse who cared for the poor, sweet little man who died is a wreck--she's two years out of school, technically excellent, and usually unflappable.

I do not know what to do. I have excellent working relationships with the attendings and all but one of the residents. The brain surgeons routinely ask that I take care of their patients, because they trust me to flip a lid if something goes wrong. Yet in two cases, *something* stopped two experienced physicians from taking me seriously enough to listen to me when I said a patient was more than we could handle and was *getting worse*.

The first woman was, thank God, fine. The second will be easily amused for the rest of her life. The third patient is dead.

I know it's not just me, since Other Nurse had the same issues with stonewalling...but still. What could I have done differently? How do doctors like to be presented with things like this? I gave 'em detailed, succinct reports on their patients, but that wasn't enough...

This has been keeping me up nights.

"...While the other one won several prizes."

It was a normal day on the urology floor, meaning a highly abnormal day for Your Faithful Correspondent. I had gotten sent to Urology to make up a staffing shortage. There I was, schooled in the ways of the brain, trying to make do with rudimentary knowledge of the bladder, bowel, and kidneys. Continent ileostomy? Neobladder? What?

As luck would have it, I got an admission from the ER. The young man was reticent about his problem--he was a little younger than me, not willing to drop trou in front of a nurse in his peer group and come clean about his difficulty.

I finally got the guy to tell me what the heck the problem *was*. "One of my balls is huge," he said, "and really sore."

Well. Well. I had to assess it, so I did.

There's more room than you would expect in the average scrotum. I've seen 'em as large as small melons, but this one took the cake. One side of his scrotum was easily, and I kid you not, the size of my head.

The other was more-or-less normal. A little edematous, a little red, but pretty much what you'd expect.

Great leaping jiminy. What the hell do you do in that situation? Turns out you use ice packs and elevate the dadratted thing on a couple of rolled towels while you page the resident on call, stat, to come see your patient. A couple of milligrams of morphine calmed my patient; a couple of minutes of hyperventilation calmed his nurse.

The resident arrived and did his exam. Turns out the patient had had a little bit of an ingrown hair or zit or something, and had squeezed it, and the resulting infection had spread.

The patient went in that afternoon for an incision and drainage. Several days of intravenous antibiotics and some dressing changes fixed him right up, but I was reminded of the old limerick:

There was a young man from Devises
Whose balls were of two different sizes.
One ball was so small, it was no ball at all--
But the other one won several prizes.

Mom, in case you're wondering, I learned the limerick from James Herriot's books.

Click here.

Ah, lovely hydrocodone. Lovely, love....zzzznnnkkk

Yes, friends, I was a narcotic virgin.

I think I've had one Darvocet once in my life, back when I was a kid and Mom gave me one in desperation after I'd flown with a sinus infection. That was too long ago for me to recall what I felt like. Similarly, I think I might've had Vicodin at some point in the past, but I don't remember anything but getting mildly, then moderately, then severely queasy, then not taking it any more.

Now I have this cough syrup. It has 5 mg of hydrocodone per teaspoon, and I'm supposed to take two teaspoons at a time, which (let me tell you) makes for a party. It also has a decongestant and an antihistamine I've never heard of, so I'm sleeping really, really well.

It's become a hobby for me to look at these experiences through the lens of how my patients might feel in the same situation. When I had a migraine, I mentally cataloged everything that was happening to me, so I could relate better to people with migraines. Now I'm all about the side effects of hydrocodone. To wit:

1. You sleep like the dead, then wake up, *plink!* with no sensation that time has passed at all. This is nice, if a little disconcerting.

2. Everything takes forever to accomplish. I'm not taking this while I'm working, but it's still odd. It takes twenty minutes to shower and ten to make coffee, because I'm....moooving...iiiiin...sllloooowww...motion.

I'm moving like Mrs. Which talked in "A Wrinkle In Time."

3. Nothing much matters. Ten minutes to make coffee? No problem. I'm coughing up green crap? Doesn't worry me in the least. Wanna cut off my big toe and stick it in my ear? Go 'head, I'll just be over here, napping.

4. I itch. All over. No rash, so no allergy, but a common side effect.

5. I'm not coughing as much. When I *do* cough, I have to make an actual thoughtful effort to manage it, because my cough reflex seems to have taken a powder. (Ha.)

Chef Boy just brought me soup, toast ingredients, and a big bunch of purple tulips. The Cat is curled up at the foot of the bed, one eye barely open, watching to see when I decide to lie down. Max is in the hallway, one eye on me and one on the door, so he can get belly-rubs from any intruders that happen into the house. I have lemonade and limeade and fresh coffee, and a book on the couch that I've been wanting to read. All this, combined with a hydrocodone haze, makes this one of the most pleasant illnesses I've ever had.

Lazy Post, with a good reason and an excuse...

I got a very nice email from a man who worked out an algorhythm to show the top 25 nursing blogs by hits on the InnerNewtTubes.

They are here.

I recommend, strongly, perusing all of 'em. I write one; most of the rest I read, and two on here were pleasant surprises to me.

Why am I doing a self-aggrandizing lazy post?

Because I just spent 2.5 hours at the doctor and came away with a diagnosis, not of allergies, but of pneumonia. Tra fricking la.

Don't worry; I don't feel bad. I just thought I had a bad cough.

No, I didn't fall through the bathroom floor.

She Came In Through The Bathroom Window

I'm moved in. I have one house, one cat, one dog (more on that in a minute), and one almost-bathroom. It needs to be grouted, but it looks *sharp*. It'll be totally usable tomorrow, after everything dries.

The moving guys who took care of the heavy stuff came in a trio. Their combined ages couldn't have been more than 65. All of them were cheerful, stringy, rangy guys who could pick up a fully-loaded cedar chest alone and haul it down three flights of stairs. I'm proud to say that five years of nursing and a year of heavy training left me able to keep up with them. I also let them punch holes in a wall (it's got to come down anyhow), much to their great delight.

Getting back to work was weird. You know how the strange people and strange cases seem to cluster? Well, we've had a couple of clustering weeks; I came back on the tail-end of the weirdness time. The census reads like the table of contents from a particularly nightmarish pathology book: worms in the brain? Got 'em. Basal cell carcinoma that ate into a sinus so that sinus and orbit had to be removed and replaced with a free muscle flap? Yep. Bizarre ventriculitis caused by God only knows what virus? Uh-huh. Autonomic dysreflexia, septic shock, dehydration, dementia, and meningitis? All in one bed, buddy.

In short, I was reminded that "Found down at the Kwik-E-Mart" is not an encouraging beginning to a history.

The Curious Incident of The Dog

Eons ago when I was still married, my then-husband found a dog in a vacant lot near our house. He (the dog, that is) looked determined to lay down and die, being nearly starved and looking like he'd been on the road a while. That, of course, is never gonna happen in *my* neighborhood, so off to the vet I went, with an 80-lb stranger in the back seat of my Civic.

Several months later, after he'd been fed well and exercised regularly, somebody at the vet's office mentioned that they thought he might be an Anatolian Shepherd mix. Anatolians, aka Kangals, are enormous livestock guard dogs native to Turkey. They're popular here and in Oklahoma because of their toughness and intelligence. I shrugged, figuring that Max wasn't big enough or furry enough to qualify.

Fast-forward four years. Ex-husband is moving, and needs somebody to take the doggo. I couldn't originally, because a large dog doesn't belong in a small apartment with somebody who works 16 hours a day. However, now I could, because I have the house and the yard and all. So I went last night to pick up Maximum Maxhound.

He must've been a half-grown puppy when we found him, is all I can say.

I now have a 115-lb monster taking up most of the kitchen floor.

The cat beat him up last night. She was unhappy with his being here and so attacked him in the living room, giving no quarter, and chased him through to the kitchen, where she cornered him by the back door and went to work on his hindquarters. He's now understandably nervous about coming back inside, so I wander out every few minutes to the yard to scratch his ears and tell him he's the best, sweetest boy ever.

And he is.

(Note: the picture above is not Max. It does, however, give you a good idea of his size.)

Warning: agraphia ahead.

Agraphia ahoy!

I'm moving on Thursday, so posting will be nonexistent until I get moved in and the bathroom finished.

Ah, yes. The bathroom.

It is not going well.

In fact, it's a hole. There are joists and studs and bare pipes and nothing else. You can fall into the crawlspace quite easily, something I almost did the other day. I was saved by a complicated and entirely instinctive movement reminiscent of something out of the Matrix series, if the Matrix series had been populated by flailing, screeching people holding prybars.

The good news is that everything else is pretty much done. I have to paint the woodwork in what will be my bedroom, but that's pretty minor. I scrubbed the kitchen down today, yuck, and am already moving things in.

Brother Bruce's Bargain Brain Barn is its usual exciting and gratifying self. Word from the carpeted areas is that charges for insurance will go up somewhere in the neighborhood of twelve percent starting in September. This is a no-big-deal thing for those of us without spouses or children, but a very big deal for those with, as their insurance actually costs them money. Us bitter, barren, lonely extras at the dinner table have everything covered. That's one benefit to being bitter and barren, I guess.

The dude with the huge glioma in his left temporal lobe? Turned out not to have a huge glioma, which is good. He instead has some wacky viral infection there, which is bad, but not as bad as a glioma. After a couple of weeks on some IV antiviral I'd never heard of and can't remember the name of now, he bounced right back and is fine and dandy.

Also, the young kid with the exploding AVM is talking, walking, and generally getting on people's nerves. That's a plus, since she was doing the staring, drooling thing last time I saw her, which was three weeks ago.

Speaking of getting on people's nerves, or maybe of staring and drooling, I may have to have A Chat with one of our resident brain cowboys.

He stares. At the nurses. Not in a smouldering, McDreamy way (as if; have you ever seen a bunch of real-life neurosurgeons?), nor in an intimidating, you-oughta-be-in-a-hajib-mindset way, but in a vaguely clinical, oddly disturbing way, as if he's wondering the best way to get to our hypothalami. He stares mostly at me, which is beginning to bug me. And will likely get him an entirely new digestive system if, after I point it out to him, he continues to do it.

He is, like all neurosurgery residents, totally socially inept. And he stares.

If you'd like something new to stare at, check out this week's Change of Shift. It's over at Nurse Ratched's. It's a Western theme, which is pretty darn cute.

I'll see you guys in ten days or so.

Noodling.

Goodness gracious. I just checked out Blogdorf Goodman for the first time and am amazed. One of the bloggers there did a whole series on makeup brushes. A series. On makeup brushes. With photos and a discussion on natural versus synthetic bristles.

I wonder if a series on catheters would grab as much attention.

In Work News, it's Christmas in August. Seems like every third person is opening his or her stocking and finding a wonderful gift: a glioblastoma! On your left temporal lobe! A meningioma! In your occipital lobe! Oh, boy! Lookit this, Mom! It's my very own spinal tumor!

Temporal lobe tumors are generally a bitch because, as you know if you're a disciple of the brain, they can cause seizures. Depending on which side they're on, they can also rob you of speech and understanding, memory, and the ability to make change.

One of my patients this week had the memory-loss and seizure problem. The memory loss is harder on us than it is on him; he keeps forgetting that what he has is a cancer that is going to kill him, nastily, so he keeps asking. And his family has to keep telling him. The seizures he has are manifested in a really weird way--sudden bursts of uncontrollable anxiety. Panic attacks, basically. I'd never seen that before, though I knew theoretically that it could happen. We put him on Keppra (a kinder, gentler anti-seizure drug) and problem solved, but still.

In House News, the bathroom walls are down. And oh my Frog, what a mess it is.

When the bathtub enclosure was built lo these many years ago, the builders installed a cabinet above the tub. Keep in mind that showers weren't standard equipment in the late 1940's, so it made sense. Need a towel? It's right there. Genius!

Except that somebody installed a shower. And did it badly. So badly, in fact, that I have a hard time believing that the thing actually worked for as long as it did.

See, when you install plumbing, it's important to make sure everything matches up. If you have cast-iron supply pipes, as I do, it's a good idea to get the proper connectors to extend piping up a wall (say) rather than jimmying something together with PVC, copper connectors, glue, caulk, and a prayer. What'll happen if you jimmy and pooky everything together is that the created joint will split and leak and take out the backside of the wall it's running up.

This was brought home to Chef Boy and me when I tapped on the wall with a pry bar (okay, banged on the wall) and the wall came down. Except for the bit surrounding the fixtures, which were glued/sweated/caulked on to the supply lines and thus have to be cut off with a hacksaw. I now have a lovely space just above the bathtub that communicates with one of the kitchen cabinets. Chef Boy suggested that we leave it as is and pass crystal decanters of bourbon and Scotch through the hole so that we can drink while bathing. For a minute, that seemed like a really, really good idea.

Today Chef Boy will install cutoffs on the sink supply lines and we'll take out the toilet, and then I'll go to work on the last wall (and probably the floor as well) with the marvelous pry bar. Later on in the week the cement board and tile will go on. The Evil Secrets of Bad Plumbing will be walled up again.

Maybe the bathroom won't smell so strongly of mouse and mold when it's done.

House Blog, Part 2

Oh, my.

I'm sure the people who lived in the house before me were marvelous folks. I'm sure they were kind to animals, fine parents, socially conscious, and committed recyclers. I'm sure they were all those things and more.

However, they lived like pigs.

I cleaned the bigger bedroom the other day; it took me fifteen gallons of cleaning solution just to do the lower half of the walls. One wall alone took nine gallons of solution. It was...an experience.

Let's not even talk about the kitchen. Suffice to say that I am looking at new stoves rather than clean the one that's in the house. I don't think it'd be possible to get it into usable condition. Thank God they didn't leave the fridge.

So today, when the numbers on the clock are bigger, I'm heading over there with more gloves, more sponges, and more cleaning solution. Today I'll clean, period, and worry about painting tomorrow.

Work

In other news, a simple tip for the family members of patients: The way to get noticed and get your questions answered is not to assault a nurse. You'll get noticed if you do, of course, but it's not the kind of notice you're likely to want to attract. Let's face it: If you kick a nurse, or take a swing at him, you're going to face security guards from countries where genocide is a way of life. They know many, many more dirty tricks than you do.

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

I finally quantified what it is about my nursing style that makes the crazies love me.

When we say "crazies" at work, we don't mean people who believe that aliens live among us or that Star Jones really lost all that weight with diet and exercise. We mean people who are so stressed, or so anxious, or so overwhelmed that the conventional modes of behavior fly out the window.

Everybody who's worked in any kind of health care knows that there are some folks whose behavior becomes unacceptable, impolite, and sometimes downright dangerous in stressful situations. When every other nurse has been fired by a patient or a patient's family, when security's been called, when the doctors refuse to go in to the room, they assign me that patient.

And invariably--I say this not to boast, but in amazement--those patients end up asking for me again the next time I work. And we get along.

I've had several patients in that situation over the last couple of weeks. In most cases, the patients themselves have a handle on what's going on; it's their family members who have lost it. What every situation had in common was this:

I explained what was going on, in English, from start to finish, and didn't assume that the patient or the husband/wife/sister/whatever knew what had been happening prior to that day. If it took re-explaining three or four times during the course of the day, or going back to Page One and going straight through to the end, that's what happened.

It's not that our docs and nurses and therapy folks don't tell people what's going on: they do. In terms of communication and keeping people in the loop, we do very well as a team. I think the assumption is, though, that people in a stressful situation are going to remember the conversation you had with them last night. This is hardly ever true; they have so much going on internally that they often forget to, you know, eat. We do this every day; they've done this exactly zero times before, and so the stress level is huge.

All of this seems really obvious now that I look at it logically. Still, it's the only commonality I can come up with over the course of several years of being the Nut Wrangler. Explain, explain, explain. Warn, reassure, explain.

And, if all else fails, Xanax works wonders.

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

Trivia Treat: Turns out one of our surgeons (not in our department, sadly, but still) used to fight in cage matches to make extra money.

How cool is that? "Twoooo goooo iiiinnnn....ONE coooommmmes ooouuut!" (/announcer voice)

Which explains a lot about this particular surgeon.

Product Reviews: Lovely Lady Lumps Edition

Here it is again! Reviews of products you might could use, wish you didn't have to, and ones you would rather avoid!

1. Title Nine "Because She Said So" sports bra:

I got sick of wrapping my boobs in two or three compression bras, so I bought two of these. They make me resemble a lingerie model from the late 1950's, but that's okay: I don't bounce. At all. Ever. Even at a dead run, or hopping on and off of a step during some new torture routine Attilla the Trainer has devised. The nice thing about looking like I'm All Boob, All The Time is that there's not as much squish to the side, so I can still do things like bench presses without running into the sides of my own breasts.

Verdict: I will only trade these in when I find another Title Nine bra I like better. I bought mine a cup size smaller, just FYI.

2. Rimmel "Volume Flash" mascara in brown:

Due to the fact that I had to give up a pile o' cash for home renovations, I'm not shopping at Sephora for things like Christian Dior mascara any more. Instead, I prowl the aisles at the local Target. And I came up with this mascara, which (dare I say it) works better, stays on longer, and clumps less than even my beloved Dior. Plus, it has one of those really skinny, ineffective-looking brushes that lets you get to every single lash.

The brown is a nice light brown, suitable for somebody with very fair skin and lashes. The only downside is that it's a bit difficult to remove: I find that my usual face-wash stuff put on without water takes it off. Any dilution results in my looking like a football player or a boxer, post-eight-rounds.

Verdict: Rocks my socks, and for only $7.99!

3. Joe's Frozen Chitterlings, pre-cleaned:

No, I did not buy these. I mention them only because I stood before the freezer case in my neighborhood grocer's, amazed that there was such a thing as frozen chitterlings. And that "chitterlings" was spelled the proper (rather than the more charming phonetic) way. "Chitterlings", for you who've never eaten them, is pronounced "chitlins" and are intestines.

Anyway, they're available frozen in some parts of the country.

Verdict: I'm not eating *anything* in the way of pre-cleaned, pre-packaged soul food unless it's Glory Greens and I'm in a hurry.

Speaking of food:

4. Balance 100-calorie Caramel-Vanilla snack bars; Soy Joy Almond-Raisin snack bars:

I mention these together because, together and separately, they are nearly the nastiest things I've ever eaten. I got 'em because they're both small enough to fit in the breast pocket of my scrub jacket. They taste horrible. The Balance bar is 100 calories of oversweetened, cardboard-like stickiness; the Soy Joy bar tastes like almond extract gone bad with an undertone of sawdust. I'd rather drink retsina than eat another one of these ever again.

Verdict: Yeah, they're expensive, big, and calorie-laden, but cut a couple of Odwalla Banana-Nut bars in half, and they fit in your pocket. They actually taste good, too.

Verdictal postscript: I'm trying to think of anything nastier than Soy Joy that I've eaten more than once, and I really can't. I tried the second Soy Joy in the conviction that nothing could taste that bad; that I must've been imagining things. I wasn't. Avoid.

5. Med-Prime suture removal kits:

I hate these fucking things with the burning hatred of a thousand suns going supernova. Med-Prime, my ass. Try Cheap-Shit Medical Supplies That Will Drive You to Drink. The "iris scissors" included in the suture "removal" kit are loose-joined, dull things that simultaneously pierce your patient's skin and refuse to gnaw through the suture in question. Some dickweed bought these for the hospital. In response, we're all hoarding the decent suture clippers; the sort that look a bit like bypass pruners in miniature.

Verdict: Anyone who orders these for hospital use should be condemned to having one thousand #2 silk sutures removed from some ticklish part of his anatomy with the scissors. God, I loathe them.

6. Dansko "Calla" clogs:

The winner, and still, after two years, champeen of the clog wars. Mine are wearing out only now. I plan to buy two more pairs with my next paycheck, because, at $115 a pop, they are Not Cheap. However, they hold up well. You can roll a bed over your foot in 'em and your toes won't break. And, unlike other Dansko clogs, the heels are nice and wide so you won't fall off of 'em.

Verdict: Trade in the Professionals, if you're the clumsy sort, and try these.

7. Target Boxed Wine:

Of all the damn things. Target actually carries wine! (Well, mine does. Along with those cute Pommey POP champagne bottles that come with a package of straws and are bottled by the same people who make Veuve Cliquot, so it's actually pretty good, but anyway.) Target boxed wine comes in White: Pinot Grigiot, White: Chardonnay, Red: Merlot, and Red: Something Else. They're drinkable, but not outstanding.

Verdict: Good for a big party, where nobody's going to be discriminating. Plus, the technology is kind of cool. Plus, at $11 for the equivalent of four bottles, how can you lose?

8. Jezebel dot com:

A great website for celebrity gossip, makeup tips, and girly things in general. Unfortunately, going to the website caused my computer to be infected with Brave Sentry, a malware program of a particularly nasty sort. In fact, now that I've upgraded my firewall, installed malware detection software, and regained access to my computer's registry, I can see that I get an average of 128 attempted downloads *each time* I visit Jezebel. Try Too Fat For Fashion or Faking Good Breeding instead.

Verdict: Unless you want to spend four hours fixing your computer, avoid.

House Blog.

They say that some things sound the same in any language. I can attest to "Shake it, don't break it" and "Hey, baby, give me a piece of that" sounding the same in gutter French or Swedish. It seems that "What the hell are you doing?" and "Stop, dammit!" sound the same in Spanish as they do in English.

The Foundation Fairies* are at work on the New House.

I could swear that I heard a guy say (translated badly from gutter Spanish), "You call that level? My *grandmother* could level better than that! Where are your eyes??"

I also heard, quite clearly, one of the Foundation Minions tell another, "That crazy (female) gringo doesn't know shit. Go turn the power on, willya?"

Things have progressed markedly since the days of hammering on the floor with one's fist and shouting. Now the Foundation Guys have laser levels that beep repeatedly when "level" has been reached. There's a limited amount of shouting and insulting that the Head Foundation Guy can do, but this HFG puts his all into it. There was an interesting call-and-response pattern I heard this morning as I was painting, all of it in Spanish; most of it I couldn't understand unless I concentrated.

"Hey!"
(from under the floor) "Hey!"
"Bring this up two more!"
(under floor) "Bring it up two more?"
"Two more! Two more!"
(under floor) "Like this?"
"Like that!"
(under floor) "Like this?"
"Just a little! Just a little!"
(under floor) "Like this?"
(A flood of descriptive and abusive Spanish that, while interesting, lost me about a third of the way through.)

It was all done in the most gorgeous (and here I'm dropping all snark) sing-song, with a sort of heave-ho mentality issuing from the depths of the foundation.

These guys work *hard*. As I told my Sainted Father that one time, it's the Illegal Immigrant Work Ethic that has made this country great.

The electricity is done, thank Frogs, and the work was passed by the city inspector. I kinda wonder who the Electrical Fairies bribed, since I didn't have the smoke-detectoring up to snuff. The living room is totally painted, and Penny The Lotion Slut's guestroom is painted the most gorgeous color of pale sunset peachy-pink you can imagine. I would've done the rest of the painting today, but I got the feeling I was really in the way of the Foundation Brownies.

In a few days I will start, with Chef Boy, on the Great Bathroom Remodeling. We'll see how many wine boxes from Target it takes for me to retain my sanity during that process.

*I call them "Fairies" not because they're fabulous (oh, snap!) but because they come after I leave and are gone before I come back, accomplishing immense amounts of work out of my sight.

*** *** ***

In other news, I once told the story of a patient who'd had five (five!!) spinal cord AVM embolizations. I am pleased to report that that patient, who was paralyzed from the chest down the last time I saw them, walked back up to the floor on Wednesday to say hi.

Occasionally this job has benefits.

New Change of Shift is up!

Right here.

My cat is aloof. What's it mean when she curls up with me?

Here.

The Weirdness of Id

How much must this suck?

You're walking around fine and dandy one day when suddenly your brain bleeds. Intraventricular hemorrhage, subarachnoid hemorrhage, whatever: suddenly, you've lost your inhibitions, your ability to form coherent sentences, and your will to do anything. You are, in short, a perfect candidate for employment on our unit.

The one thing that's better than it was before is your brain's ability to get into a groove. That would be okay if your brain were focused on ponies and butterflies, but it's usually not. In fact, I've only met one person in five years who grooved on positive things. The rest of the brain-bleed population lives nightmares over and over and over.

One patient, born in America of Iranian parents, was stuck in Paris on September 11th, trying to get home. Over and over. Another was in the middle of divorcing her abusive husband and on the run, something that had happened forty years ago. A third was trying to get the ambulance for her horribly injured youngest child. Over and over.

Mostly, people who groove on nightmares are quiet. Anxious and confused, but quiet. They can't be reoriented (sometimes trying just makes it worse) but usually they can be calmed. And, eventually, the brain heals itself to the point that they can break out of that nightmare box. Until then, they talk constantly about the nightmare they're in.

Sometimes, though, Horrible is happening in somebody's brain and there's no telling what it is. We had a patient like that last week: perfectly fine one minute, he'd suddenly sit bolt upright in bed, eyes wide and face pale, and scream.

Something was coming after him, that's for damn sure. And whatever it was, neither he nor I wanted to see it again. I had a choice. He didn't.

I had no clue what he was seeing. He couldn't articulate it. I got the feeling from watching him, though, that it wasn't as simple as watching a buddy step on a land mine planted by the Viet Cong, or seeing his house destroyed by fire with his family inside. Whatever it was that came out of the walls at him came from his own mind. I don't scare easy, but seeing his face as Horrible came at him, just before he screamed, made it hard for me to sleep for a couple of nights.

I feel like a sicko. I saw "Harry Potter" tonight...

...and in one of the first scenes, Daniel Radcliffe is in a T-shirt.

A *snug* T-shirt.

My first thought?

"Damn. Look at that vein in his bicep. I could slide an 18-gauge in that, easy."

Today

I picked seven cherry tomatoes, two bell peppers, and one cucumber.

The cantaloupe I inherited with the new house and garden is coming along well. Please send anti-bug and anti-bird vibes its way so it will actually get a chance to ripen. Thank you.

Everybody's doin' it...

Dr. Sid is doin' it. Dr. Rob is doin' it. And now I'm hopping in, with my own simple rules and few for you physicians out there who want your patients to end up in my ample lap.

How To Have Things End Up As You Would Like Them To: A guide for physicians in our hospital

1. Please be aware that, as you've been told since your first day as a resident, nurses cannot call for consults. If you write an order for a consult, you're the one who has to call the doc. Wandering vaguely away from the chart rack will not accomplish your consult; neither will being mad at me for not calling. No matter how much you yell, this will not change.

2. If you are sending a patient from your office for a consult, please note that our surgeons have office hours. You, as the referring doc, can't just send a person up to the hospital floor with no warning and expect them a) to be admitted, or b) to be seen in a timely fashion. The doc you wanted is probably up to her elbows in somebody's brain and won't be available for at least six more hours.

3. Don't lie to me. Don't call me with the news that you've got a critically ill patient on his way via ambulance for immediate admission. Not only can I not *do* anything about that (you really should call the bed-board people for admissions), but I will be supremely pissed at you when, after a two-hour scramble to get an acute-care room opened up, your critically ill patient shows up walking under his own power, having driven himself to the hospital.

4. Understand that certain things are not our specialty. Let's say that you have a patient who's post-heart/lung transplant and who is having problems. I will do my best to send them to our sister facility, Holy Kamole, because *they* took over all the heart/lung transplants four years ago. It really doesn't matter how much you want them to be at La Schwankienne; we do neuroscience. We don't know a damned thing about transplants. It's not a personal slight; you don't have to holler. It's about the best care for the patient.

5. Having the admitting physician write a consult request for a particular specialist is, I guess, okay. It's not okay when it was your idea, when you're the one who'll be consulted, and when the patient is your mother.

6. And finally--listen up, guys--when you write a consult for an inpatient, be aware that the patient will be seen first by the resident or fellow, and later by the attending (once the attending finishes office hours or surgery or whatever she's doing). This is how it works in *your very own service*. Do not--I repeat, do *not*--get snippy with the charge nurse when the senior resident or a second-year fellow is the first to have contact with your patient. (You know who you are.) I have nothing to do with it; I can't help you; perhaps you should think back over your last ten years here and see if it's ever been different.

Thank you. You may all return to your regularly scheduled rounds. Please do not rack charts with new orders. Thank you. Thank you.