I could be bounded in a nutshell, and count myself king of infinite space....

It's the last month of internship, and I have been dreaming.

Most of the dreams involve the Old House. That's the house I grew up in, the house in which my sister used to say, "Here, Jo, smell *this*!", the house El Erstwhilo and I bought from my parents when we were first married. (Yes, before you ask, it was weird. I found myself looking for things I remembered Mom having, in the places where she kept them, before my brain would remember what my body didn't know: that those things weren't there any more.)

Most of the dreams also include tornadoes, or bad storms. Some of them involve El Erstwhilo and the woman whom he left me for, who doesn't get a nickname here because my mother reads this blog. In the latest, from this afternoon's nap, I was in the upstairs bath watching a tornado come rolling in while simultaneously trying to get Max in from the back yard and applying eyeliner.

The one last night had El Erstwhilo and La Cucaracha (hey, it starts with 'c') in it: they'd covered the outside of the house with ugly beige brick and had lined the insides with panelling. Furniture was floating in midair, suspended by ropes while a new floor got laid.

My dream interpretation book, published during the height of interest in Spiritualism after the First World War, tells me that houses, especially childhood homes, are symbols of my perception of myself. Storms and tornadoes ("cyclones") say that I'm either undergoing a massive change internally, or I'm unsure of whether my current relationships are healthy. Makeup means I'm either trying to hide my true self or put my best face forward. The books say nothing about ex-husbands or cuckolding best friends or large, shaggy blond dogs with a jones for kitty bellies.

And yet, the book is right. My perception of myself has changed considerably in the last few weeks. Although I probably couldn't handle a CCU-level crisis, I can handle a lot more than I could in September. F'rinstance: I know where all the cords go, who's likely to give me report on what, which doctor wants what (fer Godssake, don't put a three-way on Doctor X's patients! He hates those damned things!), and I can give a simple, plain-English explanation of What All Those Beeping Things Mean to the most freaked-out of family members.

In short, hugs are second nature now.

Hugs were never second nature on the floor. In the CCU, people need them. I am not--despite what casual observers might say--naturally a very touchy, affectionate person. These families *need* it, though, as when a family member misread "ARTIFACT" on a monitor as "ARREST" and fled the room in a panic. A side-hug calmed her down when no amount of intellectual explanation would.

So my personal perception of Jo is changing, fearfully changing. I'm still not sure whether I'll be a *good* CCU nurse as fast as I'd like to be, but I have no doubt I'll be an *acceptable* CCU nurse.

I have one more month to commit to memory whether it's atropine-bicarb-epi-what the hell or whether it's epi-atropine-bicarb-oh-scruit. I have one more month to try to memorize what color tube gets what blood for what test, and to remember that levelling an A-line means turning it *off* to the patient and *open* to air, and why (thank Frogs for my Holy Kamole preceptor, who explained that!).

Jo is totally, completely, unironically ordinary in real life. Maybe I can move from being ordinary and acceptable in this job to being extraordinary, as I did in my last one.

We'll see. Three more weeks to go, and we'll see.

Aaaaand your Monday Remedy is....

Almost unbelievable. Too freakin' cute for words.

Sunday Silliness, courtesy of S. Fry

Newsflash: Some Nurses are Assholes!

Okay, okay. Some people are assholes. And some assholes are nurses. I expect assholishness in the general public, but I don't always expect it from nurses. When I encounter a nurse that is unprofessional, it always shocks me a bit.

I spent the day at Holy Kamole, orienting to their CCU, which is much different from Sunnydale's. For one thing, the folks at Our Lady of Perpetual Propofol see many more heart patients than we at The Brain Barn do (ie, we see exactly none). They also get fresh transplant patients, folks in end-stage whatever disease, people with flaming CMV infections everywhere but their brains....you get the idea. The patient population is varied, totally not brain-screwed, and very, very sick.

So: Imagine a freshly-scrubbed, almost-recovered-from-her-weekend Jo bopping on to the floor a bit early. (I always get where I'm going a little early, so I can orient.) The night charge was kind enough to take me around and show me the various cubbyholes, then show me where they hide the snacks, and get me into the computer system. Then the day charge showed up.

And promptly completely ignored me when I ventured to introduce myself. No, seriously. I walked up to the desk, made eye contact with him, said "Hello-my-name-is-Jo-I'm-from-Sunnydale-and-I'm-orienting-today" and watched in disbelief as he looked levelly at me, then turned his back and walked away with a heavy sigh.

Um. Okay.

Sorry to be using your oxygen.

The day improved after that, as my preceptor was one of those fantastic teachers who never gets tired of explaining *why*, exactly, you need to level this line here or give these medications in this order. I love whys and wherefores. She gave me oodles of them. She also sent me hither and yon to see things like pacemaker interrogations (for non-medical folks, that involves a computer, not tying the pacemaker to a chair and threatening it) and emergent intubations and the nastiest case of scabies I've have EVER seen (the dude's right chest was covered with crust and his nipple was totally gone). So, all in all, a good experience--if you ignore the charge nurse, which I did.

Until emergent intubation number two, for which I was the runner. The charge turned to me and said, "Get saline."

"What, exactly?" I asked. "Bag? Flush? Bullet?" (Any one of the three would've been logical.)

He sighed deeply again (good thing he's well-perfused) and said, as though I were Forrest Gump on a bad day, "I need a bag of saline. You know, the big one. The liter one. With tubing. The kind with the spike on the end. You think you can do that?"

I did not shove the bag of saline (the big one, with tubing) into his ass. Instead, I brought it back in record time, considering that the bags of fluid and the spikes are kept in totally different places across the unit from one another, and handed it to him without comment.

Then we went back to ignoring one another for another few hours.

When the night nurse who was taking my patients arrived, she looked me up and down and said, "Oh. You're a new nurse. From Sunnydale." You could've cooled beer with her voice. Again, resisting the urge to put her into one of her own beds, I gave her the most thorough report-by-system I've ever managed to pull out of my hat, without comment. (And thank Frogs I had managed to do everything including fluff-and-puff for my patient, thus leaving nothing about which she could complain.) New nurse, yes. Stupid nurse, no.

Asshole? God, I hope not.

MY PARENTS RESURRECTED ONE OF THEIR DUCKS.

No, really. This requires emergent intervention.

Through a concantenation of events I won't go into here, ducks became an inside family joke some twenty or thirty years ago. In the intervening decades, my folks have built up a collection of ducks--some mechanical, some antique, some in excruciatingly good taste, most definitely not--that makes me nervous about bringing anybody to the family home in Seattle.

To give you some idea: a friend of theirs (a Methodist pastor, so he wouldn't lie) once counted a hundred and seventeen ducks (d=117) in one of their bathrooms. The fact that, as Dad says, "A good number of them were on the shower curtain" does not excuse stuffing one-hundred-plus ducks into a seven-by-five space.

Anyway, they pulled out the duck that yells, "DON'T FORGET TO BRUSH YOUR TEETH!!" this weekend, much to the amusement of their un-grandchildren, who are almost six years old.

Reader, you must understand: it is the holiday season. In addition to the ducks (mechanical, singing, flapping, clapping, oral-hygiene-reminding), there will be at least sixty-eight (X=68) mechanical Christmas toys festooning their walls and bookshelves soon.

Imagine this: You pull up to a house in a nice Seattle neighborhood on a frosty December night. The house itself is of understated, tasteful modern design. You imagine cozy nooks and soaring ceilings, and you won't be disappointed. Inside, there's a combination of exquisite antiques, soft, comforting couches, carpets bright in pattern and intricate in design, and tiny details that catch your eye and invite further study. The walls are lined with books and things in frames that make you say, "Wait...was that a Matisse?" There's a cup of coffee in the kitchen for you, a cat who wants nothing more than to get its head rubbed...

AND SIXTY-EIGHT SCREAMING CHRISTMAS DECORATIONS, INCLUDING ONE ON THE BACK OF THE BATHROOM DOOR. THAT ONE SINGS, EVEN.

I don't spend holidays with my parents. Don't anybody dare question why.

How I Spent My Thanksgiving Vacation, by Nurse Jo

Take:

Add:

And:

Along with:

And:

And a dollop of:

Season to taste with:

Well, that was a bipolar two days.

Gracious.

I have two preceptors. I worked with one on Wednesday and the other on Thursday of this week.

Preceptor the First is....difficult to approach. She's a fantastic nurse, a very nice person; I like her a lot. I'm nervous about working with her, though, because she combines OCD-ness with such a huge amount of personal reserve that it's difficult to approach her with problems or questions. We're in the middle of testing a new computer system in the CCU, so a lot of the questions I had for her were computer-charting-related. Instead of having me fly the box and learn by doing, she would simply take over and chart *for* me as I watched, then expect me to be able to replicate the motions when it was time to do so.

I don't learn that way, sadly. I *used* to, but seven years of hands-on learning has ruined my brain for anything else, and it's probably too late to get a brain transplant and still pass my classroom final exam.

Wednesday ended with an emergent intubation to which I was invited (like Queen Victoria "invited" people to show up in the throne room) by the charge. Rudely. As in, I was in the middle of something else that was just a little bit important, there were already eight people in the room (two docs, three RTs, three nurses), and I got snarled at to come in and start an IV.

Which is fine. I can start IVs all day, with my hands behind my back, in my sleep, you name it. The particular IV I had to start was in the hand, and the dude I was starting it on was elderly, very fragile, and had extremely large veins. In a situation like that, I use the technique I learned years ago of putting the hand way below the heart and starting the IV without a tourniquet, as filling the vein tends to make it easier to blow.

I had gotten a nice, fat, 18-gauge IV into a hand vein when the CN rushed over, grabbed the dude's hand, and said sharply, "What the hell are you doing?" The vein, of course, blew. She then reminded me how to start an IV properly (ie, her way) and gave me a lecture on not losing my head in stressful situations. I looked at her levelly and said, "I have led a code before, you know."

Then I went away after the dude was intubated, started two impossible IVs for another nurse, and was told I needed to apologize to the CN by my preceptor.

It was a bad day. It was such a bad day that I vented to both my Brother In BFE and Sister Rat about it, then went to bed in tears. It was one of those days when you feel you're trying to run up a staircase coated with pig fat while somebody yanks on the scruff of your neck at odd times, making you lose your footing.

Thursday was different. Preceptor the Second is a total goofball. I am a total goofball. Neither one of us have any filters to speak of, so we'll talk about farting over lunch (note: I thought the nurses on my old floor were filterless. I was wrong), do yoga poses in the nurses' station, and eat cake when it presents itself, then be sugar-rushed all day. Besides that, she's detail-oriented in the same way I am, without being totally OCD about small things.

It was still a day when I felt like I was completely behind. I would've drowned had it not been for her help entering orders and turning patients and dealing with the second-largest bowel explosion I've ever seen, but it was a *good* day. A patient who'd been heavily sedated and intubated the day before got better, and I admitted-then-discharged one patient and admitted another (and actually got the swing of getting somebody into an ICU bed, wahoo!).

The charge nurse from the day before was mercifully absent, so I got to send her an apologetic email, doing the last ten meters on my belly.

It is hard to learn new things when you're a new nurse. It's harder--*much* harder--to go from being an expert to being a newbie at something. Your pride takes a hit, your ego gets involved, and you end up trying to prove things when you really don't have to. That much I learned from Wednesday. I learned from Thursday that a preceptor who's just as loony as her intern can make a hell of a difference in terms of that intern setting her (massive) ego aside and actually learning stuff and being humble enough not to freak out about it.

It's amazing what a difference personality makes. With Preceptor the First, I'm a little afraid to ask questions, for fear that she'll swoop in and just plain take over. With Preceptor the Second, nothing's off-limits and I have no fear of looking stupid. Both of them are excellent instructors; there's just the ease of meshing personalities with PtS. I'm learning two different ways of going about things, which is valuable: if one thing doesn't work, I can try the other and it might just make things happen. I certainly don't want to drop PtF as a trainer, but I do find myself a little more tense on those days and a little more wary of what might happen.

Years ago when I was first starting nursing, I got a crazy patient--and I mean *crazy*, as in, I've not had anybody to match her since--and she and I did not get along. This of course caused much hand-wringing with my boss, my preceptor, and the educator for the department. Because I was a new nurse, I couldn't simply say, "This person is a fucking nutjob and I refused to play her game, therefore, she decided to report me." Instead, there was a long meeting with all three of my superiors during which I finally had to come up with some deep psychological reason why I couldn't get along with this person (I said she reminded me of my then, now thankfully dead, mother in law) and listen to a whole bunch of bullshit about how I needed to set personal feelings aside in dealing with people who were nuts.

I had worked for three years at that point in an industry known for being a target for wackjobs, and had actually been a target, personally, for some of those wackjobs. Yet none of that counted. I was PISSED. I was treated as though this job was my first rodeo, and none of my previous experience was taken into account. The ability to call out a nutjob and treat that nutjob as such was taken away from me, and I had to take the fall for somebody else's inability to be a sane human being.

That's kind of what's going on now. It's assumed that I have the technical skill to deal with any number of problems. In terms of the personal angle, though, pretty much everybody assumes that I'm a complete n00b with no clue. It happens more with PtF and the charge nurse than it does with PtS, but that's not their fault; they're trying to make me the best critical-care nurse I can be. It's up to me to lose the ego, gain the patience, and prove that I can do this without completely losing my head and holding somebody's smoking entrails up before their dying eyes.

Which means I will need much more cake.

I was looking for the perfect spacer post and found it at Movin' Meat:

I Love xkcd from NoamR on Vimeo.

This will make the most sense to rabid xkcd fans like myself. I'm pleased that they included the "Hammertime" comic, which was my first exposure to the strip and remains one of my favoritest ever.

As my pal Mazen says from time to time,

"Deez? Eez bool-cheat."

Yes, it is. It is indeed bool-cheat.

I fear my gallbladder is on the fritz. (Slightly used, low-mileage gallbladder: anybody got one?) After my twice-monthly cheezburger last week (nom nom nom nom), I was down for two days with abdominal pain, nausea, vomiting, a low-grade temp, and other things you really don't want to hear about. Since then, my right upper abdominal quadrant has hurt like a son of a bitch, and I really don't have a lot of appetite.

Friends came over last night for homemade bread, beef stew, and apple crisp, and I didn't want any of it. That, my friends, is how bad it is. That is how much bool-cheat we're dealin' with: When Mama don't want to eat, you might as well kiss the world goodbye.

I see the Muppet Doctor tomorrow for what I hope will be a diagnosis. I sincerely hope it's not a toomah.

So I wasn't in the best of moods when I showed up to work today.

I was in even less of a good mood once I saw my patient.

Eight drips.

Eight. Freaking. Fluids. Going. At Once.

Lasix. Insulin. Levothyroxine. Bicarb. Two pressors. Fluids. And a rider for the mag and potassium and everything else we had to hang.

My bad mood turned worse when I found out why this poor guy had eight drips on him:

One of those "devastating" bleeds.

Young kid, mid-thirties (anybody younger than me is a "young kid"), two little children, loving wife, close enough to his coworkers that they consider him part of the family.

And a devastating bleed with no history of anything: no hypertension, no diabetes, no nothing. He was brain dead when I showed up, and did not improve.

It was a bad day for me and for him.

It's gonna be a good day, though, for a whole bunch of people, and here's why:

His kidneys are going to two different folks who have both been on the transplant list for a couple of years.

His liver is going to a guy who was sent home on hospice last week.

His heart is going to somebody.

His lungs? Going to somebody.

His pancreas, amazingly, is going to somebody else. (Pancreas transplants usually work best when the donor is very young; this guy was in great shape, so we can use his pancreas.)

Bones? Skin? Tendons? Intestines? Nerves? (They transplant *nerves* now? The transplant coordinator assured me they can.) Corneas? Check, check, check, check, check, and ditto.

There are going to be at least ten people, by my calculations, who have this one person to thank for their lives, their vision, their ability to produce insulin, and their ease in walking. Never mind the at-least-five people who will have skin grafts thanks to him. Never mind the folks who will get bits of intestine that will allow them to have something close to a normal life again.

It was horrible, and it was wonderful. In the middle of drawing the nearly forty tubes of blood that needed to be drawn prior to "harvesting" (or "retrieval", as some people call it, but I prefer "harvesting"), I realized that this one man, though he was lost to his family and his friends, would *literally make living possible* for any number of people.

Young people make fantastic donors and really, really crappy patients. Inertia will only take you so far, and sometimes the dead are harder to keep breathing than the living-yet-very-sick. This guy, despite all the odds, managed to get off his pressor drips and his insulin and everything else well within the time limits specified by the transplant experts; he ended the day on nothing but plain normal saline. That means that he'll be scooped out (to put it bluntly) like a melon, with wooden dowels replacing his bones and clothing covering his skin donor sites.....

....but there will be a handful of people who have him to thank for their lives. Their LIVES.

Most of us, me included, can't guarantee we'll touch that many people in a lasting way in the course of a career that stretches twenty years. He did it in one day.

It was sad. It was happy. I watched the transplant nurse's computer, and saw how all the acknowledgements came in from various transplant centers. I imagined how it would feel to have that beeper that's stayed silent for so long finally go off, and to know that your second chance came at the expense of somebody else's.

When, not if, but when my aneurysm blows and I infarct at least one half of my brain, do this:

Take what you can. I don't care how tricky or political or corrupt the system is, the ends justify the means in this case. Use my kidneys, my heart, my cruddy lungs, whatever.

Donate the rest to a medical school. They can have fun studying my muscles and my skull, if nothing else.

Compost the rest out in the back yard, and plant a garden over it. In the high summer, when the produce is ready to pick, go out and grab a tomato off the vine, polish it on your shirt, and bite into it. My epitaph will read, "That Jo! She was one heck of a tomato!"

Tales from the CVCCU

As part of our training, we interns have to go to the cardiovascular CCU at Holy Kamole. They deal with things there that, thank Frog, I will never have to see. Bone-marrow transplants gone wrong I can handle; neurological disorders hold no sway in my nightmares. But heart and lung and kidney and what-have-you transplants? Are the stuff of horrid, horrid dreams.

I am meant to do a thorough neuro exam every hour. I am meant to understand dermatomes, Brown-Sequard syndrome, and incomplete cord transections. I am not meant to handle eight vasopressor drips on one patient.

So it was with fear and trembling that I got to the unit to follow an experienced CV nurse. The patient she had was one of those who requires two nurses: every once in a while, you'll see a one-on-one (for instance, if somebody's undergoing continuous, slow dialysis), but two-to-ones are very, very rare.

What does it take to be a two-to-one patient?

Let's start with a rare genetic disorder that only about a thousand people in the world have, and make it one that only, say, vegetarian left-handed expatriate Iranians living in Hungary are prone to. (Of *course* that isn't the real disorder. Do you think I'd violate HHIIPPAAA that way?) Be certain that your patient fits none of those categories.

Add on the necessity of not one, not two, but three--so far--solid organ transplants over the lifespan of this particular patient. If you can make one of them a re-transplant, so much the better.

Make sure that that weird genetic disorder isn't diagnosed until after the first solid-organ transplant; that way, you'll stand a good chance of ruining whatever organ you transplant the first time with the complications of said genetic disorder. (As an added bonus, make sure that the patient's sisters and brother all find out that they're carriers of this nasty disease, and fuck their brains, their future plans, and their reproductive decisions up as a result.)

If you can manage a rare-but-dangerous viral infection, tack that on as well.

Oh, and be sure you put in for an order of adult respiratory distress syndrome, with a side of sepsis.

What you end up with is an absolutely beautiful young woman on a ventilator, with a midline incision that runs from belly to brisket, six pressor drips, and very little chance of ever waking up.

I left my job at Planned Parenthood the day that a twenty-seven year old woman came in with her pregnant thirteen-year-old daughter. The woman asked me if I expected her to cry over her daughter's being pregnant; the idea that any other possibility would present itself showed me such a huge gulf between her experience and mine that I could no longer deal with the disconnect. I had thought that that was as bad as it got.

Until I saw a smart, funny, gorgeous girl of twenty-three hooked up to hinty-bazillion machines, all of which were dedicated to keeping her body alive until, frankly, her parents and siblings could work up the courage to say goodbye.

The day wasn't made any easier by the fact that I had known her before, years ago, when she came in to our floor and ended up being diagnosed with that crazy genetic disorder. I thought then that she wouldn't make it to nineteen; I was wrong. Her parents showed me the pictures of her on the campaign trail for Obama, the snapshots of her hanging out with Sasha and Malia and Michelle and Barack. They told me about how she felt so strongly about particular issues up for debate in the Texas Legislature that she disregarded the advice of her doctors and went to testify as an advocate for battered women, how she ignored the symptoms of organ rejection in order to go to a conference on providing health care to uninsured people. There was a framed picture of her getting her Master's degree on the table by the bed.

And two pumps with three channels each, a balloon pump, a ventilator, and three pages of IV drips that had to be administered at exactly the right times.

I guess it bears mentioning here that her parents and older sister recognized me the minute I walked into the room and called me by name. It sucks when people you have to disappoint remember you so well.

We walk a fine line, nurses and doctors. On the one hand--and I think this is more true of nurses than of doctors, except in rare cases--we gain a degree of intimacy with families that would be inconceivable in most settings. On the other, we have to maintain that professional distance that allows us to advocate, to educate, to break bad news.

Sometimes, that last is easy. You can manage, even with people you see more than once or twice, to keep your distance. Sometimes it's very, very hard. And sometimes, despite your best intentions, you fail completely at being a detached professional person.

I was not the person who extubated her. I was the person, though, who turned off all of the drips, and hung the morphine up, and titrated it so that she didn't show any distress, and who laid my useless expensive stethoscope against a chest in order to hear what wasn't there.

I was the one who had to look across her body and tell her parents and her brother and her sisters, "She's gone, now."

And I was the one who broke every professional boundary imaginable by standing in her room with them and crying over the loss of a reasonable, decent, driven young person who had bad, bad genetic luck.

In a way, I'm glad it was me. I was there when she found out she had this thing wrong with her that would shorten her life; I was there when she told her parents, quite matter-of-factly, "This won't change any of the plans I've got." My ability to translate medicalese into English eased their transition from normal family to family with dangerous medical condition; it helped that I could put things in every-day language and thus calm some of their fears.

But even two nurses, six drips, a balloon pump, and all the translation talent in the world can't save somebody, sometimes.

Still, I'm really, really glad I was there. I'm glad I got to see what she'd done.

I'm glad I got to say goodbye.

Sunday Sublime

Somebody snuck a camera into the CCU.

Because this is, to the last detail, how we spend our days.

I'm the one in pink.

Highlights from the night's hippie action

Beloved Sister, on the phone: "So...what's that sound like a cat yowling?"

Jo: "I think it's a girl. And an accordion."

Beloved Sis: "Really? An accordion?"

Jo: "Yeah, last year after the party, there was some guy walking up and down the street, playing the accordion and singing."

Beloved Sis: "So what are they doing right now?"

Jo: "I *think* it's Toxic Airborne Event's 'Does This Mean You're Moving On'".

Beloved Sis: "....oh..."

Jo: "It's......peppy."

Beloved Sis: "Now *that's* a word I haven't heard in a while."

later

Jo: "Oh, Christ, they've gotten out the tuba."

Beloved Sister: "These are my kind of hippies."

Why I love my town.

The trust-fund hippies across the street are having a party. There are guys with dreadlocks and large dogs patrolling the street on longboards, telling people not to park here--go park a couple streets over, where the school parking lot is open and free.

I just got back from Large Chain Grocery Store, where I heard over the P.A. system: Tori Amos, Sugarland, Barry Manilow, and Rage Against The Machine. Also an announcement from management that "All employees need to straighten up and fly right!" before the song of the same name started to play. What other grocery store has its own DJ?

There is a HangerRama happening tonight. I'm not sure I'm going; it is, as the name implies, going to be held in a large hanger outside of town.

A sheriff's deputy was toodling down the road today, blasting Brave Combo out of his squad car window.

Tomorrow The Rat, The Corpsman, The Guy With The Huge Beard, and B. will all be having huge amounts of beef stew with bacon, home-made bread, wilted spinach salad, and apple crisp here. Don't you wish you could come?

In better news:

My laundry is done, my house is clean, the cats are happy, Max is groomed, I am clean (although out of shampoo) and I have chicken pot pie (chickenpotpiechickenpotpienomnomnomnom) for lunch tomorrow.

Also a Hellish Workout with Attila, but that's nothing new.

It's been a good day off.

This may be the first time I've ever written a song in honor of a patient.

To the tune of "Mister Sandman":

Mister Dickwad,

Please get well soon;

Can't wait to see a diff'rent face in your room.

You drove me crazy for thirty-six hours,

You pushed the limits of my nursing powers!

Dickwad, I'm at the end

Of any rope I had: I am not your friend.

Please, please get out of your behh-heeed,

Mister Dickwad, heal up your head!

(Backup singers: fuck fuck fuck fuck fuck fuck fuck fuck fuck fuck fuck fuck)

Mister Dickwad, please don't you say,

That sterile fields make no difference each way;

Please don't imply that my training ain't real

Get meningitis: we'll see how you feel!

Dickwad, I've had enough

Of condescension and of your acting tough,

Please, please get out of your bed:

Mister Dickwad, heal up your head!

(Backup singers: dumb dumb dumb dumb dumb dumb dumb dumb...)

Mister Dickwad, can't you shut up?

I need some Scotch, yes, at least half a cup.

I'm tired of your ass-grabbing behavior

Your weakened state here will not be your savior!

Dickwad, when the cops find

Your charred remains, I will be on their mind.

But you know I'll be acquitted:

Mister Dickwad, you are half-witted!

Sadly, this particular patient was alert, oriented in all spheres, and totally intact. Also sadly, he was just a bit too big for me to strangle efficiently.

Sometimes I just want to go back to waiting tables.

The problem with having a clumsy cat...

...is that he tries to jump up in your lap while you're blogging, and this is the result:

Owie. Owie owie ow owowowow.

I have cussed and poured myself a Scotch and put peroxide (bad) and Bacitracin (better) on it, and now I need to go apologize to Flashes for scaring him half to death when he was only trying to be sweet.

The bitch of it is that I was just getting rid of the other kitteh-inflicted scars and weightlifting bruises on my legs, and now this. My jammy-pants will need some help in the morning, I can already tell.

God, I fucking love my job.

I mean, really. What could be more perfect than CCU? Well, watching an intubation in a controlled setting was almost more perfect, but I'll get to that in a second.

Critical care is *so* different from floor nursing, even acute floor nursing. There's less downtime, there are sicker patients (duh), there's a whole lot more for a nurse to do, and the interventions have immediate, tangible results. I'll admit to being enchanted with the whole immediate-gratification thing, but I'm also reassured that the people I'm taking care of have been recognized to be actually, really and truly, no-foolin' sick. I no longer have to go head-to-head with residents who don't know me, trying to convince them that their patient really doesn't belong on the floor. There's also more autonomy in this job than I ever dreamed of.

We have a whole hell of a lot of freedom for two reasons: first, Sunnydale operates on a series of protocols. We've got protocols for everything: magnesium or potassium too low? Sodium too high? Is the patient sitting up on 50 of propofol and gesturing wildly? We got a protocol for that, son, and you can just go 'head and implement that sucker. (This, of course, requires that a nurse actually pay attention to what's going on, something I'm still working to perfect.)

Second, Sunnydale has a lot of residents. When you have a resident who's post-graduate year two and is on her second round of critical care rotations and a nurse who's got thirteen years of CCU experience, the nurse is going to take the lead. The women and men I work with are not shy about this; I watched twice today as nurses led residents through sticky situations and everything turned out fine.

And the teamwork with this group? Is outstanding. I say that as somebody coming from a floor that's recognized as not only being the nuttiest, most loose-cannon floor in the system, but as the floor with the tightest teamwork outside of the CCU. This CCU group makes my old coworkers look like a bunch of slackers.

For instance, (and here's where I get to talk about the intubation, oh boy!) we had a patient who needed to be intubated for something like the fourth time today. I stood around and watched, taking mental notes, as recorders cycled in and out and another person ran for a bag of dopamine and somebody drew up and labelled all the paralytics. It was like a code, in that everybody automatically fell into position and started marching, but much calmer. Grim, in fact. (It was grim because the patient should've really been intubated at 0700, but that's another story.)

Something that never would've happened on the floor: Junior Resident was trying to pass a #7 ET tube, and the attending gestured to me. "Come over here" he said flatly, and showed me where to squeeze and press on the patient's neck to make the vocal folds come into clearer view for J.R. Check that out! Mashing on the larynx can really make a difference!

Something else that rarely happened on the floor: I heard an attending read a family the riot act today, concerning their behavior to the nursing staff. Mostly, the residents just let us on the floor deal with touchy situations on our own; here the attendings draw themselves up to their full heights (in this case, it's something over six-foot-four), stroke their beards thoughtfully, and then go lay down the law to the obnoxious parties in such a way that no stone is unturned and no ass un-remodeled. It's impressive, and it certainly does make the job easier.

Which brings me to two points I never believed until now: that the relationship between doctors and nurses in the CCU is different, and that CCU nurses are different.

I had good collegial relationships with all the guys and gals up on the floor, don't get me wrong. Ricka and Skippy and Ray and Wolfie and Jack and I were on first-name bases with each other, and we bounced ideas off each other and didn't hesitate to admit when one or the other of us were stumped.

This is much different. Not only am I working much more closely with Ricka and Skippy et al, there's a different feel to how they treat me. Instead of simply asking for information, they want information and input. I'm seen much more as the go-to person for whatever question they have, and I'm expected to have not only the answers, but a rationale for anything that might be going wrong or anything new I want to try. It's intimidating and exciting and very intellectually challenging.

Plus, the nurses are different. It's something I never really understood until now, but it's true. If you want a drug-guide-style run-down of anything you're putting into a patient's body, and how it might work differently if given by mouth rather than intravenously, the nurses I work with now will do that for you, off the tops of their collective heads. They're very, very sharp. They're incredibly bright. Even the dumb ones are brighter than the brightest people I worked with on the floor. They're completely in control of what's going on at any given time, and are the calmest, most no-drama bunch I've ever worked with.

Plus, and this is something specific to our CCU, they all love each other--really and truly. There are no cliques, no backbiting, no competitions over this/that/the other thing. Disagreements--and I've seen a few, on both patient-related and personal matters--are brought out in the open and dealt with right away, and not given time to fester. The folks who precept the noobs like me are obviously enjoying it and fight for the chance to do so.

I ran into a woman I used to work with last night. I hadn't seen her since before I started the internship, and the first thing she said to me was, "Jo! You've lost weight!" She immediately backtracked from that, furrowing her brow, and said, "No, maybe not. You just look *happy*." She said that last in a disbelieving tone of voice.

I *am* happy. I'm very thankful I chanced this, and I wish I had done it years ago. I'm still worried that I won't measure up in class, but I feel like I'm getting a handle on the practice just fine. I'm excited, rather than scared shitless, when I think about finally being let out on my own--it's like walking out on ice you know is safe, but you've convinced yourself might not be: a combination of scared-but-comfortable and pure-dee excited. Every day on the unit, not to put too fine a point on it, is like a first date with somebody you know you already like and click with: all the niggly stuff is already taken care of; you just have to figure out how best you fit together.

Man, I fucking *love* my job.

Please, I'm begging you:

If there's anybody out there who reads/speaks German fluently, or who can read/speak technical German, could you contact me at the link to the right, under "Speak"?

Years ago I posted about a Mercedes Selekta typewriter I'd found, and about how I couldn't translate the manual. It turns out that there's a very pleasant person out in the ether with the same trouble, and more than that, his machine is broken. The manual is in the most dense, multisyllabic German I have ever seen, so I can't be of any help to him. I'm hoping we could at least get some of the manual translated, so his machine will become un-stuck.

Many, many thanks. Of all the requests I've gotten over the years of having this blog, this was the most charming. (Or second most-charming; I dunno.)

Fort Hood, Texas, 11/5/09.

Product Review: Things That Have Stood The Test Of Time Edition!

Faithful Minions will recall that I occasionally do product reviews here. They can range from the medical to the girly, with large doses of general-life stuff thrown in.

Herein are my reviews of things which have stood the test of time. Be amazed.

1. Neuton Electric Lawn Mower

I bought this a year ago and have used it on long grass, short grass, wet grass, dry grass, in a boat, with a goat...oop, sorry. I've used it in every condition imaginable in Central Texas, which involve bushwhacking and muddy ground and very grouchy toads.

Provided I don't try to mow very wet, very high grass in very humid conditions, I can do a quarter-acre on one battery. Given that dry, low-grass, pleasant conditions never exist in Texas when grass is actively growing, I now own three batteries at $99 a pop. Howsumever! The batteries hold a charge, last a long time, and keep the mower powered. It's quiet, it's heavy--but the weight of the machine is positioned exactly over the cutting blades, so it doesn't feel heavy--and it does a hell of a job, even on catalpa seedlings.

The safety key on the mower is kerfuffled, according to a newsy letter sent out by the Neuton people, but my mower hasn't caught fire yet. I'll fix it sometime in January.

Rating: A++

2. Miele House Mower (vacuum)

I love this thing. If I had to save one appliance from a house fire, this would be it, even before my coffeemaker. The only complaint I have is that the bags are so damn expensive. It sucks up everything, yet is so quiet that Max is unmoved and the cats actually try to play with the vacuum head.

Rating: A+

3. Laphroaig 15 -year single malt Scotch

This is my go-to drink for the wintry months. I am not so fashionable as to switch to gin in the summer; instead, I go to beer (more on that in a second). This is the best Scotch I can reasonably afford ($70/750 ml), and I do so as often as possible. My beloved brother-in-law once sent me a tiny bottle of 35-year-old single malt, and I can honestly say that that's one of two Scotches I've had that are better. (The other is Bruichladdich, which is almost impossible to get around here.)

Malty, smoky, peaty, and reasonably smooth. A good Scotch for steak or burgers or tacos. Or by itself. Which reminds me, Mama needs a glass.

Rating: A.

4. Stone Brewery 13th-Anniversary Ale

Here I'm inserting a ringer; this beer is not meant to be cellared. Like Chicken-Killer, it should be drunk fresh, even though it's more a barley-wine style than an ale. It's dark, extremely strong (be careful! I think it rings in at something like 13%), and has a gorgeous, complex hoppy aftertaste. Mama here can have about six ounces of it before she falls over, but that only prolongs the enjoyment. Again, do not try to cellar this beer. The beauty of it is the fresh hop finish after the gentle carmelly nose.

Rating, based on fresh product: A

5. L'Oreal Volume Naturale Mascara in Black-Brown

I've had quite the time with mascaras over the years. For a while, Chanel was my go-to, but it got clumpy way too fast, and had too much fragrance. I do not need perfumed eyelashes. After that, it was MAC Loud Lash, which of course (like the Gap's Essential Jeans) went out of production as soon as I discovered it, if not before. L'Oreal has a pretty good product here, and it's keeping my DTs under control.

It's not hugely volumizing, so if you only have six eyelashes, look elsewhere. Likewise, if you want something that absolutely refuses to come off regardless of conditions, try to find a couple of tubes of MAC Professional, but don't say I didn't warn you. It goes on evenly, is thin enough not to clump, dries fast (so you don't get the dreaded Great Lash Spikes), and comes off with soap and water. It does run if you have oily undereye skin, so be aware of that and use powder if necessary.

Rating: B

6. MBTs with Birkenstock insoles

Those of you who have been reading for a while will remember my adventures in the early days of owning MBTs: a strained MCL, turned ankles, and very sore feet.

I have horrible feet. (Thanks, Mom.) I have bunions, completely cubical big toes (which require a huge toebox), narrow heels (which require a double-last), plantar fasciitis, sesamoiditis, and no arches to speak of. In short, I am a Hobbit, best suited to second breakfasts and lazy pipes outside my freshly-painted round door. I am not suited to nursing.

The combination of MBTs and Birk insoles has saved my career, and I am not exaggerating in the least. Three days off work, on narcotics, and in constant searing pain convinced me that Something Had To Be Done. If it were not for the combination of arch support, the rocker sole, and a decent amount of hug around my heels, I'd be at a desk, denying your insurance claim.

Both of these products require professional fitting. Both of them are hideously expensive. The upside is that both of them last forever, as near as I can tell, and they give you really great legs and a perky ass.

Rating: A++

Thus endeth the Delayed Gratification Product Review Session. I'll be back later with reviews of elastic thingies, underwear, and chocolate. Stay tuned!

Bonus Lazy Wednesday Post: Apple Crisp Thingy!

Preheat your oven to 350* or thereabouts. Ten degrees either way won't matter.

Peel, if you feel like it, and core two apples (if they're big) or three (if they're small). I use a mixture of 2/3 Honeycrisp to 1/3 Granny Smith, if you're being particular.

Slice them thickly or chop them into chunks, whichever takes less energy.

Open a bottle of wine or beer. Take a swig.

Set the chopped apples aside in a pie pan.

Take a big bowl, or maybe just a big-ish bowl, out of the cabinet, or you can use a roasting pan, or whatever. No biggie.

Mix roughly a cup of rolled oats (not steel cut or instant) with a half-cup of flour in that bowl/pan/whatever.

Add about a third of a cup of brown sugar.

Sprinkle on some nutmeg and cinnamon. Maybe toss in some salt if you can be bothered.

Take another swig.

In the microwave, or with the power of your mind, melt about a quarter cup of butter. Sometimes I use more--way more, like a half-cup. Anyway, melt away.

When the butter's done melting, and you've maybe had a few Fritos and perhaps a slice of leftover pizza and put on your sweatpants, dump that stuff into your flour/oat mixture and stir like crazy for as long as you can stand it, or until the ingredients are pretty much mixed.

Take another swig. Consider the genesis of Fritos. Be thankful for them.

Now dump that flour/oat stuff atop your apples, making at least some effort to get it mostly even across and around the apples.

Pop that bad boy in the oven for 40 minutes or thereabouts, or until the apples are tender. If you can't be bothered to fish a knife out of a drawer, just look for little bubbles of apple-y juices around the edge.

Top with cream or ice cream or just eat it on its own.

Apply to face.

Lazy Wednesday Link Round-Up

First, Nurse K is back! Not that I knew that she ever went away in the first place; somehow, I either totally missed or forgot about her blog. Either way, I'm pleased to be reading it/reading it again.

Another blog I've just run across is Made A Difference For That One. Check it out: he's a surgeon in Iraq, with fascinating stories.

There's currently a frenzy over The Joint Commission and Press-Ganey at Sunnydale, and it's raising my blood pressure. MDOD has a nice, nice takedown of the whole PG system; be sure to read the latest comments.

Check out another doc blog, Ten Out of Ten (another one I had somehow missed). I don't know what is up with people not cluing me in to the good writers and genius funny people, but it has to stop.

And that is all from here. I'll have more exciting, glamorous tales from the CCU training ground next week, promise.

Holy crap*.

It took six hours, most of a sixer of Stone IPA, a pizza from the little joint down the street, and infinite curses and thumped thumbs, but the utility room is painted, the IKEA shit is assembled, the shelves are up, and the boys are amusing themselves in the leftover boxes.

And not a moment too soon. The neighbors are coming over tomorrow for dinner.

And I am going off to bed. Sheesh.



*Why did I do all this in one day, including trips to Home Despot and Ace? Because Attila looked doubtful this morning and said, "Uh...I don't know if you can get this all done by Wednesday."

I'll show *her*.

What I Did Today

Fair warning: If you are at all faint of heart or queasy of stomach, do NOT continue to scroll down for the majority of this post. Beloved Sister, this means YOU.

Today I decided to take the sink out of the utility room. It's a bathroom sink of the molded-fiberglass type, and it--along with the cabinet on which it sat--turned out to be the only overbuilt things in this house. Everything else that I've needed to tear out has come along nicely, but this nearly stumped me.

This is the sink in question. You can see from the steel wool on the floor that I had had some trouble last winter with mice in the house; they were coming from under that sink. Also visible in the foreground is my Weapon Of Destruction. I had to take the whole damn thing out in one piece, sink, cabinet, and all, as the previous owners of the house apparently installed the sink using construction adhesive and the Power Of Isis.

And here's what I found when I removed that sink and cabinet:

Yes, friends and neighbors, that is torn-up insulation. And old church tracts. And some weird plastic things, and part of an electric toothbrush, and TONS OF OLD RAT SHIT.

This is by far the most nightmarish thing I've found in redoing the house so far.

Now I have a nice box built to cover the old plumbing, like so:

Much nicer. The whole thing's held in place with three screws, so I can take it down without any hassle when I'm ready to replumb.

Tomorrow is painting and shelf-building and weight-bench-repairing day.

Sheesh.

Remind me again why I live in Texas, will you?

Sometimes I wonder why I'm staying in a climate where normal human beings (ie, your faithful correspondent) can't live without multiple layers of various sorts of protection.

After a lovely lunch yesterday with my old (in terms of duration, not age) friend T, I realized I was massively, massively sunburnt.

Through 45 SPF sunscreen.

And only on one side. Well, actually, one side of my face and the opposite side of my chest.

I look like Two-Face.

Do people in places like Stockholm and Edinburgh ever get sunburned? I mean, seriously red to the point that it doesn't fade overnight and leaves them looking odd and lopsided? Is there a climate that'd be friendly to a fair-skinned redhead who likes wearing tweed? Should I just chuck it all and move to the UK? (Bonus: Boden clothes would arrive faster!)

Drat.