Saturday, February 28, 2009

In other news, I've found my soulmate.


Psalm 66

So I'm baking stromboli when the smoke alarm goes off. 

I went into the kitchen to find clouds of smoke where some cheese had dripped onto the floor of the oven. Off went the oven (the stromboli was done anyhow), up went the windows, open went the doors, front and back. I turned on every fan in the house and set up my big box fan blowing to the back door.

The smoke alarm shut up.

I yanked the stromboli out of the oven and stuck them on a plate. Then I started to wash the cookie sheet they'd been on.

My feet were. . . . . .warm. And wet. Warm. And wet. Wet. 

Wet feet. 

This is not good.

Oh, dear.

The waste pipes under the kitchen sink had somehow come apart.

So. I squatted down and repaired them as best I could with no tools and no extra pipe, then returned to washing up.

You have led us through fire and flood, O Lord, and brought us to a place of abundance.

I'm going to go now and make sure that place of abundance contains plenty of beer.

Friday, February 27, 2009

I have two favors to ask from you, my minions.

1. If you ever see me fall over onto the floor, unconscious and obviously the victim of some enormous bleed in my brain, step over me. If you must, stop and tell me that you'll miss me, but please keep going. 

2. If you love somebody, tell them *now*. Don't put it off. Call them, email them, text-message them, send a homing pigeon--whatever it takes. If you've been putting it off for five minutes or five days or five years, do it NOW.

The young ones are hard--any nurse will tell you that. The ones that get to me the most, though, are the old people, not just young-old, but *old* old, people in their late 80's on up into their 90's, who still have families and spouses that love them. For some reason, it's hard for me to watch a husband sitting by his wife's bedside, looking back over sixty years of marriage--or more--and knowing that this is it, that she doesn't recognize him any more, and having to make the decision to go to palliative care. He was the one that found her and held her head in his lap as he called 911, and he was the one that the EMTs had to help up off of the floor after they'd strapped her to a stretcher.

The middle-aged are hard, too. These are the folks only a year or two older than I am, who have young to teenaged kids at home and mostly stable relationships. One man's wife told me that she hadn't told him one morning that she loved him, because he was asleep and she hadn't wanted to wake him. Later that day, he was found down at home after a bleed from a previously undiagnosed congenital arterio-venous malformation. He'd been having symptoms for weeks but hadn't mentioned them, because he hadn't wanted to worry her. She found it all out from his colleagues, who were all...wait for it...paramedics. Like he was.

He won't be getting out of bed.

And then there are the young ones. 

This happened years ago, but it came back to me (does anything ever really leave you?) this week: I first noticed that something was different when a group of impossibly tall, impossibly slender, impossibly beautiful young men and women started visiting one room in particular, carrying impossibly expensive minimalist flower arrangements.

A couple of days later, I got assigned to the patient in the room. She had been a model and was now in status epilepticus--a type of seizure activity that we can't stop and that usually ends up wearing out your brain and killing you. Even heavily sedated to the point that she needed help breathing, she was still seizing. You couldn't see it on her face or in her body, but the EEG was insane. 

All of her model friends had been visiting for a couple of weeks. They'd put up contact sheets of her work, pictures of her daughter, and filled the room with flowers. They came in groups and singly, sitting shifts with her as their work schedules allowed. One guy came more than the rest. He'd help bathe her and rub lotion on her feet, working her feet back and forth to try to relieve the contractures that were starting there, and would massage her hands to help loosen her wrists. Throughout all of that, she never opened her eyes or even responded to pain.

I walked in late one evening just before shift change to find him in bed with her, with her head cradled on his shoulder. That was a little odd, but I wasn't able to do more than pause as I walked into the room before he said this: "I love her, and I never told her so. I was always too afraid to tell her I love her."

People: There Is Not Time To Put Things Off Until Later. Even if you *do* have fifty, sixty, a hundred years left of your life, you still don't have time to put things off. Go and do it now: tell that person that you love them, even if it means waking them up. Swallow your fear and speak up, even if it means you'll get laughed out of the room. There is not time enough in the world to heal the regrets you'll have if you don't do it now.

And, please: if you find me on the floor, just keep going. I will have done everything I needed to do by the time that happens.

Tuesday, February 24, 2009

What's In *Your* Wallet?

A quick rundown of the contents of my purse, before I go to bed. For entertainment purposes only; please do not attempt this at home.

1. My Work Pouch, which contains two small tubes of toothpaste, the caps of which have both come off, one small tube of triple antibiotic ointment, assorted pens, highlighters, dry-erase markers, alcohol swabs, blunt cannulas, needles, tape rolls in various stages of lintiness, and one tablet of...what is this? Orphenadrine CR. Whatever the hell that is.

2. Datebook. Cell phone, with three numbers in it. My Sunnydale ID, with angel pins (2) and horny toad pin (1) and TEAM Playa pin (1) on it. I look like an axe murderer in the picture. The back of the ID has a picture of a 1950's housewife holding a cup of coffee and the words "I haven't had my coffee yet; don't make me kill you" taped to it.

3. A compact of powder so old I don't remember when I bought it. I do not use powder. I'm not even sure it's mine.

4. Two lipsticks and one jar of Carmex.

5. Three hair clips, a barrette, a hair elastic, and a hairbrush. None of which I use during the typical day at work. Which is why I look like an axe murderer in my ID photo.

6. Wallet. Change purse containing one pound of quarters. (I ended up washing the car in the driveway.)

7. Bag of assorted prescription antidepressants and OTC pain medications. When other nurses need an aspirin, I point them to the bag with the warning "Don't take the pretty red ones."

8. A box of Sensa, part of my unending quest to get rid of this avoirdupois around my waist.

9. Max's new rabies tag.

10. A list of services my vet provides for kittens. No word on what services they provide for kangaroos. 

11. Four green tea bags. I hate green tea.

12. A book of coupons for products I don't use that I'm going to give to a coupon-clipping coworker.

13. The same damn red rubber catheter that's been riding around in this bag for what seems like forever.

14. A stopcock (wrapped) for a lumbar drain. What the hell?

15. Lint. And some old orders I need to shred.

16. FMLA paperwork.

17. Two paperclips and a book of matches from an Italian restaurant here in town that I haven't been to in 20 years.

What's in your wallet?

Usually I'm just a dipwad. Today I'm a dipwad in pain.

Chef-Boy-O and I went out this afternoon for lunch. I'd spent an hour with Atilla and then an hour mowing the lawn (*love* the Neuton mower!) and I figured we deserved, you know, a couple of veggie sandwiches and a Black Butte or two. We sat outside, because it's 73 out and gorgeous and breezy and the birds were singing.

I'd forgotten that I work twelve hours a day. And that it's been winter here lately.

And that I have red hair.

You can see where this is going, right?

I'm sunburned. On the right side of my body.

My right arm is pink. The right side of my face is pink. My right collarbone and chest are pink. There is a clean line of demarcation down my nose between pasty-white-freckled and pink-radioactive-freckled skin. 

Nearly forty is too old to be forgetting the sunscreen. Jesus.

Monday, February 23, 2009

Musings, product review, odds & ends

If only all I needed to stop mouth-breathing was a Perfect Breather, I would have much better days at work. If you treat nurses as though they are morons, they will act moronic. 

Thankfully, the moron-baiting is not on my unit, but on another unit I floated to for the first time a couple of weeks ago. Jo's Second Law of Nursing has been revised to read: The number of exclamation points ending a sentence that states the obvious is inversely proportional to the perceived intelligence of those reading the sentence. In other words, if you have laminated posters up all over your unit that say things like "EVERYONE must pitch in to keep the break room clean!!!!!!!" then it's obvious you're treating your employees like morons.

Seven exclamation points? They don't grow on pepper plants, you know.

On second look, that dude reminds me of Hannibal Lecter. 

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

In other news, I'm replaying the following over and over in order to deal with moronicity:

and, especially:

(Fiddly embedding fixed, I think. And isn't it funny how, even when you haven't heard a song in TWENTY YEARS, you can still remember every damn word?)

Yeah, I'm a bug for the '80's. Even though--and this might shock those of you who know me in the meatworld--I have never seen Pretty In Pink or Sixteen Candles. I prefer Some Kind of Wonderful over The Breakfast Club, though. Crazy romantic, that's me.

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

Flying Dog's Double Dog Pale Ale: almost as good as Great Divide Brewery's Fresh Hop.

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

Max went to the vet today. He's lost 15 pounds in six months, and I hadn't noticed. I'm a bad puppy mama. Anyway, his kidneys seem fine, and the vet didn't notice any weirdness in his belly, so the general consensus is that he's simply not being fed enough (hanging head in shame). He got FIVE cups of food today and is walking around slowly, belly rounded out, looking quite complacent.

I think, since Strider left, that he's running around more (well, duh, since he's not afraid of being attacked) and is generally happier and is therefore burning more calories. So he's getting more food until such time as I can make some satin balls for him (no comments from the peanut gallery, plz.) and give him EGGS.

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

Good God. Double Dog has 11.5% alcohol. No wonder I feel so cheerful after a half of one. And to think, five years ago Delirium Tremens and Nocturne were too strong for me.

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

I read Coraline and The Graveyard Book this week while I was off. Coraline is easily the most frightening book I've ever read--even surpassing Stephen King--and The Graveyard Book is one of the best. It's right up there with The Phantom Tollbooth. I read it once and I plan to start it again tonight; that's the highest recommendation I can give a book.

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

Do any of you fine readers do Sculpey or Fimo clay work? If so, or if you know somebody that does, I have a commission for you. I've got a project involving frogs that has to be done by the middle of April. Email me at the link to the right.

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

I leave you with this:

Saturday, February 21, 2009

How to have a truly crappy week.

1. Go in for a minor surgical procedure that requires a regional nerve block. End up with an autoimmune demyelinating disease that nobody recognizes and can't seem to treat.

2. See your doctor about a week-long bout of back pain after you spend a weekend moving. Discover a golf-ball sized metastatic tumor in your spine.

3. Feel vaguely faint during your son's Bar Mitzvah. Find out you have a dandy case of cancer in your liver, lungs, and brain, and wonder where the origin is.

4. Get your lumbar spine pain dealt with, then bleed out on the table because some genius nicked an artery. Receive more than twenty units of various blood products. Be transferred to Sunnydale General and get more blood products. Feel like hell later.

5. Go from walking to not moving in a week's time because of another weird, rare demyelinating disease that doesn't respond to treatment.

6. Have all of those patients, each young and previously healthy and inescapably cheery and hopeful, as yours for several days in a row. Throw in a couple of long-time patients who have returned to your floor for palliative care. Add two enormous technological and management blunders. Stir well and pour over ice.

It's not often that I ditch Chef Boy at the end of a long week and come home and have a good howl, but last night was one of those nights. I am spent, emotionally and physically, and I don't want to go back to work tomorrow. My patients this week haven't been hard in the sense of having a lot going on--no tube feeds, no ventilator-dependent folks, no ten medications to hang and crush by 8 am--but they've been hard emotionally.

What you don't realize when you start being a nurse is how fiercely you're going to love some of your patients. They don't come around often, but when they do they're the type that you remember for years afterward, or forever. I had five of those this week, along with their families. When a kid asks you, looking dead in your eyes, if his mom is going to be okay and all you can say is, "We don't know", well, that's the definition of helpless.

The floor feels uneven under my feet, and it's not just because the house's foundation has shifted again. 

Back to bed, back to bed. Everything looks better after a nap.

Sunday, February 15, 2009

I love you guys, but please.

Cut your damn nails.

I *mean*.

A couple weeks ago, while I was at the Doc-In-A-Box, waiting to be diagnosed with "viral syndrome" (what you get when you get the flu after having a flu shot), my vitals and history were taken by a very nice LPN with NAILS.

Now, nails on women bug me. Nails on men are worse. Dirty, too-long nails on men are the absolute worst of all, but long nails are almost as bad. This poor guy had long, broken, filthy nails. 

I dunno--maybe he worked on cars in his spare time. I know that after I've gardened or pulled up bushes or worked on the Honda, my nails are a sight--but I scrub the everloving hell out of them prior to going to work, and have been known to use white nail polish in moderation so I don't scare my patients.

Most importantly, my nails are short. I do not keep my fingernails long so they click when I play the piano. As the firefighter from Islington observed, "You keep your hair short. You keep your nails short. Not terribly feminine, are you?" No, not really; but I'm clean. 

Please, guys--and this includes two guys in particular with whom I work--keep those nails trimmed. Unless you're a professional classical guitarist, there's really no excuse.

And gals--don't get me started on the acrylics, okay? We've been over acrylics, too-tight scrub tops and visible whale tails/tramp stamps before. 

Thank you. I have to go back to work again tomorrow, and I'd really like to see this issue resolved by then.

What to Expect When You're Expecting A Lumbar Drain!

(This is the second in an occasional series on the weird things that can go wrong with your brain and what we do about them at Sunnydale General.)

So you've developed a leak somewhere in your skull, and cerebrospinal fluid (CSF) is dripping out your nose, or your ear, or under your skin. This is not good. In addition to being a serious risk for meningitis, it's a pain in the ass--you're getting headaches and feeling generally under the weather.

Or maybe you've developed hydrocephalus because your CSF isn't circulating properly. Maybe you've got normal pressure hydrocephalus (NPH) because you're getting older, and it's one of those things that sometimes happens. Maybe you've had brain surgery in the past and the circulation problem stems from that. 

In any event, your doctor wants you to have a lumbar drain.

What in Hell is A Lumbar Drain, Anyhow?

A lumbar drain is a tiny tube that goes into the small of your back and allows CSF to drain out. The rate and amount of drainage is controlled by a nurse, in concert with a pressure burette (a little tube with a float in it) or a burette with a stopcock that can be turned manually. It's a temporary measure, used to reduce fluid pressure long enough for a leak to heal or for us to make sure that a more permanent solution, like a ventriculoperitoneal shunt, will actually work.

So How Will Draining Fluid Out of My Back Help My Brain?

Remember those cartoons where Wiley E. Coyote is chasing the Roadrunner through the desert, and the temperature climbs so high that the mercury bursts through the top of the thermometer? Imagine your brain and spine as that thermometer. If Wiley were to drill an itty-bitty hole at the bottom of the thermometer, enough mercury would leak out that there wouldn't be enough left to bust through the glass at the top. There would still be enough to do the job of showing the temperature; it just wouldn't be under enough pressure to do actual harm to the glass.

That, in a clumsy nutshell, is how lumbar drains work. We pull *just enough* CSF off of your brain to bring the pressure down. In the case of a CSF leak, this allows bone and soft tissue to heal by taking the constant outward pressure off of it. In the case of NPH, it allows your brain to relax, because it's not constantly getting squished up against the inside of your skull.

The big difference between Wiley's thermometer and your lumbar drain is that you will not, at any point in the process, have an anvil marked ACME dropped on you.

Great.  How Do You Put This Thing In?

I'm so glad you asked. Putting in a lumbar drain is a bedside procedure. Except in rare cases when we have to do it under X-ray, it'll be done in your room. Setting up for the insertion takes fifteen minutes or so; putting in it takes less than five.

The doctor will use a fairly sizeable needle to puncture the skin of your back in a particular place where your vertebrae are separated. Then she'll run a very thin tube (the drain) with an even thinner wire in it (to give it some stiffness) up your back, inside your spinal column but outside your spinal cord itself. Then the wire comes out, and the drain gets connected to a closed burette and a drainage bag. The whole shootin' match is sterile. The drain will be stitched in to lessen the possibility of it being pulled out, and the area where it enters your back will be covered with a big sterile dressing.

This sounds horrible, but it's not that bad, according to the hundreds of patients I've had who've had it done. Your skin is thoroughly numbed before the big needle hits it, and I have really, really good drugs for you besides. The two most uncomfortable parts of the whole procedure are getting the lidocaine (skin-numbing medicine) injected into your back--that burns like a sonofoabitch--and having the drain run up your back. Occasionally, the movement of the drain tubing causes sharp, sciatica-like pains down one or both legs. Luckily, this is momentary and does not happen more than once or twice. 

Now I Have This Tube Coming Out Of My Back. What Next?

Next comes the draining. Every four to six hours you'll have roughly a tablespoon of fluid drained out of your back. Ideally, that should take a half hour to an hour. You'll have to lie down horizontally during the draining and for a half hour to an hour afterwards to avoid getting a headache. 

Aside from the times you're draining out fluid, you can do pretty much whatever you like except shower. Showering could mess up the dressing and cause an infection. You can walk, eat, talk on the phone, do a restrained and gentle Charleston (as long as you keep the drain with you), whatever. The drain will probably be hitched to an IV pole, which will limit your mobility a bit, but we sure don't want you just staying in bed.

What Can Go Wrong? 

Well, you could get an infection. That's the number-one risk of any procedure that breaks your skin. We try to keep the possibility of that down by being sterile during the insertion, and by not letting you shower or mess up the dressing afterwards.

You could get a headache from over-draining. That's fixable, though, with fluid and caffeine and pain medicine.

The drain could break off at the point where it enters your body (extremely rare; I've only seen it once), or the point where we attach it to the burette tubing (much more common; happens maybe one in twenty times). If that occurs, all you have to do is call your nurse. He or she will handle it, along with the neuro doctor. It's not a big deal for you, and it doesn't mean you've done anything wrong or stupid--sometimes that little drain tube just stretches and snaps. 

The consent you'll sign for the drain placement will talk about possible herniation of the brain or hemorrhage into the spinal cord, but I have never once seen or even heard of those things happening.

How Long Will I Have To Have This Thing In, and What Happens When It Comes Out?

You'll usually have the drain in less than a week. That reduces the risk of infection, and if we can't fix your leak in seven days of draining, you'll probably need surgery.

Once it's taken out, you'll have a sterile dressing placed over the spot where the drain went in, and you'll be told not to shower for another 24 hours. After that, you can go back to showering, parasailing, juggling chainsaws--whatever passes for normal activity for you.

Anything Else I Need To Know?

Well, lumbar drains are great for healing small CSF leaks, but sometimes they fail and you need a fat graft to block the leak. They're also great for reducing NPH, but sometimes they just plain don't work. As with any first- or second-line treatment, there's the possibility that you'll have to have something more extensive done to fix your problem. 

Also, during the time that you have the drain in, your nurse will be taking samples of your CSF from the burette. You will not feel this. It's to make sure that you're not cooking some sort of infection up in your spine. You won't get antibiotics unless you do get an infection, which is very, very rare. (I'm trying to remember if I've ever had a patient get an infection from a lumbar drain, and I can't recall. I don't think so.)

*** *** ***

And that, friends and neighbors, is a quick guide to lumbar drains. Next up: fat grafts and VP shunts! Wahoo!

Saturday, February 14, 2009

Valentine's Day Special: A Long-Overdue Love Letter.

I remember when we first met. I was so young; I didn't know what I was doing. All I knew at the time was that this was something special, something rare.

There were months, later, when I didn't even think about you. Whole years could go by, and I wouldn't wonder about you--wonder when I'd see you again, if you were still the same as I remembered, if it could be as good again as when I was young.

The last time I saw you was years ago. A good friend brought you over after dinner. I didn't realize then that that would be the last time for a long time that we would meet. Had I known then what I know now, I would've made more of an effort to make our time together last.

I saw you again yesterday, and all those feelings came back. My heart beat a little faster; I felt kind of nervous, just being in the same car with you. And, later that evening, when we finally got the chance to be alone together, it was just as good as I'd remembered.

Tiramisu, tiramisu! How could I have neglected you all these years?

Happy Pudgy-Kid-With-A-Bow-And-Arrow Day!

Friday, February 13, 2009

Bark, Bugs, Lizards, and Leaves.

Vignettes of My Birthday Dinner.

But first, a product review! I bought Green's All Natural Tripel Blonde Ale without realizing that it does not contain, according to the label:

"...any of the following: Wheat and/or Barley, Crustaceans (whew! -Ed.), Eggs, Fish, Peanuts, Soya beans, Milk, Lactose, Nuts, Celery (what about that great Boulevard Celery Beer? -Ed.), Mustard, Sesame Seeds, Sulphur dioxide and Sulfites."
This beer sucks. It starts out tasting a little like a lambec, because it's laid on lees and is, duh, Belgian. It has a nice light body, true, but a strange bitter aftertaste that has nothing in the world to do with hops. Rather than sitting up against your palate the way hoppiness does, this particular bitterness (which is probably due to the rice used to brew this..."beer") sits on the back of your tongue, along either side, and ruins your taste for the following things:

1. Triple cream cheese.
2. Salametto (dry salami) (more about this in a minute)
3. Danish butter. DANISH BUTTER!!!
4. Really good bread.

Oh, and strawberries. Which Chef Boy asked me to bring out of the 'fridge. When I reminded him to wash them prior to eating them, he told me he never washes strawberries. I told him, "I don't mind eating dead smoked raw pig covered in mold, but I have to draw the line somewhere in the safety department!"

Because Salametto is dry dead smoked raw pork. And fat. And various other things (which the manufacturer assures me make up less than two percent of the total ingredients by weight), all covered in mold, all of which combine to make something that, as CB said, "tastes like it's been hanging in a seventh-century church in Italy with doddering old men looking after it."

Then we noticed the label. It was made in Berkeley. But I'm sure it was smoked over burning Birkenstocks.

By the way, if you have to eat only one butter for the rest of your life, make it Danish butter. Spread it on thick enough that you can see toothmarks in it, then call your cardiologist. Because, my friends, Danish butter is made from cultured cream with just a tiny bit of salt. You don't want to use it for cooking, unless you're making something that you want to taste mostly of butter, but DAMN is it good for just plain eating.

And now I'm going off to finish my bottle of POP and eat some of the chocolate miniature omigod cheesecake that CB keeps pushing on me, even though I'm not all that fond of chocolate. I have a pound and a half of tiramisu waiting for me, after all.

Tuesday, February 10, 2009

Two things I have running through my head today:

"Conchita The Waitress" from (I think) The Process, by Brave Combo.

And this:

Monday, February 09, 2009

In which Jo answers questions posed by a semi-anonymous reader.

A couple of weeks ago (or a little more), I got a very nice email from a young man (God, I love being able to say that) who had some questions about nursing and about the blog. He'd read a bit and was interested in learning about stuff I don't necessarily mention here. With his permission (Hi, Chris!), I have excerpted some of his questions and my answers. I think this might be for a class of some sort; Chris, I hope you get a decent grade on your paper.*

You sound sometimes like you really hate your job.

Honey, *everybody* sounds like they hate their job sometimes. I don't. I get frustrated and angry sometimes--not with patients, but with manglement and doctors and sometimes family members--but I love what I do. It's like a cocktail party, but with more blood.

What's the thing that pisses you off about nursing the most?

On a micro level, it's the lack of positive reinforcement I get from my bosses. Yes, I have more than one, and yes, they all suck at telling you you're doing a good job. Fuck up on your charting and you get an immediate email and a correctional meeting; manage to get a hostile family member to calm the hell down and get on board with a plan of care and you hear nothing. My bosses, for the most part, suck rocks. That's discouraging, but not enough that I'm gonna find another job. (I originally typed "mob" for "job", and that's about right.)

On a macro level, it's the "Dare To Care" stereotype of nurses and nursing. If you've read back over the last year or so, you've seen how I yammer on about being a scientist first and a warm, fuzzy person second. One interesting thing that illustrates what I mean: we had a doc write for QID (four-times daily) massages for a patient. Uh...I can't *do* QID, thirty-minute massages. Leaving out that I don't have the training, I have four or five other patients who are, you know, in varying stages of critical. We had to do some hasty education with that doc.

What's the one thing about your job you like best?

Making a difference, as hokey as that sounds. If I'm able to touch a patient with my bare hands when I know they haven't been touched by anybody without gloves in a week, I know it'll make both of us feel better. I love being able to relieve pain and alleviate fear. I love being able to educate. I love being able to learn, most of all--and I learn things from my patients every day. I know more now about structural engineering, how to manage Crohn's disease, Asian art, nonstochastic physics, politics, and being a rodeo clown than I ever imagined I would know.

The patients are the absolute best part of my job, hands and spines and brain pans down.

You sound like you work for Dr. House. Is everything always so complex at your job?

No. I write about the cool stuff; the stuff people might not have heard about before. Lumbar surgery and neck surgery aren't all that interesting. Lumbar surgery on an 800-pound patient is more interesting. Brain worms are *way* more interesting even than that. 

Plus, I do work at a research hospital. We see shit every day that most nurses never see in a lifetime. I Googled a diagnosis that a patient of mine had once and got 35 results. So the stories about CJD or crazy-ass neuroleptic syndromes or conversion disorder might make it on to the blog most often, but they're probably only about 40% of what I do. The other 60% is plain old boring ordinary craniotomies and lumbar laminectomies.

LVN or RN?

Based on my experience, I'd have to say go for the RN. That'll differ from place to place, of course, but Texas is moving away from using LVNs as primary caregivers. Big County Hospital now, in fact, requires that all entry-level nurses have a BSN. 

There's a joke: "What's the difference between an LVN and an RN? About ten thousand dollars a year." That's *kinda* true, and *kinda* not. A lot of the things I do an LVN could do as well or better. Some things, though, LVNs can't do because of the guidelines set out by our state board. For instance, while they can intervene to fix a problem, they can't assess the patient--either baseline or in response to their fix. Now, most places you'll find LVNs acting basically as an RN, doing assessments and whatnot, but they're not *technically* supposed to. 

It's a silly distinction on a lot of levels. Unfortunately, the way things are here, you're pretty much locked into working either at a long-term-care place or overnights with shitty staffing in a hospital if you're an LVN. You have a lot more freedom as an RN.

So, yeah: RN. The choice between a two-year and a four-year degree is a whole 'nother ball of brain worms, though.

What one piece of advice would you give somebody starting nursing school or starting a nursing career?

Find a mentor. Do it as fast as you can, and lean on that person for support throughout your schooling or the first few years of your career. It makes a huge difference.

My mentor in nursing school was one of my instructors. She was, hands down, the best teacher I have ever had in any subject in any school I've attended. Luckily, she was both an active nurse and my clinical instructor, so I got to see a real pro in action during clinicals.

The thing that impressed me most about her, and what made me want to be like her, was her combination of dignity and warmth. When she dealt with doctors, she had their respect. She stood very straight and was extremely professional--almost like something out of an old movie, but without the "Yes, Doctor" subservience. She knew her worth and the worth of her work.

And with patients, she was amazing. She was the person who taught me how to approach people first thing during the shift. She would walk into the room, introduce herself before she approached the bed, and then make the person in the bed or the chair her *total* focus for five or six or ten minutes. Sometimes she'd just rest a hand on their arm while they talked to her; other times, she'd fix some seemingly-minor (but huge to the patient) problem right away, without waiting. In that small space of time, she established a rapport with the patient that let her give really good care, because the patient knew she wasn't going to get distracted or screw them over by being in a hurry.

I learned more from just watching her in one semester than I did the first three years I was nursing. She was the best.

Hm. Maybe I ought to drop her an email and let her know all this. I doubt she'd remember me, but it's nice to hear when you've made a difference.

Any other questions you want answered? Post 'em here or drop me a line.

*Dude: Edit out the word "fuck", okay?

Oh. So that's where they come from.


It's only made of short stories

I still haven't found what I'm looking for

Y'learn something new every day, I guess. I've seen seizures that manifest as the good, old-fashioned generalized tonic-clonic (shaking, grunting, scary, traumatic for everybody) sort; I've seen seizures that manifest as anxiety attacks or giggling fits or simply staring off into space for a bit.

I had never seen a somebody seize where the only symptom was that they were looking for something they couldn't find. 

It took us a while to figure out what was going on. There weren't any acute neurological changes that I could see in the patient during these episodes--he stayed alert, oriented, aware. There weren't any acute changes that we could see in MRIs or repeated CT scans. We figured it was some weird anxiety thing going on--until the video EEG showed seizure activity concurrent with the patient's desire to find his wallet.

The residents and I were looking over the video record and saw the first telltale signs of a complex partial seizure corresponding to the patient's asking where his wallet was. 

Well, I will be damned. Okay, then. Load 'em up on Keppra. 

Short, sharp. Shocked.

Another nurse's patient had complained for the last hour or so of shooting, stabbing pain in one particular area of his shoulder. Given that he'd had a lumbar laminectomy, we couldn't figure out why his left shoulder would feel as though something was stinging it. Was it a problem with positioning during the surgery? Was it some unrelated problem in his cervical spine? Was it just one of those weird things that would go away on its own?

We rolled him and checked the shoulder. Nothing. We did range-of-motion. Nothing. Xrays showed nothing. Still that sharp pain. It wasn't consistent, and it tended to happen when he lifted his left arm up to grab something off the table. 

Finally, we rolled him one last time. His nurse straightened the collar of his schwanky new, just-out-of-the-wrapping pajamas, and jerked, winced, and cursed softly. She'd stuck herself on a pin.

A pin. In the collar of the new, schwanky peejays. We found the source of the stabbing pain--but who puts pins in pajamas? It's like starching baby clothes.

You mean this opera involves handcuffs?

Word salad is the strangest, funniest, sometimes most charming part of a brain injury. It's the inability of the brain to make your mouth come out with the right word at the right time, so things tend to get a little skewed. Patients will ask when their sweater is due, rather than their medications, or tell you that you're the flossiest sausage they've ever seen.

Each person tends to substitute words in a particular way, so after a day or so you can figure out what they mean. I'm still scratching my head, though, over the guy who looked at me solemnly and said "You're handcuff and chocolate, Nurse."

It might be the best compliment I've ever gotten.

The trouble with normal

Looking around, I see that I have a collection of medical books and magazines from the 1920's through the 1940's. Most of 'em have subjects like "Clinical Syphillology" (1938), or "Your Health: HOW TO AVOID A NERVE CRACK-UP" (1943), and all but one were found for my by my Beloved Sister.

I'm thinking it might be fun to excerpt some of the articles--especially ones from the popular press--just to see how "normal" has changed in the last 60-odd years. F'rinstance, didja know that some folks thought it was harmful for people over 35 to exercise at all? I wonder what Attilla the Cheerleader would think of that.

(For those who are interested, titles come, in order, from:
Neko Case
Michelle Shocked
Bruce Cockburn)

Friday, February 06, 2009

Wow. I get letters. Okay, then: a clarification.

Boy, you blog about emails and what do you get? More emails. And comments. And the sense that not everybody understands what the heck this whole...what you call it? "Blogging" thing is about.

So let's start at the beginning, shall we?

1. "Leave the poor patients out of it."

I do, my friend; I do. The patients I blog about here have been so combinized, fictionalized, sex-change-ized, and anonymized that often, reading back over the past couple of years, *I* can't remember who I was talking about. As I've said before, if you think you recognize yourself, whether you're patient, doctor, nurse, administrator, or taxi driver, you're delusional.

I don't know how to say it any more clearly than that, and I don't know how to do it any better. A blog about nursing wouldn't be much good unless it was, you know, about *nursing*. And nursing has to do with taking care of patients.

2. "Could you please recommend a good neurosurgeon/neurologist/internalist in New Jersey/Boise/Guatemala?"

No, I'm sorry. I can't. I work in a very insular, very circumscribed world in which the surgeons are the researchers are the pioneers are the only people doing X, Y, and sometimes Z. I don't know jack about normal hospitals or neuroscientists. 

3. "Can you recommend a good nursing school/tell me what nursing school will be like?"

Again, no. I'm sorry. My experience is seven years past now and is unlikely to reflect on your experience at all. I can offer tips on care plans--if you crazy kids are even doing care plans these days--and I can offer sympathy and encouragement, but you're better off doing a Google search for solid information.

4. "Your blog isn't work/child/parent/bunny safe! My boss is mad at me because of your blog! What if a child found your blog! There's too much profanity! You're mean! There's nothing of educational value to be found on this blog!" (note: last sentence taken verbatim from an email. Yeah, I know.)

(*Rubbing forehead*) 

If you are surfing the Innertubenets at work, what your boss finds on your computer is your problem. It is neither my problem nor my fault that you're wasting time here. *shrug*

If your child is reading my blog, that's your problem. It is not mine. This blog is not child-safe, nor has it ever pretended to be. (See above, re: profanity.) It is equally un-parent-safe; my Beloved Mom screens what she'll let my Sainted Father read here, probably because she knows his eyeballs would melt like something out of Indiana Jones...but that's beside the point.

I will not change either tone or content of the blog in order to conform to what people think is appropriate for groups of people that shouldn't be reading the blog in the first place. My response to the cry of "What about THE CHILDREN???" is a blank stare and the question, "So? What about 'em?"

As for educational value: I am putting this in bold because it is important, so listen up:

This is not a public service blog. This is not an educational blog. It has never been and never will be either. Posts with tags or titles including the words "Public Service Announcement" are titled and tagged with tongue firmly in cheek.

If you want reliable information on medical conditions or varying political views, I suggest you investigate medical journals and op-ed pages. If you want what I give you, which is neither reliable nor balanced, sit on down and stay a while.

Re: Me being mean: Here, yes. In real life? Only when necessary. And since we're here, I feel I can say that you should take yourself elsewhere and play with your dolly until you feel better.

5. "Can you tell me what to do about (obscure medical condition)?"

Oh, God, honey. No. Go see a doctor. Don't ask some stranger on the 'Net about your OMC. While I sympathize and will worry about you and ask for updates, I won't give you advice. The only advice I am qualified to give is that you'd get from any (other) moron on the street: If it won't stop bleeding, see a doctor. *Very* occasionally I'll stick my beak in, but only in those situations that seem urgent or emergent. If you've got trouble, see somebody in person.

6. "Your probably ugly you act so mean and uppity your probably fat and gay too why dont you leave nursing i hope i never get a nurse like you if i was their id kick your fat ugly gay ass."

Guilty as charged. Except for the "gay" part. Mostly, I am not gay. Mostly, I am sort of cranky.

You'd better hope I *don't* leave nursing. If I did, I'd quit blogging. If I quit blogging, you'd not have this blog to read. And if you didn't have this blog to read, how would you get your blood pressure up to a level at which your brain is (temporarily) perfused?

Oh, and: Punctuation. Look into it.

Are there any further questions? Any issues that need further clarification?


Good. We now return you to your regularly scheduled, compassionate, intelligent, moderate, beautifully-written, touching fuzzy stories of love in the....wups. Sorry! Wrong blog.

Monday, February 02, 2009

Let's talk about compassion.

I've gotten a couple of comments in the last week that I haven't published. Both of 'em came from women (or a woman, posting as two) who claim to have kid(s) with AVMs on their faces; both of 'em took me to task for a lack of compassion. Apparently, I'm supposed to have compassion when I'm posting here, about my patients, and the doctors, and my nutso coworkers. (I should mention that both comments were personally abusive and name-calling, which triggers the auto-dump feature on the Nurse Jo Robot. That's why they're not here.)

Normally, criticism doesn't bother me. Blame it on the codeine, 'cause I'm gonna answer my critics:

Lady (or Ladies), you don't want me to have compassion on this blog.

Why not? Because, if I'm compassionate here, it means one of two things:

1. I've not used up all my compassion on my patients.
2. I'm drunk.

Let's be real, People: You don't come here for compassion and warm fuzzies. It's like the man said--come for the stories, stay for the snark. And, honestly, who wants to read me tear my heart out over patients that've torn my heart out?

I could talk about walking down the hall with Darlene, her arm around my waist, as we discussed the best way to tell her eight-year-old daughter that Mom wasn't going to live much longer. I could talk about Velma, and how she cried about having to go to hospice, because her mind was still there though her body wasn't. Or I could tell you about Ben, who told me frankly over dinner that he was damned ready to die, but was holding on for the good of his wife and kids, who weren't ready to let him go yet.

But you don't want to hear about that. Nor do you want to hear about the 13-year-old girl with the horrendous congenital AVM that would likely kill her, whose toenails I painted the night before she went into surgery (all but one, so they could put a pulse ox on in the OR), so they'd be pretty for the surgeons. You don't particularly care about the fifteen-year-old boy whose Moya Moya had so screwed up his brain that I was the only one who could get him to consent to surgery, and only then after coming in early and rocking him on his bed like a baby. And I'm certain, as the mother of an eleven-year-old with an AVM, that you don't care about the time I summoned up all the crappy, rusty Danish I could muster to help comfort a dying woman who couldn't remember that she wasn't at home, in Copenhagen.

You'd rather hear the snark, and read the snappy lines. I don't blame you. If my working life were snappy lines and snark, it'd be something for ABC or FOX to run in a half-hour between family comedies. It wouldn't be what I live every day, where real people hurt, and die, and sometimes don't die...and those of us who are living are left to pick up the pieces.

This is an important point for those of us who blog, and those of us who nurse: People will criticize you for not being the constant comforting angel that they think you ought to be. To hell with them. The important thing is that you do what you are meant to do for those people who find themselves in your care. 

That means you won't always be unsnarky when somebody wants you to be. You may not always want to talk about work when you get home. Sometimes, if you're a bit under the weather or a little too far into your cups, you might surprise your drinking companion with some heartbreaking story. The important thing is that when it counts, where it counts--with your patients--you aren't holding back.

I spend enough time questioning whether or not I did what was best for my patients. I spend hours after every work day going over every. damn. thing. I did. and trying to figure out if there were a way to say it better, do it more gently. In the middle of my day, I am a nurse. When I come home, I am a blogger. If the nurse part bleeds into the blogger part, it means I'm not doing my job--either job--well enough.

And so, critics, up yours. It's a shame you didn't read farther or dig deeper. I'm sorry for you, and I'm sorry for your kid--but I'm not sorry for my patients. What they get is the absolute best of what I have to give. What the blog gets is the cynical, tired leftovers.

Would you rather it be the other way 'round?