Thursday, October 23, 2008

What I cook on my day off: The Thank God It's Fall edition...

Maybe next year I'll have a So Happy It's Summer edition, too.

Today the low was 33. Wahoo! The guy on the radio mentioned that it would be a chilly day, with highs only in the low 70's. Everybody in Colorado and Minnesota is laughing right now. Everybody in Maine and North Dakota is crying.

So today I cooked a pot pie. Pot pies are easy and basic: all you need is a sauce and some biscuit dough to go over the top of whatever you put in the sauce. You can make 'em with a cream-based sauce and chicken and call it chicken pot pie, or use leftover stew meat and a thickened beef broth and call it shepherd's pie. Here are the very basic basics of the dish:

First, preheat your oven to 400 (200C or Gas Mark 6) and butter a  9" x 13" pan (largish; I don't know what the metric equivalent is).

For the sauce:

Two cups of broth--your choice of chicken, vegetable, or beef. (call it 500 ml.)
Four tablespoons of butter (half a stick)
A half-cup of flour (115 g)
About a cup and a half, give or take, of whole milk or half-and-half, if you want to make chicken or veggie pot pie with a cream base. (you metricians can figure that one out)

(If you don't want to use the milk, you'll need a little extra broth.)

Melt the butter in a largeish saucepan. Add the flour and stir it in with a whisk, then cook over medium heat for a minute or two so it'll lose the floury flavor.

Dump in the broth. Continue to cook over medium heat, Without Boiling, until the mixture thickens. Remove from the heat. Add milk products if you're using 'em. Stir well and set aside.

Now. From here on out you can play around. The pot pie I made today included white mushrooms, carrots, onions, and baby peas sauteed in the ass-end of some bacon I had lying around, plenty of black pepper, and some seared portabellini mushrooms (baby portabellas). It's vegetarian except for the addition of the pig. 

For a real vegetarian version, you could roast carrots, garlic, and parsnips or turnips along with some nice firm mushrooms, (everything cut into big chunks) and then combine it with the peas and onions and use a thyme-seasoned cream sauce.

For chicken pot pie, you can cook chunks of chicken in the broth prior to adding it to the flour and butter mixture (and remembering to skim the ook off the top of the broth, please), then add peas/carrots/onion/mushroom to the whole shebang. Chicken pot pie traditionally uses the cream-and-broth sauce.

For shepherd's pie, you can use beef broth without cream and add turnips and carrots to the mix, topping the whole kaboodle with some nice garlicky mashed potatoes.

The only important thing is that the innards of the dish be fairly highly spiced. As for topping, you can use a drop biscuit recipe or a good pie crust recipe. Please do not use those awful lardy soapy-tasting unfoldable pie crusts you can get at the store. Drop biscuits are easier. To wit:

Mix two cups of flour (460 g)
two and a half teaspoons of baking powder (12 g)
a teaspoon of salt, and (5 g)
six tablespoons of butter (3/4 of a stick)

in your food processor. Process until it gets sort of sandy.

Add enough milk or half-and-half until the mixture is wet but not batter-y. You don't want the traditional dry biscuit dough you can roll out, but you also don't want it soupy. About a cup will be fine. 

Then you drop your non-soupy biscuit dough on top of your giganto pan of nummy soupy goodness and bake it for 30 to 45 minutes or until the biscuits are a nice golden brown.


Saturday, October 18, 2008

Jo Muses: The Love/Hate Edition

I'm reading Heat by Bill Buford right now, partly because I mistook "Buford" for "Bryson" and thought, "Wow! Bill Bryson's written a book on learning to cook?" and partly because it sounded interesting--a blow-by-blow account of learning to be a chef by doing, rather than by schooling.

One of the most interesting bits in the book describes the process of learning to use a knife as though it's an extension of your fingers rather than something you pick up and put down. ChefBoy has, of course, this talent. I have the same talent--all nurses do--but in a different way.

Think of how you learned to start an IV. (New nurses and students, listen up! This will be heartening, I promise.) At first, you had to think about every step in the process, and things like tape felt foreign--getting stuck to every conceivable surface except the one you were aiming for; flushes went on the floor, gloves seemed too thick or too loose. Then, one day, it all came together, and what's more, the IV needle itself suddenly became something you could feel *through*--you could tell when you hit the vein dead on or when you'd scooted to the side of it.

Buford describes this as analogous to the process of learning to throw a ball--learning like a child, he calls it--and that's exactly what you're doing when you learn how exactly to juggle IV bags, tubing, medications, piggyback setups, needles, flushes, and everything else as though you've grown a third hand. It's visual and physical rather than primarily about reading and memorizing, and it uses a totally different part of your brain. 

I love that explanation.

Something I hate: Being tossed--lobbed, really--gently under the bus by somebody who's made an amazing, stellar, incredible, obvious, historical, unbelievable screwup. I won't go into detail, but suffice to say: Doctor ResidentBoy, if you fuck up and expect to blame me for your fuckup, not only will my boss not believe you, but *your* boss won't believe you. I know what you did was embarrassing, but it's not nearly as embarrassing as knowing that I know what you tried to do. 

I know what you did last weekend. And I will continue to smile and be helpful and pleasant and take care of your patients the best way I know how, but if you dance too close to the cliff again, I will not haul your ass back from the precipice. Have a nice day!

The first rule of nursing, after "If you have to jack with it, it's wrong" is If You Screw Up, Admit It And Move On. People screw up, okay? Nobody's going to remember that particular screwup in a year--or if they do, they'll remember it in a hazy, amusing, gosh-wasn't-that-funny kind of way. 

That is also the first rule of medicine, right after "Do no harm."

Another thing I love: Waking up in the morning on the first really cool day of fall, with all the windows open, and dogs and cats sprawled everywhere on and off the bed, and realizing that I do not have to get out from under the covers and work out or go to work. It's totally different from checking in the mirror to see exactly how far down the tire tracks from that bus go.

Wednesday, October 15, 2008

Carnival of Crackpots!

Once, many years ago, I read a book called Letters to Ms. It had selections from the first ten years of the magazine's editorial letters, divided into sections like "Praise", "Criticism" and "Crackpots". In the introduction, the editor told the story of how Gloria Steinem once got a postcard accusing her of being a "Commie witch bitch lesbo...who sleeps with n$#*%*#s. Isn't that just like a Jew?" Ms. Steinem reportedly pinned the postcard up in her office to remind her of what she was doing right.

May got an interesting comment the other day about how female nurses are perverts who grope unconscious male patients. It was, of course, in all caps. No other content, either; apparently the crackpot who sent that one in had only that to say.

And I get the occasional crackpot as well. It's not enough that people post bizarre two- or three-word comments ("Obama Sucks!" "Clinton Kills Babies!" "Repent or DIE!"); sometimes they send me emails, too. The most recent one was a Photoshopped picture of Obama shining Sarah Palin's shoes. Lovely. 

Then there was the long, ambitious screed about how nurses these days look totally unprofessional in scrubs and should wear dresses and pumps instead, with white stockings. If the guy (yes, it was a guy) writing had stopped there, it wouldn't have reached Crackpot status, but he continued rambling, working in Feminazis and lesbians and the death of American society and how we were all going to burn when the Second Coming finally shows up, and how if men would only take back their rightful place in society, things would get considerably better, what with the Blacks and Jews and Wimmins knowing their place again, and all had gone wrong because nurses now wear pants.

Paragraph breaks, people. Paragraph breaks. Just because you're insane doesn't mean you should ignore the rules of composition.

And, of course, I get the occasional Crap Email From A Dude (Jezebel FTW), usually somebody who is or claims to be a third- or fourth-year medical student or a first-year resident, about how much nurses in general and I in particular suck. Mostly those are over-written, longish screeds that have a high syllable-to-content ratio. Only once has one been even vaguely threatening, and that poor sot wrote from his school address. With his actual name attached. And all the ISP information there, too. 

*sigh* What is it with kids these days? Back when *I* was writing veiled threats in email, I not only was grateful to be able to do it on a greenscale screen, but I knew enough to use a Web-based email anonymizer.

Overall, I would say that the male-to-female ratio of Crackpots is four or five to one. The men are more concerned with me being a ball-busting feminazi bitch who castrates the decent, hardworking men she runs across (actual quote!) or my refusal to fit into their stereotype of nurse-as-handmaiden and tend therefore to be more openly offensive. The few female practitioners of Crackpottery are much, much more worried about the state of my eternal soul and whether or not, with my attitude, I'll ever find a nice (presumably uncastrated; won't that be a surprise to ChefBoy) man to marry. Once in a while they send things that play music and show fluttering putti or cherubs or whatever when you open them, then cause my virus-snagger to go nuts.

There are a lot of really, really cool emails too. The vast majority of emails I get are from people who were either students or new nurses when I started blogging, or who went back to school in part (so they say) because of what I've written here. That warms the cockles of my hard, blackened, castrating feminazi heart. Or it would, if I hadn't already given it to Satan to show my allegiance (actual quote!)

I'll just keep deleting the nasties and keeping the nice ones for now. Meanwhile, I'm off to make a big ol' pan of macaroni and cheese and some tasty castrated-male soup with a side of shredded nurse caps. Yum!

Sunday, October 12, 2008

Morning Drama

Max somehow rolled under my very low platform bed while he was asleep last night:

Those are his paws sticking out from under the bed.

When he woke up and decided he wanted to get up, there was much whimpering and scrabbling of paws until I went and lifted the bed off of him. Even lying down on his stomach, he's taller than the bottom of the bed, which presented some problems. Poor guy. Meanwhile, there's Strider:

I can haz chiropractor?

Sunday, October 05, 2008

Buzz...*click* Buzz...*click*

Manglement has rolled out a New Plan for us.

It involves, as do so many things that Manglement thinks up, Customer Service.

See, Manglement recently discovered the Intertubes. They learned, much to their shock and awe, that people go online on the Innerweb to see what sort of ratings hospitals and doctors get. It's not just which hospital is covered by your insurance package any more, no sir; it's the Customer Service rating of said hospital that might just determine where you go.

So Manglement came up with a way for us to improve our Customer Service Performance. Wait for it: it's going to knock your non-skid socks off:

The members of The Healthcare Team are to make hourly rounds.

No, no. I'm not joking. Doesn't matter who does it: nurse's aide, nurse, physical therapist, respiratory therapist, occupational therapist, wound care specialist--you name it, they can round. And when they round, they have a script to follow. I'll give you mine, as I am the Nursing member of The Healthcare Team:

"Hello, Mr/Mrs/Ms Blankety. My name is Jo. I will be your nurse for the day/night. My goal for this shift is to provide Outstanding Patient Care. In order to provide Outstanding Patient Care, I or another member of Your Healthcare Team will be making Hourly Rounds to make sure All Your Needs Are Met. (Here I am supposed to sit by the side of the bed; on what, I'm not clear. Perhaps, given the dearth of chairs at Sunnydale General, I am supposed to carry my own from room to room.) What are your goals for today? Do you need help to the bathroom? Are you comfortable? Would you like assistance in repositioning? Thank you. I look forward to providing Outstanding Care to you today."

Note that I have Capitalized Some Words in this script. Here's where the fun begins:

Manglement of Sunnydale General has dragooned certain poor sots in middle management to go 'round to various folks' rooms during the day and night shift and read questions to them. The questions are meant to show the Level Of Satisfaction With Customer Service. The questions read something like this: "Did your nurse or another Member Of The Healthcare Team perform Hourly Rounds?" "Did your nurse Provide Outstanding Care?"

Remember that script and those questions. It becomes important later.

Being the sort of outcome-driven little person that I am, I asked during our staff meeting if Customer Service initiatives like this one had shown any impact on quality of care. In other words, *good* nurses, aides, and therapists are already making hourly or nearly-hourly rounds, asking about pain control, and taking folks to the bathroom; has mandating that shown any decrease in, say, preventable falls or bedsores or the like? What's the measurable outcome in terms of quality of care?

First answer: "That's not what this is supposed to measure. Falls and bedsores are measured by the Joint Commission's Core Measure standards."

Okay, but my question remains: Has this business of the scripted rounds shown any increase in quality of care?

Second answer: "Well, we imagine it would. After all, if you're rounding on your patient hourly, you're more likely to notice their skin color and stuff like that."

Okay, great. But still, have there been any studies to show that this scripted rounding increases quality of care?

Third answer: "No. But we know that it increases Customer Satisfaction."

Customer Satisfaction, that is, as measured by the scripted questions that middle managers have to ask the patients--questions that we, as nurses etc., have trained them to answer correctly by using key phrases in *our* scripts. That way, Upper Manglement can take the raw data collected by the middle managers and point out that Sunnydale General has incredibly high Customer Satisfaction scores, simply because we healthcare providers have trained our patients to respond, like Pavlov's dogs, to the ringing bells of "Hourly Rounds" and "Outstanding Care".

Now, I have lots of problems with the idea that a hospital patient is a customer. Not all of those problems spring from a condescending, paternalistic worldview, so save your angry emails. Many of those problems spring from this simple idea: 

If you treat a patient as a customer, you are treating them for the wrong reasons.

Let me say that again: If you treat a patient as a customer, you are treating them for the wrong reasons.

I doubt--seriously doubt, having done it for years myself--that retail clerks or waiters get up in the morning filled with glee at the thought of going to work again. As cynical and grumpy as I can be here, I really and truly do look forward to working nearly every day. 

I look forward to it because I have patients: people I care for, in multiple senses of the word. I can educate them, learn things from them, make them happier or more comfortable or help them to heal. They are not my "customers"--if they were, what would be the point of actually giving a damn? I could provide a service for pay, sure, and could take my heart and brain out of the equation.

Reducing patients to "customers" undermines the mission of medicine: to assist the person who's sick in healing. However, reducing patients to "customers" does something lovely for Manglement: it boosts their scores in patient satisfaction and means they get more money, because they can publicize those boosted scores and bring more patients in.

Don't I care about my patients' happiness? You damn well better be sure I do. But I do it without scripts and without mandates from Manglement. I do it because it is the right thing to do. Dammit.

Saturday, October 04, 2008

Interesting email I got....

There's an interesting article up at Nursing Degrees about what drives nurses out of the profession. 

Here 'tis:

Housekeeping: It's a Good Thing.

Why, yes, I changed the format. I'm so glad you noticed. Do you like the little nurse up in the corner? I do. That's a candid photo a coworker took of me as I swanned from room to room this past week, dispensing oral Dilaudid and love to all my patients.

This new Blogger template is so easy to use that I've decided to stop being a rebel Luddite and actually add things like tags and updated links to the blog. So, in the next few weeks, you'll be seeing some changes:

1. New, updated links to blogs like Macho Nurse and Cooking Nurse. 

2. Tags! It's hard, when you're looking for a mac-and-cheese recipe or Rules For Residents, to have to wander back through the archives and read post after post, hoping you'll hit the right one.

3. Some form of organization for the archives. I've not looked into the capabilities of the new template thoroughly yet, so I don't know what sort of form that'll take, but I'll figure something out. I'm kind of tired of just having things listed by date.

4. More pictures of the dogs. Better grammar. More ranting. More naps.

Not all of these changes will happen at once, of course, but be watching.

As for the "Followers" pictures up top...I may have to ditch those. It scares me to have little people watching me all the time, plus I can already tell I'll get all competitive and weird and start counting followers.


Organizing Jo