Mama's got a brand-new bag...of troubles.

It's astonishing how appropriate this is, and on how many levels.

Merry Christmas, Happy New Year, and thank God 2010 is nearly here. I had hoped 2009 would be a non-sucky year, and for the first half, it was. The last few weeks, though, have really amped up the suckage, to such a degree that I find myself panting for an artificially-imposed break from the past.

Trouble the First: Turns out that I am hypertensive as heck (Stage I), probably sodium-reactive. I've been following my blood pressure lately with a nice little sphygmomuh-nuh-muh-nuh (doo doo dee doo doo) and lo and behold, my systolic has been hovering around 150, my diastolic in the low 90's. This Is Not Good, especially since back in the spring, I was a nice, boring 110/68.

Guess what? A lot of the foods that are low-points on the Weight Watchers plan, like Boca Burgers, are hugely high in sodium. I made a point the last few days of not eating any salt to speak of, and my pressures have already dropped into the 130's. Which means, of course, that I'm cleaning out fridge, freezer, and pantry. *sigh* No more gruyere potato gratin for me; instead, it'll be sweet potatoes (high in potassium!) done a dozen interesting ways.

Trouble the Second: I'm slated to work with two of the bigger assholes I've met in my nursing career, and that's saying a lot. Both of 'em are blowhards, both of 'em profess to expertise which they have not, and both of 'em work nights. With any luck, I'll get on to days before I have to deal with them in more unpleasant ways than their sticking their beaks in where they don't belong.

Example: Preceptor the First allowed me to take report alone the last couple of weeks of my internship, and this bothered one of the Blowhards no end. At one point, he corned me and asked me repeatedly if I thought it was a good idea that an inexperienced CCU nurse be allowed to take report alone, as it sure wasn't okay with him. It took me saying three times, with increasing force, "It's okay with the manager, it's okay with the educators, and it's okay with my preceptor." Finally, I finished up with "If you have a problem with this, despite it being okay with all of your superiors, perhaps you should speak to the DON."

Example: I had taken care of a patient with one of those walk/talk/die frontal subdural hematomas you hear so much about all day, upping his meds as necessary when it became clear he was going into DTs (with a BAC of 0.09, no less). The oncoming nurse for the shift didn't like that I had held things like Librium and Ativan when he'd become sedated to the point that I couldn't assess his neuro status, and proceeded to yell at me on the floor about it.

I looked grave, told her that I was not as experienced with detox nursing as I was with neuro, thanked her for her advice, and asked her further questions about what *she* would've done in the situation. That led a coworker to remark, "You rolled over and showed her your belly." I shot back, "What you don't know is that I've got a poison spur midway between my navel and my neck." If she does it again, we're going, right then and there, to the manager's office, because it's obvious she has a problem with me that needs third-party mediation.

I've learned that the easiest way to make a bully back off is to call them on it, then make them answer to a higher-up for their bullying, *right then*. I meet passive-aggressive and aggressive-aggressive with a hard slap across the muzzle and a sharp yank on the chain.

Trouble the Third: The last half of this year has been notable for its lack of logic. Not just *my* lack of logic, but the entire fucking Universe's lack of logic. Honestly? If the nursing journals I read suddenly started writing articles in the style of ee cummings, I would not be surprised.

jothenurse

lived in a pretty how town

(with up

so many

floating

brains

down)

Okay, enough of that. Suffice to say that people have been stupid this year. They've been driving like morons, making bad decisions that affect *me* (which simply is not done), and generally pissing me off. My biggest resolution--actually, my only "resolution"--this year is therefore to either not get annoyed with idiots, or to purge them systematically from my surroundings.

Which is why I'll be painting the Honda a nice blush pink and adding a gun turret.

I'll catch you guys on the flip sometime during the first week of the new year. Kiss the old year goodbye, and stay safe during your revelries!

Hm.

Sunday Sonnet

Sir Philip Sidney

Thou blind man's mark, thou fool's self-chosen snare,
Fond fancy's scum, and dregs of scattered thought ;
Band of all evils, cradle of causeless care ;
Thou web of will, whose end is never wrought ;
Desire, desire ! I have too dearly bought,
With price of mangled mind, thy worthless ware ;
Too long, too long, asleep thou hast me brought,
Who shouldst my mind to higher things prepare.
But yet in vain thou hast my ruin sought ;
In vain thou madest me to vain things aspire ;
In vain thou kindlest all thy smoky fire ;
For virtue hath this better lesson taught,—
Within myself to seek my only hire,
Desiring nought but how to kill desire.

Merry Christmas to all, and to all a good night!

For the first time that I can remember, it's snowing on Christmas Eve.

I went to get chow for the Max-Zoats in the rain. When I got home, I let him in. Just as I did, the rain turned into snow.

I wish you a hopeful Christmas and a brave New Year.

A space where something is wanting; a break.

Did you know (I didn't) that the word "hiatus" and the word "yawn" have the same Latin root? "Hiatus" was apparently adopted more or less wholesale, while "yawn" went through the Old English (ginian) wringer to become, well, "yawn", from the word hiare.

The things you learn when you blog. It's amazing.

The above is a nice way of saying that Head Nurse will be on hiatus (a pause, a space, an anatomical feature [see also: foramen]) until after the holidays. I will be back, a la the Terminator; I just have a lot to do in the next three weeks or so. The last thing I want is for the fine quality you've come to expect from HN to suffer under the pressures of work and life.

This is not to imply that you won't get the random picture of Max or the cats covered in Christmas lights; just don't expect anything substantive (Peanut Gallery: "We don't!") until the second or third week of January. At that time, I'll be back with exciting tales of sleeping during the day and working at night. Expect me to sparkle.

Happy holidays, everybody, whether you celebrate with candles, trees, or dried fruit. Be well, be grateful, and be lucky in the new year.

Jude is the patron saint of lost causes. He carries a carpenter's level and a club.

Sunday Beatles!

Check the dude at the end with the carnations behind his ears.

Odds and Ends, Bits and Bobs

I am so glad I live in the twenty-first century, when most people bathe.

I met a man the other day whose gums were black. BLACK. I say "gums" because there weren't that many teeth left, and the ones that were still hanging on weren't in much better shape than his gums. Ew.

Plus, you could smell him from the door.

Plus, his wife, whom I bathed four times in the course of two twelve-hour shifts, smelled just as bad. The night nurse bathed her, too, which makes me wonder just how long she'd been marinating in a fug of sweat, oil, bacon grease, and cigarette smoke. When you wash your patient's hair for the third time and the water still comes out a yellowish-brown? You know there's a problem.

Love my job; happy to be here.

Letters: I get letters!

Mostly, the people who write me are sweet, complimentary, and encouraging. Sometimes I get something abusive via email, but not often. This week I got an email I wish I'd saved. It was probably the longest email I'd ever gotten from anyone, and covered such subjects as the New World Order, feminism, brain surgery, and how Big Brother Bruce's Bargain Brain Barn (aka Sunnydale) is involved in a Jewish/Communist/Lesbian plot to put chips in all of us.

It was like surfing an enormous wave, reading that email. The quality of the writing wasn't much, but Lord were the ideas somethin' *else*. Sadly, I deleted it, and Yahoo doesn't save every rant I delete.

Please, Mister Feminism is Destroying The World and All You Need Is A Good Man to Discipline You Before the Communists Come For All of Us, could you re-send? Thanks.

Decisions, Decisions

There are a number of Big Things about to happen here at Casa Jo, and more importantly, in The Mind of Jo. Some of them might have a bearing on my career; some not. I'll let you all know when I've worked out the sniggles and tail-ends of things and done some soul-searching; meanwhile, happy thoughts etc. are welcome.

Finally, Merry Christmas! We Decorated For You!

The boys opened a present this morning at oh-dear-thirty, then spent half an hour batting the contents of the box around before I was able to haul my ever-widening ass out of bed and remove it from their paws. Thanks for the popcorn popper, Mom!

They also (I suspect it was Notamus) chewed through the string of lights on the tree. I'm glad it wasn't plugged in at the time.

Sweet Dreams Wednesday:

Part of you pours out of me in these lines from time to time:

I could be bounded in a nutshell, part two.

Stress. That's the reason. I swear, it's got to be stress.

I'm dreaming less at night, because I'm sleeping so badly, and more during naps in the middle of the afternoon. Today I laid down for an hour and slept for four, turning off my alarm without even remembering it, and I dreamed.

It was one of those internally-cohesive, externally-bizarre dreams that borrowed from The Handmaid's Tale: a veil and a heavy, bulky gown to wear after I'd been kidnapped by religious extremists of some variety; the attempts at escape that were foiled by being in the wrong place at the wrong time; finally, the opportunity to escape presented itself and I took it.

Only to be recaptured as I hid behind a door in a hallway. As the veil descended on my head again, I knew I should fight back, but I was so tired. I just gave up.

I woke up still tired, still sleepy, unsure what time of day it was, and disturbed by whatever deep meanings might've been hidden in the defragmenting of my mental disk. It's a sure thing, as Dorothy Sayers points out, that your dreams always mean something Much Worse: "If I really wanted to be passionately embraced by Peter, I should dream of something like dentists or gardening." Unfortunately, there were no dentists or gardening in this dream, just as there is no Peter in my waking life. (That looks unfortunately like a double entendre, doesn't it? Oh, well; leave it lay. Oh, dear. There I go again.)

Snoopy in Peanuts has his own theory about bad dreams: they're caused by double-topping pizzas just before bed. Again, unfortunately, there is no more double-topping pizza in my waking life than there is Peter Wimsey at the moment, so I can't blame that either. Likewise, there's nobody trying to steal my soul (as far as I know) and I'm not beset by witches, incubi, The Illuminati, or the SEC.

So it's got to be stress.

In a week I'll be free of preceptors and evaluations and be a CCU nurse on my own. In mid-January, though, I'll go *back* to preceptors and orientation as I switch from days to nights. Although I don't feel nervous about the changes when I'm awake--in fact, I'm really looking forward to making everything happen correctly without help--apparently it's disturbing me on a subconscious level.

I have to wonder how bad it would be without Attila coming by every day this week and kicking my ass with a combination of weights and cardio.

Beer helps, as does the distraction of other peoples' problems. So does clearing out the office/guestroom and neatening up my desk for the fortieth time this week. Tomorrow I'll go to IKEA to return a couple of doors that don't fit the widget I bought to house the catboxes and batteries and other detritus in the utility room, and then on Friday and Saturday I'll work with Preceptor the Second, which will be good. Getting my ass kicked at work, being made to think critically about situations, is the best cure for work-related anxiety I know.

Still, I would give a lot to float up out of the strong circle of Peter Wimsey's arms as I awaken, rather than fighting out from under a heavy black wool veil composed of equal parts old choir robe and my great-grandmother's winter scarf.

Remember that post about the dude in the reindeer sweater with the unwashed hair and corduroys?

Looks like I dodged a bullet.

Tuesday Vega

I had forgotten this song even existed until this past weekend.

SUZANNE VEGA-IN LIVERPOOL
Uploaded by pierrot77. - Explore more music videos.

I wish the Etsy seller still had this in stock, as I can't find a purse shaped like a sheep:

Mea Culpa. Mea Maxima Culpa.

So I'm standing in the med room today, and I'm kicking myself for momentarily confusing which patient was on a nicardipine drip (which is meant to lower blood pressure) and which one was on an amiodarone drip (which is meant to keep you from going into deadly arrhythmias) and getting all upset about not knowing enough, and I squirted myself in the face with the arterial line I was setting up, and started kicking myself about that, and I realized:

I am too impatient.

I am too damned impatient. With myself, with other people, with machines, with *everything*.

If there's one person who's going to be hammering on the microwave, yelling "HURRY UP!!" it's going to be me. If there's somebody who's yelling, "Make up your damned MIND, already!" at the guy in line ahead of her at Big Bob's Bargain Burger Barn, it's me. If there's an individual who wants everything exactly as she thinks it ought to be, both from herself and from other people (and yes, from machines)....well. You're looking at her.

*sigh*

The thought that I am just too damned impatient struck me with such force that I actually took the three minutes it would take to look at my calendar. *Flip* *flip* *flippity*.... yep. About two and a half months ago, give or take, I actually started doing this new thing. And I think that I ought to have everything that I want, in terms of knowledge and skill, rightthehellnow.

Being stubborn and being impatient are my two biggest faults. Arrogance runs a close third: after all, I *am* the most brilliant, most intuitive, most diagnostically-gifted nurse you've ever met, even if I can't tell amiodarone from nicardipine; why aren't you appreciating that?

The task for this week? Putting impatience and stubborness in their places. I plan to step back, to let things fall they way that they ought to, the way you shake your hair out after a good blow-out. Maybe, just maybe, if I work hard on not crowding myself or forcing the situation, I'll be able to stay focused and actually remember who has what drip and which way that (redacted) tubing is pointed, so I don't get soaked and feel even dumber.

Say your prayers, People. This might be the beginning of a new era.

Sunday Sublime

Conversation

Call me back when you're not driving; I have questions to ask.

The brain runs along facts like the tongue runs along teeth: a middle-aged man (when did we get to be middle-aged?), not in the best of shape (who is?) has clots in his brain that are affecting his sight and giving him headaches

(How could my friend, who is seventeen forever in my mind, with a bad 80's haircut, have clots in his brain? We swam together during summer camp when we were both eight. How could he have grown up so fast?)

The brain runs along the facts: a week's worth of headaches, a visit to the emergency department when things suddenly got worse, with loss of vision. CT scans and an MRI (MRIs freak him out; yes, they are freaky, I think I know, I think I know) and the discovery of clots in his brain

In his brain. One of my dearest friends, long-lost and finally found, now with clots in his brain that threaten his sight and his mind.

(I know all these things; I know how things tend to end. I know about the Decadron and the pain medications and the nausea and dizziness and the exhaustion at the end of the day after being asked sixteen times, "Tell me where you are." I know the high-pitched, slightly-too-loud voices of the nurses, alert for any change. I know the pronator drift test that you hope they'll pass every time, and the sudden lurch in the stomach when they're too tired, or too sleepy, and the arm drifts down)

And the IVs, and the feeling that this room is the world for you. Did you know that your vision shortens after five days in a hospital room? Oliver Sacks wrote about that, quite movingly.

(Tell me how he is. Tell me he is giggling over the things he reads on Facebook. Tell me his mind isn't gone, that he remembers what the neurosurgeon told him. Tell me he is just the same)

I have never been on both sides of the bed at once. This is terrible, in the old sense of the word: as in, inspiring terror. They have questions, and I have questions, trying to tease out what actually happened and what the plans are, and they want answers.

So do I.

That was the internship that was, or: Not with a bang, but a whimper.

Well, it's done. Six hours of testing and a whole lot of sitting-in-class, working-with-preceptors, learning-new-things, tearing-my-hair-out, but it's done.

The class portion of my internship, that is. I still have two more weeks of clinicals in which to screw up in some unimaginable fashion and be asked to pack my bags. Unless I knock over a ventriculostomy, yank a bolt out of somebody's head, or disconnect some incredibly essential line while dancing naked through the nurses' station, I think I'll be okay.

Don't relax, people. I am more than capable of shedding my scrubs and doing something really, really ridiculous.

For the last three months, I've lived on about a third (actually, it's closer to a quarter) of my usual income, without a set schedule (more on that in a moment), doing things I'm not used to doing, like sitting on my ass for eight hours at a stretch, listening to droning people talk about The Contagious Disease Du Jour. It's been stressful. In fact, I was driving in the other day, watching the fog come up off the farmland, and realized that there is not one single part of my life that hasn't been stressful lately.

I wonder if *that's* why I needed the Zantac. Ya think?

Anyway. These last two weeks about did me in. They're a perfect example of why, though I love guys in general and the two guys who've been arranging this internship in particular, guys should not be allowed to run things. Listen, children, and I will tell you a story:

We interns have to have a certain number of class hours and a certain number of clinical hours to make everything copacetic with Sunnydale's requirements. Earlier in the internship, we would blaze through classes in about half the time allotted and all be let out early. That was hard on the ol' paycheck, but nice in terms of having time off to study.

Suddenly, though, one of the Sumdoodz who run the program looked up and realized that we, as a group, were short some huge number of classroom hours *because* they'd been letting us out early all along, and that we had to make those hours up. There was much panic and many cries of distress and the Doodz ran around with their collective hair aflame for a day or two, then made a decision:

We'd make up all our shorted hours in two weeks.

Which meant that, for two weeks, we all sat. In a classroom. Or a lecture hall. Or a lab. Sat. Sitsitsitsitsitsatsatsatyawnsitsitsit. By golly, we were making up those classroom hours, but that's all they were: hours spent in a classroom. We were well on our way to making it all good with the powers that be at Sunnydale... ... ...except somebody mentioned that, if we continued like this, we interns were going to accrue some fairly substantial overtime in the process, which is a no-no.

More hair aflame, more screeching, more frantic emails from the Doodz, more drama.

Eventually, I don't know how, they got it all worked out. We all got an unexpected day off today to keep us from running into overtime, and somehow we all ended up with enough classroom hours. Except that now, since they cancelled clinical hours in order to *get* us those classroom hours, we're on clinical rotations for two extra weeks. To make up the hours we lost these last two weeks. Because we were short on classroom hours from being let out six hours early every day.

Yep. Five minutes' planning early on would've saved a whole, *whole* lot of burnt hair. But, at the end of the day, it's not my problem; I just show up when and where I'm told to and do what's expected of me. (Mostly, lately, that's been sitting. Have I mentioned that?) When I'm on the floor, my standards are a little higher, but when I'm listening to some guy from Backobeyondistan talking about how, exactly, a novel drug I'm never going to use interferes with protein synthesis in the yammagobble whingding wahoozit, I just show up.

(To be honest, the doc from Backobeyondistan was quite a good speaker. Charming accent, concise way of laying out information, and he managed to make a pharmacology lecture about whatever the hell it was funny. When he put up an LOLcat slide, I knew we were in for a good time. But it still took five hours.)

So. Just after Christmas, I'll be starting as a real, fully-fledged nurse in the CCU. I'll be working nights (which will be fodder for a whole lot of new posts) and trying to get my feet under me.

Scary as it is, it sure beats sitting for eight hours.

As Pens the Lotion Slut says, "I AM DRINKING BEER."

It has not been a beautiful day in Nurse Jo's neighborhood. Not at all.

Because the person who directs my Clinical Experience is a little.... .... ....well, she's weird, I had got to go to a two-part ACLS class this week, rather than renewing in April at the six-hour test-and-megacode extravaganza that I'd normally do. That meant two days of long classes covering things that I really don't ever want to have to deal with, and then a megacode at the end of the day today.

Followed by another megacode.

Yes, my friends, we tested *twice*. Once on a nice, boring, nonanimated dummy, and once on an animated dummy that costs a gazillion bucks and has no bones to speak of (the dude running the lab got really exercised when I bent the dummy's leg backward and said "Look! Osteomalacia!") and could speak and blink and breathe and all that happy shit. This was because the group I was in got selected randomly for a study on who did better in a code--a group with a nonanimated dummy, or a group without.

My hands and shoulders are sore as hell, because there were two very capable women in the group who were both unfortunately the size of my little finger, one guy, and me. Guess who got to do most of the compressions on both code tests? If I tell you that my private nickname for the guy is "Mister Lazy ThinksHe'sAmusing," will you guess right?

And if I tell you that I was, at one point, stuck for more than an hour and a freaking half in a room with Mister Lazy ThinksHe'sAmusing and another classmate whose nickname is HandsyMan, will you pity me? Will you hand me another beer? Please say yes.

Oh, never mind. I just got one on my own.

For some reason, since I've been single again, I've been attracting the sort of men one usually only sees in sitcoms and bad Craigslist ads. If he's got a girlfriend, he's hit on me. If he's an instructor in a nursing program and has a Marine Corps symbol (although if he's been any closer to the Marines than I've been, I'll eat my socks) dangling in his chest hairs, right above where his potbelly begins, he's said something inappropriate to me. If he's married but handsy, I've had to duck out from under unwanted shoulder-rubs, Angela-Merkel-style, more than once in the last month. And the topper came, as I was telling the Brother in BFE the other week, a couple weeks ago at my favorite bar.

My favorite bar is a class establishment that attracts only the finest folks--dames like myself. I was minding my own business, tucking into a poblano-stuffed chicken breast or some of the shrimp enchiladas that Antonio makes, or maybe it was a burger, when a drink appeared next to me.

I looked across the bar. There were three possible drink-senders, none of whom looked real promising. So I asked the bartender, Ray, who'd sent it. "The guy with the bad hair" she replied.

"Which one?" I asked.

"The one who doesn't look like he's bathed for a week."

Yes, fiends and neighbors, the dude with the bad greasy black hair, the corduroy Sansabelt-wannabes with the patch pockets on the front, and the reindeer sweater had sent me a drink.

He'd asked Ray what I was drinking. She'd told him single-malt Scotch, so he'd sent me Maker's Mark.

Oh, dear.

Ooooohhhhh, deeeeaaaaar.

I smiled, toasted him silently from across the bar, and returned firmly to my book. A few seconds later, somebody cleared his throat right next to me. Damn. Sansabelt Reindeer Man. So I thanked him politely and looked interested politely as he proceeded to try to make conversation. After all, they know me there: if anything untoward were to happen, Ray and her barback would throw the guy out on his ear. And he was really sweet, if kind of inert in a geeky way, until--and here you have to take a deep breath--he comingled the Star Wars and Star Trek universes in a way that showed me he was ignorant of both.

The way I figure, if you're living in Mom's basement, you have time to study these things, to work them out. Don't try to impress the girl who knows Yoda's middle name (it's Heironymous). Don't try to snow me with yammering about how we could go where no man has gone before if I'd just take hold of your lightsaber. Okay, it wasn't quite *that* bad, but it was close.

I've learned a lot of things in nearly forty years. I learn a lot of things from each guy I date, and I learn a lot when I'm single, too. And I've learned a lot--a lot--from this internship.

What I didn't expect to learn at any time was how to avoid weirdos in bars and how to avoid ass-pats while doing compressions.

*sigh*

Things I need to catch up on, if I ever get a day off:

1. ACLS protocols. They've changed. I think I can squeak by tomorrow, during the megacode (is it just me, or does that sound like some sort of large Precambrian fish species?), but I really need to brush up.

2. Dad's new book. It got a good review in the Seattle PI. My dad has his own Amazon page! Wahoo! Welcome to the 20th Century, Sainted Father!

3. Cleaning the bathroom. The new mascara I'm using leaves little....flecks everywhere.

4. Buying a Christmas tree, dog food, a new curtain rod, a splashguard for the shower, and some dried beans.

5. Sleep. I must catch up on sleep. Five (or maybe six! They haven't decided yet!) days of classes this week will kill me.

Why you should never lean on a counter at Jo's house:

Courtesy of Sister Rat, via her Crackberry.

Sunday Housecleaning Selections:

Found completely by chance

In Which Jo Feels Like A Real CCU Nurse.

Yank the blood out. Put the blood back in. Hook up the machine that scrubs the blood and yank out more blood. Make sure it's going back where it belongs: you don't want the patient exsanguinating all over the bed! God, lungs sound like crap. And sats are crap, come to think of it. And the vent's yowling at me.

Fiddle with the vent. Call RT. The vent won't stop alarming; could you please come help me out? The marvelous, marvelous RT department at Sunnydale dispatches one of their folks. She fixes the problem in about two seconds, helps me turn the patient, suctions him, and disappears in a golden cloud, angels following. (Have I mentioned how much I love respiratory therapists? Their motto should be: Removing Asses From Slings, One RN At A Time.)

Patient is hypotensive. Drop rate on bloodscrubber. Still hypotensive. Reposition patient. No go. Up the pressors. Hmmmm....better, but still not great. Best call the doc while I'm dropping the sixteenth blood draw of the day off at the lab. How the hell do you end up with a stage IV ulcer *there*?

Doc has no freakin' clue what to do; tells me to figure it out. Uh...yeah. Okay. *deep breath* Drop rate further, up that other rate a little more, cut back on this one and raise that one just a titch. Voila! A MAP of 68, just where I want it! Wow. This pressor stuff really works.

Wups! Bed and scrubber are alarming at the same time. Check scrubber first. Reposition patient. Figure out that their access is wonkily positional; deal with that. Deal with bed. Deal with cooling blanket. Deal with IV pump that has suddenly blown a gasket. Draw more blood.

Change a couple of ew yick dressings. Meditate on the enormous *thing* coming out of my patient's head and be glad they're not awake to worry about it. Wonder why the notch has suddenly disappeared from my A-line tracing. Discover that that, too, is positional. CVP and MAP look good, CPP is right where it should be.

Lunch.

Pee.

Up the rate on this drip, drop the rate on that one, change a bag on the scrubber, hang a new bag of stuff here and there. Check insulin drip. Check potassium drip. Check the anticoagulant infusion and the calcium infusion and that thing that's supposed to keep my patient calm. All good, all serene.

Don't kick that machine. It will make whooping noises for several minutes if you do that, and you won't be able to turn the alarm off. Wups!

CPP's okay, but MAP is dropping again. Am I more worried about kidneys or brain right now? Kidneys, actually (how odd, not to be worried about the brain). Cut back here, reposition there, up this, drop that. Patient suddenly isn't moving his right side. Well, that sucks rocks. Call doc. Too unstable to go for a CT; we can't do anything about that. Keep monitoring.

Right side comes back. So does bowel function (the patient's, not mine). Deal with that, change a dressing again, reposition. Make sure the wire coming out of the head isn't kinked. Pupils are still happy and reactive, right side seems okay, all good on the technical front. But those pressures still aren't where I want them. Fiddle some more.

Now patient drops *left* side. It's not ischemic, and I've never seen a bleed in an anticoagulated patient that simply resolves. In fifteen minutes, left side is back.

Docs rounding. Answer myriad questions, some of which are actually not covered by the paperwork they're holding. Get new orders. Change drips around. Change settings hither and yon. Make a couple of jokes with the pulmonologist. Glance out the window: when did it get dark? Grab lab results out of computer, ponder.

Charge rounds. Quick report, interrupted for bag-changing. Make sure all tubings are fresh. Make sure everything is clean, neat, stocked, and generally shipshape for oncoming shift.

Night relief arrives. *whew* Thank Frogs she's had this patient before. Head-to-toe together at the bedside, go over settings for one-two-three-four-five-six holy cow machines. Sign off. Remove self from computer.

Burger. Beer. Bed.

I feel kind of sorry for my preceptor.

Preceptor The First, that is. Because it's obvious our personalities don't mesh. At all.

Not that we don't get along; we do. She's a very good, very competent nurse. She's excellent with the patients, she never misses a trick, she can be relied upon in a crisis. It's just...well, she's from Venus and I'm from Mars. Or she's from Dubuque and I'm from Dubai. Or she's from Van Alsteen and I'm from the Van Allen Belt (holla!). You get the idea: both of us are pleasant, rational people, but we simply don't click.

Which means that in addition to those long, uncomfortable silences after which both of you turn to somebody else with a small-talk remark, there's a total lack of telepathy.

Those of you who've been nurses (or students, actually) for more than a week know how important telepathy is. It's the thing that keeps you from running into somebody who's helping you set up a monitor; it's that indefinable *something* that lets your coworkers know that you are totally in the weeds and good Frog could you use a hand. That is missing.

So, after I took on a third patient (sometimes they get tripled in the CCU, if one or more of the existing patients isn't complex), I was completely swamped. And the usual wild-eyed looks toward my preceptor as I was tied up on the phone or chasing down a doctor weren't working.

Finally, I went to her with a couple of requests: could she please take X, Y, and Z into room 4 for that patient, and please please pretty please could she do A and B for the patient in 6?

(For the nonce, Patient Number Four was uncomplicated but liked to chat. And Patient Number Six was stable, but had one of those oh-God-please-don't-let-the-pump-fail drips that you have nightmares about, with the extra added bonus of side effects like orthostatic hypotension combined with explosive diarrhea.)

She looked at me for a moment, her forehead wrinkling. "You want me to do *what*?" she asked.

"Take XYZ into 4 and help 6 to the commode. Please."

Another long moment's silence as she studied my face.

"You know, it would've taken you the same time to do that as it took you to ask me to. I thought you wanted some real help."

The new, snark-free Jo did not point out that the fifteen seconds PtF had just wasted in contemplation and in pointing out the obvious made the first part of her statement indeed true. Nor did the new, snark-free Jo retort that this *was* real help; that getting a hard-to-move patient with a tendency to crump while vertical was about the most important thing on my to-do list, lest I spend the next 45 minutes cleaning up one of the side effects of that drug.

Thankfully, another nurse had overheard that conversation and rushed into 6, managed to get the patient up and steady, and worked it so that I only had to scrub down part of one wall when that poor guy's bowels cut loose. (Note to self: explore side effects of any potentially life-saving drug before deciding to take it.) PtF then, to give her credit, hustled away to take care of Miz Chatty in 4, but yeah, that was thirty seconds wasted and another layer of stress I didn't need.

In short, I am not in the mood for philosophical discussions of time management when I ask for help. I *know* I'm snowed; if I weren't I wouldn't be begging.

At the same time, pity the poor preceptor who has to deal with me. I get scatterbrained and stressed easily, and my tone of voice at those times makes some people think I'm dealing calmly with a crisis. I tend to forget obvious stuff at weird times. I'm easily distracted by shiny objects and minor problems. I have a very, very short temper. And, worst of all, I get frustrated--quickly and seriously--by the fact that I don't know as much as I want to and can't do as much as I'd like to as well as I think I should.

So basically, what we have here is a failure to communicate. It's not anybody's fault; it's just the way PtF and I are wired. I'm sure she'll be as happy as I'll be to have the precepting part of our working relationship over and done with; things will be much easier once we don't have to be joined at the hip for twenty-four hours in forty-eight.

Meanwhile, back at Casa del Gato, I just spilled a half-cup of coffee everywhere and have to keep the gatos from drinking it. There's a crisis I can handle.

Weird Stuff My Cats Eat, because nobody cares what *I* had for lunch....

Notamus (big grey boy):

kiwi fruit

oatmeal

Kashi GoLean

clementine oranges

grapes

rice

lentils

Cheerios

apple slices

lettuce

carrots

ramen

Boca burgers

broccoli

Flashes (smaller stripey boy):

Cat food

Mashed potatoes. (???)

Plain. Mashed. Potatoes. With no butter or cream or anything.

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.