Thursday, May 28, 2009

Quick update

Between three posts in two days, a long chat with the Brother In Beer, and computer charting, I have worked up a lovely case of tendonitis in my right paw. 

I'll be taking a break through the weekend to allow that paw to heal up. Keep those cards and letters coming, people, and don't forget to tip your waitress!

An excellent question

we are not so dissimilar, new nurses and new doctors. so why the disconnect? if we can all acknowledge that we're all here for the same reason - to learn how to do our jobs, and to do as much good as possible, with as little harm - can't we meet in the middle? with the greater good as our goal?

That particular question came from the comments on the post before last, and it's a hell of a poser. Why can't we, in the immortal words of R. King, all just get along?

Ego. Fear. Exhaustion. Territorialness (well, it's a word *now*). Bad examples set by other people. 

I have heard, oh my friends, horror stories from residents and nurses alike about how they're treated by each other. I read once, on another blog, of how an older nurse told the new nurses in her charge to treat residents badly so they'd know their place. I once witnessed an attending telling a resident that nurses tended to get hysterical over nothing. That was the same guy who swept an entire counter full of charts off into the face of a charge nurse, so consider the source--but it goes to show you that there are bad, bad examples on both sides.

There's also the issue of turfing, or of being territorial. We all want what's best for the people in our care, and sometimes we disagree on how to accomplish what's best for those people. If two people have equally compelling arguments on two sides of an issue, and they're both convinced they're right, you tend to get discord. Sometimes it's hard to admit that, even though you have a good plan, somebody else might have a *better* one. We tend to fall a little in love with both our patients and our treatment ideas; getting over that posessiveness can be difficult. So we fight.

And exhaustion. Imagine, if you're a new nurse, doing everything you're doing now, but with increased power and no sleep for the last 48 hours. (Yeah, yeah, I know there are work-week limits now, but they're honored more in the breach.) Imagine that everything that you do will be gone over with a fine-toothed comb by people whose job it is to teach you hard lessons quickly and sharply. Imagine that, if you screw up, it could easily kill somebody--and you feel like there's nobody checking your work.

Contrariwise, residents, imagine being a new nurse: you're dropped onto the floor after a couple of years of school and told--and it's really true--that you are ultimately responsible for every single thing that happens to your patient. Doc writes a bad order? Pharmacy doesn't catch it? Charge nurse and second nurse go ahead and sign it off, and you give that drug or perform that treatment and it hurts that patient? That is, ultimately, the nurse's responsibility. You're also expected to supervise other people, play peacemaker with family members, coordinate getting the person to radiology/ultrasound/CT/whatever, and still find time to make sure they're not lying in their own shit.

Ego and fear go hand in hand. Everybody's afraid of screwing up and looking stupid. Everybody's afraid of losing some perceived power they have in any situation. And that tends to make people jerky at best and assholish at worst. 

The thing is, though, that doctors and nurses have the same feelings and the same reactions to situations. We all get frustrated, we all remind ourselves that you can't medicate crazy, and sometimes we all just need a cup of caffeine and a shower. 

My advice? If you want to work with people who aren't jerks, find a facility that fosters respect among colleagues. If you're unlucky enough to have an attending who shoves charts off of counters and yells at his residents and nurses in common areas, try to be the opposite of that person. Likewise, if you're a new nurse with a preceptor or mentor who views residents and interns with disdain, ask for another preceptor or find another person to hang out with.

Most of all, when you get angry or frustrated, try to remember that the other person is likely just as angry, frustrated, and frightened as you are. If you yell, apologize. If you break down in tears of frustration, that's okay. If you need to, you can take a deep breath, give the issue a rest for two minutes, and return to it in a calmer state of mind.

All of us are in the same boat. Rather than smacking each other with the oars, we ought to dig in and start rowing. Forgiveness, a sense of humor, and keeping hold of your self-respect helps a lot.

Wednesday, May 27, 2009

Speaking of Learning Experiences....

I intend the following as a comfort, not as a cautionary tale. If ever you feel like you've really blown it, come on back and re-read this entry.

It was one of those days with a vengeance. We were short on both sides of the staffing sheet, had a unit full of high-acuity patients, it was a weekend, and I was in charge of the floor. Any one of those things would be a recipe for suckage, but combine them all (because I am *not* a good charge nurse *at all*) and you have pure, unmitigated Hell.

It was so bad that I got on the horn and had lunch delivered, because I knew nobody would have time to even hit a vending machine.

So. It's a bad, crazy, things-going-wrong-everywhere day. One of our patients took a sudden turn for the worse and had to have a lumbar tap in order to get some cerebrospinal fluid for various tests.

Now, CSF is considered a "precious" fluid. It's hard to get, you don't want to take too much of it at once, and it's very delicate. It has to make it to the lab in, like, ten minutes or it's no good for testing.

Our patient not only was a hard tap, she had to be tapped under fluoroscopy. That means necessary exposure to X-rays, which you want to avoid if at all possible.

We sent the patient down to radiology and she had the tap done. The chart came back up with the patient, we put her to bed and stuck the chart in the rack, and went on with the day. 

(You can see where this is going, right?)

Lab samples have to be labeled in a particularly tricky way. For that reason, it's up to the nurse to label the samples on the floor, in the patient's presence, while looking at the armband on the patient's wrist. If you have a sample that's been drawn somewhere else, there are a couple of unique identifiers that are slapped onto the sample tubes, but the rest of the labeling and sending the samples to the lab are the floor nurse's responsibility.

(Now it's all coming clear, isn't it?)

The CSF that had been drawn, with great difficulty under X-ray, and with the patient heavily sedated, sat in the chart in a plastic bag for seven hours.

Seven hours.

And it was my fault. Yeah, yeah, the floor nurse should've checked the chart, but *I* was charge and had had the chart in my hands multiple times in that seven hours. I never once double-checked, as I was supposed to, that the samples had actually been sent. So, when the lab called to ask where in blazes those samples were, I was flummoxed.

Until I opened the chart. Then I was queasy.

(See what I mean about Learning Experience, Nuclear-Grade?)

I did what I had to do: I called the doc. The conversation went something like this:

Doc on phone, returning page: "This is Scott."
Me, shuddering internally: "Hey, Scotty. You wanna yell at me now, or yell at me after you find out how bad I fucked up?"
Doc: ".... ..... ......shit. Jo, what happened?"
Me: "That CSF didn't get sent. It's still in the bag on my desk."
Doc: "Oh, that's fine. We just need it for (insert name of obscure test here), and it doesn't have to be fresh for that."
Me, weak with relief: "Oh, thank God. Okay, then; sorry to scare you."
Doc: "No problem. Boy, am I glad it wasn't something important."
Me: "Meee tooo, Scotty. Me too."

I got really lucky. More importantly, our patient got really lucky: she didn't have to be exposed to ionizing radiation again, didn't have to get tapped again, and the thing that was wrong with her wasn't going to get worse with a seven-hour delay in test results.

Nevertheless, the point here is that I Fucked Up. Royally. I have been doing this, as I've pointed out in other places, for seven years. I *know* what the drill is with lab samples. I *know* how to take care of them. And yet, with the stress of the day, all of that went out the window and I made a huge, potentially damaging mistake.

Next time I'll be more paranoid. I won't assume that the patient's nurse has checked the chart; she might be too busy, or might forget. I won't relax until I see that the samples have been received by the lab and entered into the computer. I'll hand-carry the damn things down myself, charge nurse or not. 

So don't feel bad if you screw up. It happens to all of us. The best you can do is try to fix the mistake, recognize where the mistake started--because it's never just one thing; it's always a chain of events that leads to a mistake--and make plans to avoid it next time.

Everybody has it that bad. I promise.

A colleague-shaped blur went past me this week and resolved itself, once I caught up to it, as Marcia, one of the new nurses on our floor. She just got out of her internship and has been looking a bit white around the eyeballs lately.

"What's up?" I asked. "D'you need any help with anything?" 
"No..." she replied, "It's just one of those learning experience kind of days."

Ooooohhhh yeah. I remember those days. Sometimes (meaning about three shifts out of five) I still have them. There is nothing worse than being a new nurse and having Learning Experiences every. damn. day. you work.

Because, no matter how hard you try, you still feel like either an asshole or an idiot (or both) by about noon. This is common, and it's caused by the fact that you think you've actually learned something in nursing school. 

Not that I'm bagging on nursing school. It's like this: You learn all this very useful information, and all these valuable facts, but you don't--you *can't*--learn how to put them into practice until you've been, well, *practicing* for a while. Coming out of nursing school and expecting to have a handle on being a nurse is a lot like taking driver's ed without ever getting into a car, then expecting to be able to handle rush-hour traffic. On a different planet. With totally different physical laws.

Part of the problem, I think, is that you're trying to put things that you learned in a static fashion into practice in motion. I know that's a weird way to look at it, but bear with me. When you're in nursing school, you get a case study or a scenario to work with, and you can go through it step by step in a logical fashion.  You're sitting down, what you're working on is the only thing you have to deal with. Once you get out onto the floor, though, you have that scenario *and* about fourteen other things--literally--happening at the same time, and you have to keep track of all of them, and call bells are going off, and people are falling over in the bathroom, and you're running down the hall. 

Not only does your brain have to get good at sorting, discarding, and shoving things into medium-term memory, but you have to do it all on the run and while paranoid. 

This is why new nurses have breakdowns, start drinking, and think about going back to banking.

The good news is that things do get better. I don't know how it happens, but somehow your brain gets good at remembering five or six things for an hour or two, ranking those things in order of importance automatically, and then (most important) discarding them once you've dealt with whatever they are. Thinking back, it took about six months for that to start happening for me, and another year for it to get really good. Now I can go to the grocery store without a list and not forget anything. It's a good skill to have.

Also, you get used to thinking on your feet. It'll get to the point eventually that it'll be hard for you to really grasp a new concept without being in motion as you learn it. There's some neurological basis for that, but I'm down two Hop Head Reds at the moment and can't remember what it is. Anyway, you'll get so used to learning and coping while on the fly that it'll seem weird to discuss a problem with a doc if you're standing still.

And finally, you'll lose your pride. I don't mean that in a negative way: you don't turn into some sort of snivelling creature who winces any time anybody corrects you. I mean that you realize that mistakes happen multiple times a day, and catching and correcting them before they do harm is the important thing. You'll also learn that nobody knows everything, and even experienced nurses screw up in impressive, mind-boggling ways. Your ego learns to lie down and take a nap while you're at work, and mistakes quit seeming so damn personal.

Listen: I screw up at least six times in a shift, every shift. Most of the time, thanks to experience, I catch those screwups before they head out the door. Sometimes, I manage something so amazing that it qualifies as a Learning Experience, Nuclear Grade--and I've been doing this full-time, in one specialty, since 2002. Thankfully, my pride doesn't take a hit (or not much of one) every time that happens, because I've learned that I'm not the only one.

There are also things that I still do not know. Some of them are very basic; others are kind of arcane. I ask a lot of questions (one of the docs has nicknamed me the Elephant's Child) and do a lot of reading and try to get in on cool bedside procedures when I can. Those habits are among the most valuable you can develop as a new nurse. Not only do they mean you'll never stop learning, but an honest curiosity about things will put you in good stead with doctors and other nurses who like to teach and learn themselves.

Eventually it will all come together. You'll look up one day and realize you've filled out your chart's checkboxes in three minutes, your patients are all medicated and comfortable, and you actually have time to pee. Six months later you'll have time for lunch. Two years later you'll have enough downtime to fill in a couple of boxes on a crossword. More than that, you'll be able to form a synthesis with speed and accuracy and keep a dozen metaphorical balls in the air without flipping out.

Getting there sucks. The nightmares suck, the fear that you're going to hurt somebody really sucks, and the anxiety is awful. But it all does ease out over time. 

New nurses, listen up: Cut yourself some slack. Be easy on yourself when you look stupid, as you most certainly will. Don't expect to be an instant expert, or even instantly competent at everything. Recognize that you have strengths and play to those. Recognize your weaknesses, too, and learn how to hedge around them and how to compensate.

And for God's sake, don't go back to banking. We need you here with us. I am glad and proud and tickled to death to be working with you, because you teach me so much. You also remind me why the heck I got into this business. So thank you.

And if you need some help, don't hesitate to ask. We've got twelve hours, after all.

Sunday, May 24, 2009

I spent all day screwing, and boy am I sore...

...but the deck is DONE.

It's 12' x 12', built out of pressure-treated lumber, and is solid. It's not *quite* square--there's about an inch of weirdness going on at the far corner--but I don't think it's going to fall down in a heap the minute people start stepping on it.

Friend Suz The Critter Whisperer is going to email me pictures that I can then put up here.

Next up: Will Nurse Jo survive the Deck-oration process? Tune in to find out!

Saturday, May 23, 2009

Yes, yes, I know. I am a romantic fool.

But this really got me.

Siding! Renovation! Gutulousness!

First, a new cat picture. This is, of course, Notamus. He is exhausted after his under-the-house adventures.

It's hard to get pictures of Flashes, because he's rarely this lazy. I have a number of great pictures of Flashes' butt, the corner of one ear, or a totally blank frame, because he's always moving at high speed.

Next, the new sill plate and patch work on the house. You can kind of see why I need new siding.

Aaaaand new windows. Look up there, in the corner of this window. That's a plant. No, it's not growing from the inside of the room. It's taken root in the rotting wood of the window and is sending shoots out into the inside of the window.

A lovely "before" shot of the front of the house. Note the cruddy gray Masonite siding, the bad paint-matching near the front door, and the white Dutch lap siding that was covered up until a couple of days ago. The original siding (the white stuff) is at least a half-inch thick and is solid wood. If I had a million dollars and unlimited time, I would get it scraped and painted and say to hell with vinyl. 

If you look just above the date stamp, where the bloom of the butterfly bush is pointing, you can see where the siding is beginning to pull away from the wall in a big wavy area. This is the east side of the house, where things were in pretty good shape--the north side was losing siding at a shocking rate. I could grab pieces of it and just crumble it in my hand.

And isn't that a nice half-assed patch job on the front stoop? The concrete shifted after a hundred-year flood a few years ago, and there's nothing anybody can do to shift it back. It's kind of obvious that there's a large crack in the concrete, but what the hell--nobody wearing stilettos will ever be able to ring my doorbell.

The new siding is mostly on the front of the house now, though there are a few spots where it's not *quite* done. I anticipate it'll all be finished by Thursday. Huzzah! I'm hoping against hope that new windows and doors can go in late this week or early next. The dust is beginning to bug me.

In the meantime, the nice man from the lumberyard delivered sixteen tons of dimensional lumber and Dek-Blocks and decomposed granite et cetera yesterday. If it doesn't rain buckets today and tomorrow, I plan to make at least a good start on a deck in the back yard. Pictures, of course, will be forthcoming.

The siding job has gone remarkably smoothly. Honestly? I think you get what you pay for, at least to a certain extent, with stuff like this. The company I went with was slightly more expensive than the others, but the project manager has been by a couple of times and has called to make sure it's all going well. The workers themselves, while scary-looking, have turned out to be really nice, really careful craftsmen. The only hang-up so far has been a permitting issue with the city, which takes a minimum of five days to do *anything*, including answer the phone.

It's nice to come home from work and see what they've done during the day. Makes me feel like I've got a real house now, rather than a mungy little dump.

I suppose this means I'll have to start mowing the grass and, you know, actually *cleaning*.

Friday, May 22, 2009

Tuesday, May 19, 2009

*sigh* >rubs forehead<

Very Simple Requests:

Please do not ride that stallion if you don't know for sure that he can be ridden. Stallions are not usually the first choice for riding. If the stallion can't be ridden, he will almost certainly either sweep you off his back by running under a low branch, or step on your head, or both.

Go to a bar with padded floors if you plan to fall off your barstool.

Do not--I repeat, do *not*--attempt to chew through the tubing that runs from your PCA pump to your IV line. PCAs have an anti-siphon device, which means that no matter how hard you suck on the tubing, you won't get extra medicine.

While we're at it, please don't try to hide Phenergan in your bed.

Or Oxycontin in your purse. I'll find it.

And don't steal the damn DVD player out of your room. I'll walk you down and find it when you're loading up your car. It'll be really embarrassing when I have to look you in the eye, smile brightly, and say, "I'll just take this back up to the room for you."

Helmets are a good idea if you're riding any sort of two-wheeled vehicle. This goes double for motorcycles and triple for bicycles, since the idiots riding bikes these days seem not to be able to stay upright. Or, for that matter, able to avoid running into large metal signs headfirst.

By the way: a 300-cc Vespa is not appropriate transportation on the interstate.

Graduation parties are nice. They're fun. They're not nice or fun, though, when they involve enough alcohol and cocaine to put you into an anoxic state for several minutes.

And speaking of cocaine, please don't try snorting it in your hospital room. I'll find out, and neither one of us will be happy.

If you really *want* to throw your IV pump across the room, go ahead. If you then want to protest to the police that you're ready to get the hell out of this dump, go ahead. We'll transfer you to County, where mama don't play. You'll discover the joys of five-point leather restraints. Have a nice day!

Live poultry is not allowed inside the hospital. Thank you for your cooperation.

Nobody ever said trying to dive from the second-story balcony into the pool was a good idea.

If you're trying to fake having had a stroke, please remember that one-sided weakness will always be present. It will not come and go depending on convenience. Also, please remember that everybody here knows who you are, so you might want to try slurring your words with everyone, not just with your nurse for the day and the doctors.

Likewise, if you're trying to fake a seizure, please be aware that seizures sometimes happen when there's nobody around. They don't happen suddenly, as you're reading a book, just when you hear me open the door. And they generally don't involve bending backwards in the bed and trying to touch your head with your heels. That's strychnine poisoning you're thinking of.

It's probably not wise to ask me out. Ever. My standards aren't brutally high, but "neurologically intact, mostly" is right there at the top of the list.

Sometimes I wonder who lets these people in.

Saturday, May 16, 2009

Oh, what the hell. One more:

Saturday Silliness.

Music to rewire switches by: here. (Sadly, embedding is disabled.)

Music to plumb the kitchen sink by:

Music to consider hanging ceiling fans by:

Music to scrub the bathroom by:

Music to say "What the hell" to:

Thursday, May 14, 2009

In Which Jo Reaches Out From Under The House To Post.

Notamus, the grey cat, is nicknamed Notty (homonym Naughty). This is for a reason.

He rushes doors. Any door, any portal, any open window is fair game. I had thought that this tendency to run straight for an open space was confined to those open spaces that were vertical, but I was wrong.

Today he went under the house. Not just under the house, but under the house while Felipe, Juan, Frederico, and Alberto were working on it. (Query: Why is every jefe of every leveling job named Felipe? Is it just the crews that work on my house, or what?)

Felipe is a short, taciturn guy who refuses to be shaken by anything. Alberto is young, voluble, and tended to giggle. I heard his giggles all morning through the floor whenever anything struck him as funny, which was about every thirty seconds. Frederico is a sharp-dressed vato with designs shaved into his beard and buzz cut and sparkly fronts on. And poor Juan was the guy over whose back Notamus ran to get under the house. The first I knew of it was a choked scream from the access hatch. Somehow the door to the office had come open, and Notamus had obeyed the Prime Kitteh Directive: If it's open, go for it.

After reassuring Juan that that enormous grey thing that ran past him was only a gato, and a friendly gato at that, I spent five minutes on my belly, head down in the hatch, calling here-kitty-kitty to no avail. I finally said the hell with it and got under the house with the boys, crawled to the very furthest corner of the very furthest row of piers, and played here-kitty-kitty there for twenty minutes as they worked around me.

I gave up after that and figured Notty would come out on his own. Which he did, thirty minutes later. I found him angry and freaked out, hanging by his claws on the outside of the kitchen screen door.

Poor Felipe handed me out of the access and, after taking a look at my front (I'd crawled under there in capri pants, a t-shirt, and sandals) said "Oooohhhhh my God." I think he saw angry letters about open access hatches in his future, but it wasn't their fault my cat went berzerkers.

It's not a bad crawlspace, as crawlspaces go. It's short, of course, which makes turning around and doubling back difficult--especially if you're more than four feet tall and busty and assy into the bargain. It's dry, I only saw one rat skeleton, and it's pretty well-ventilated. There aren't too many pipes to crawl over and nothing dropped down the back of my neck, thank God. 

The best part of all of it was this: When Felipe helped me out of the hatch, my pants didn't fall off. Almost, but not quite. I was pleased that I was able to get out of there with at least some dignity intact.

Monday, May 11, 2009

Oh, and did I mention? (Home renovation warning!)

The siding guys are going to be here tomorrow to start tearing off the rotting masonite siding.

See, masonite is great stuff--in a dry place. Why anybody would try to make siding out of it is beyond me, especially here, where we have two rainy seasons a year, followed by alternating heat and cold. This masonite has lasted, oh, about five years. It's now falling off the house in sheets, which is not good either esthetically or structurally.

So it's getting replaced. With vinyl siding which, thankfully, doesn't look like Vinyl Siding. Underneath it will be some sort of marvelous wrap that deters bugs and moisture buildup, and backing it will be insulation, ditto, that will give my walls an R-value of something like 15. The soffits, fascia, walls, porch ceiling--essentially anything that's wood--will be replaced with this stuff. 

I got a quote on having the rotten wood replaced and the whole place painted, and it came in at a couple grand more than having the joint resided, so residing it is. They're also putting cute little faux-colonial columns up in the front rather than the bizarre wrought-iron trellises (trelli?) that are there now. I'm going to have them save the trelli so I can use them on a deck I'm building in the back.

Also this week, there will be a group of very nice men coming out to reshim the house. It was levelled two years ago when I bought it, but it's shifted since and has dropped about an inch in spots. 

And then, about the time that the siding guys are done working their magic, the window and door guys will show up to replace all the grotty, rotten, unscreened, non-working windows in the joint with super-efficient double-glazed ones. And to put on two doors, both of which will be burglar, zombie, velociraptor, and salesman-proof. It struck me as I signed all the papers (and thus signed away my life, my paychecks, my liver, and my firstborn) that I have never lived in a house in which all the windows opened. This will be a new experience. 

All in all, this place will be way too nice for the likes of me when it's all said and done. 

In further plans, I'll be building a deck in the back (floating; not attached to the house) and constructing a Max-Approved Doghouse, since he really hates the one he has now and would prefer to sleep in the rain. Everybody is hereby invited to Jo's Siding, Window-and-Door, Deck, and Finally Nice Backyard party some time in August, during the hottest part of the year. Make your plans now.

And, if anybody has a few hours between now and then, I could sure use some help hauling dimensional lumber. Just sayin'.

Think you have what it takes to be a nurse? Let's find out!

I've come up with a list of things a person ought to have if they're going to be a nurse. They're not the qualities you'll find in your average Introduction To Nursing Practice course, no--these are real-life skills and personality traits that'll actually help you keep your sanity and your job.

1. A nurse must have the ability to call bullshit without making a Federal case out of it or getting into an argument.

This is a skill that's developed over time. Once, many moons ago, a resident berated me in the presence of a patient. Unfortunately for the resident, he not only flipped his lid, in a "you're going to kill this patient!!" sort of way, but he also was dead wrong. 

What I would do now is take said resident out of the room and tell him once, firmly, that a) he's not to talk that way in front of a patient; b) he's not to talk that way to me again, ever; and c) he read the tubing wrong and was mistaken. Instead, what I did then was try to be a Good Nurse.

I didn't do it over the patient's head, but I tried to somehow make up for the resident's mistake by double-checking everything and then gently approaching him about his mistake. That trick never works with people who are willing to accuse you of incompetence in front of a patient. Calling bullshit immediately, calmly, and without room for argument would've been a much better decision.

2. A nurse must have an unlimited tolerance for management's good ideas.

Which, let's face it, are rarely good ideas. Take, for instance, our TEAM initiative, which I've not talked about much lately. I haven't talked about it much because, frankly, it was a flaming failure and a giant clusterfuck, and pretty much has sunk below the surface.

Anyway. TEAM is an acronym that stood for "Together Everyone Assmunches Management". Or something like that. I don't recall. The purpose of the TEAM initiative was to recognize Stellar Team Players in the Hospital System, especially as it related to Customer Service. 

What actually happened was this: certain players solicited positive comments and notes and surveys (filled out in-house while the patient was still there) and so got good CS reviews regardless of their actual level of skill or competence. Other players made pacts with employees on their own and other floors to fill out surveys and send nice notes to Management whenever one of their bunch did something even vaguely out of the ordinary ("She didn't spit on me when I was lying in the ditch! What a doll!"). 

Management, being intelligent, took only a year and a half to notice that the same people who kept getting really, really crappy performance reviews were the ones who got stellar TEAM scores...and that the same people kept winning the TEAM Player awards over and over. So TEAM quietly went under after Management's attempt to clean it up failed.

3. A nurse must have a tin ear and no sense of smell.

This is becoming much more important as the focus on Customer Service increases. In an attempt to make hospitals less hospital-like, Muzak is now piped in to most patient care areas, all lobbies, and three-quarters of the cafeterias in hospitals across the country. If you think competing television shows at electronics stores are bad, try competing Muzak in the lobby/cafeteria area/outside patio at Sunnydale General. That stuff gets stuck in your right temporal lobe and replays until you want to take a DeWalt to your own head.

Also, in an attempt to make hospitals less hospital-like, a number of places, Sunnydale included, are laying carpet in the hallways and rooms of the acute-care floors. Now, I don't know about you, but my first instinct when it comes to places that people are likely to poop, bleed, barf, and pee unexpectedly is not to carpet it. Cover it with plastic, maybe, or tile, but not carpet. Besides the smell factor, the carpet will hold all the nasty bacteria that you can drop on it, and breed more--and make it nearly impossible to disinfect an isolation room. 

Which means that we're now getting designated isolation rooms. See number two above.

4. A nurse must be unafraid of bladder rupture, megacolon, or severe dehydration.

Let's face it, people: as the economy continues its slow slide into chaos, even nursing will start being a non-growth career. As such, hospital managements will work out ways to get even more work out of fewer people. Some of my colleagues at other hospitals already have designated times for bathroom breaks and little tags on their IDs that allow them to be tracked (just in case they cheat and go pee early, I guess). Pretty soon, just having a big bladder won't be enough. You'll have to court infection and rupture with a devil-may-care attitude and a smile, all while attending to the Customer Service needs of your Guests.

5. A nurse must have a cast-iron stomach.

As the focus on budget increases and costs rise, what's one of the first things to go (besides staffing, supplies, and support)? Food. And not food service for patients--which is a good thing, as you kind of need to eat when you're recovering from surgery. Instead, food service for employees gets more expensive and less reliable. I recently paid seven dollars for a salad that was brown in spots and rotten in others. When I took it back to the cafeteria, I was told that I couldn't get a refund; instead, I could take my pick of other salads on the salad line. 

I'm brown-bagging it from here on out.

So: Can you do it? Can you be a nurse? Do you have the skills, the balls, the brains, and the patience? Or would you rather go into accounting, or waste management, or hooking, or--worst of all--be a hospital manager?

Friday, May 08, 2009

Product Reviews: This Shit? Right Here? Is The Bomb. Edition.

This product review is brought to you by Sierra Nevada Torpedo Extra IPA. It's a good, solid, tasty IPA without too much bitterness. 

Product Review: This Shit? Right Here? Is The Bomb.

I read a review on Beauty Wonkette of diptyque's Huiles Precieuses (that's Precious Oils for you non-Francophones) that was positively pornographic and decided I had to try the stuff for myself. After all, I reasoned, I'd just broken up with my boyfriend; what better time to try a body oil that inspired one-handed typing on the part of the reviewer?

People, take note: I bought both the body wash (more on that in a second) and the body oil, and I have to say: Even Though It Cost Me As Much As Two Weeks' Worth Of Groceries, Both Are Worth Every Penny.

The body oil comes in a small glass bottle with its own eyedropper. That, I think, is so that you don't immediately compare the size of the bottle with the price that you paid for it and foam at the mouth. The benefit of the eyedropper becomes apparent once you start using the stuff--two drops of this oil will not only moisturize both of your arms (it absorbs insanely quickly) but will send you into herbal-scented reveries and make you forget where you are.

I'm not kidding. I got out of the shower after using the body wash and put the body oil on and was shocked to find myself still in my small bathroom with the vaguely grotty bathmat and cat hair everywhere.

It smells like...well, it's hard to describe. It's sweet, like irises. It's also spicy with sandalwood and vaguely musky, and there's a sharp note that I think might come from rosemary or rue. Once it's been on your skin for a few minutes, it smells powdery and flowery, but there's still that deep bass note of wood and musk that warns passers-by that this is some Serious Shit Goin' On. A little goes a long, long way.

Plus, you know, it absorbs fast and moisturizes. I even put some on my hair.

Now, as to the shower gel: you know those little shops in Paris or Montreal or Chicago that are full of herbs and fresh fruit? The ones where a little wizened granny presides over glass jars full of God-knows-what, and the smell of the place stays on your skin, but in a good way, for hours? Mix that with the smell of yarrow and dried cattails and my paternal grandmother's house and you have the body wash. It's complex, but it's not overbearing. 

And, again, a little goes a long way. I used, no shit, about a quarter teaspoon of the stuff on a maguey-leaf washcloth and had plenty of suds left over. The whole time I was washing the citronella and grass clippings and sweat off my skin, I was laughing. It smelled that good, and it left me that clean, but without being dried-out and itchy.

The body oil is $78 for 4.25 ounces. The body wash is $46 for just short of 7 ounces. Believe me when I say that these, given how little you have to use to get what you want, are actually a really good value. I can see the body wash lasting longer than my super-duper-sized bottles of store-brand Dove. I mean, seriously: the body wash has a top on it that allows you to dispense four microns of the stuff at a time, and that's about all you need. I used less than nine drops of the body oil *all over*, including my hair.

Still, I plan to save these both for very special occasions. Men of Texas, be warned: my shower routine is no longer taking prisoners.

Sometimes, those prayers aren't answered.

The best we could've hoped for was for the patient to end up with persistent weakness on one side and some word-finding difficulty, followed by a long decline and eventual demise. The worst we all feared was that he'd end up hemiplegic, mute, gorked out, and unable to provide for his wife and kids.

It was one of those cases. There was a nasty looking widget deep in his brain in a very bad spot that had been found incidentally. We'd scanned and done angiograms and generally worked him up eight ways from Sunday, and the general consensus was that something was going to kill him sooner or later, but it would be better not to die with whatever it was that was in his brain.

So off he went to surgery. About five hours in, my pager went off: did I have the patient's wife's contact information?

I called the OR floater: No, it's all there in the chart. Well, nobody's answering that number; did I have another? No? It's kind of important that the surgeon finds the family stat. Okay, okay, I'll hunt around for more contact information.

After a frantic half-hour of calling various numbers, I heard the overhead pager go off. Overhead pages at Sunnydale General are reserved for the most dire of emergencies, and here was my patient's name on the OHP, with the request that his family return to the first-floor consulting area immediately.

I started to pray for our best possible outcome. Moderate hemiplegia and aphasia seemed like a really good thing.

My prayers did not get answered.

When I finally found his family, about an hour and a half later, they were already in the ICU waiting room. I stepped off the elevator, met his wife's eyes, and was unsurprised when she burst into tears. I had already been leaking a bit myself, and started up again at the sight of her.

What I wasn't expecting was what happened when I finally got across the room to her and her parents and friends: they were all laughing and crying and hugging me and each other, all at once. Turns out that nasty mass in my patient's brain was totally benign. The surgeon had tried to get hold of the family to tell them that and ask if they wanted the mass in or out; he ended up making a decision on his own and simply leaving it in. It's not going to hurt anything or cause any more problems than the occasional headache, if that. Now that it's deflated and dealt with, he'll be perfectly fine.

People crying in the ICU waiting room is not unusual. What is unusual is a nurse whooping and laughing and dancing around, while tears run down her cheeks and she hugs and high-fives everybody in one corner.

I saw him a couple of hours after that, once he'd settled in and had a nap. He recognized me immediately, spoke clearly and fluently, and moved all his extremities well. 

"I am so totally gonna kick your ass for scaring me that way," I said.

"Yeah, I know," he replied, "but it all went okay, right?"

"Yep." I said. "It's perfect. You're perfect. You're fine."

He smiled and went back to sleep.

Tuesday, May 05, 2009

Well, gosh. That's kind of a drag.

This is Cinco de Mayo, right? So there are gonna be fireworks, right? Right.

I just heard a few fireworks go off. 

Then a few more. This was happening, by the way, just down the street.

Then I heard a noise like a spark had hit a box of fireworks and they'd all gone off within seconds of one another.

Now I'm hearing sirens.

Sucks to be you, dude. At least we've had enough rain lately that you won't catch the grass on fire. 

Wonder if whoever-it-was kept his hands intact.

A journey long and strange.

Seven hundred posts ago, I started blogging. That was April 25th of 2004. There was one post previous to that, but I think I deleted it, as it was the typical first post of the new blogger.

Just over five years and seven hundred posts. Wow.

In five years, I've become ACLS and stepdown qualified. I've learned how to level ventriculostomies and fix broken lumbar drains. I can tell when diabetes insipidus is coming and when a patient's just diuresing from surgery. I can handle a brain coming out of its confines into the open air, a patient with a fever of 104-plus, wounds that pop open, people that fall, seizures, heart attacks, and strokes. 

I've said goodbye to five classes of surgeons who've gone on to practicing independently, and I've said goodbye to at least that many colleagues who've died unexpectedly.

I've held people who were dying in my arms, sometimes in order to turn them and sometimes because they just needed comfort. 

I've been hit, kicked, cussed at, spit on, thrown up on, shit on, peed on, and generally frazzled by the needs of hundreds of people, a minority of whom were in full control of their faculties. 

I've argued with, cried with, drunk coffee with, and commiserated with doctors and other nurses. 

I've considered going back to waiting tables more than once. 

I've answered hundreds of emails from other nurses and nursing students. 

Once, as I put my hand on a dying patient's chest to say goodbye, I felt her heart stop.

Once, after a long, tricky surgery, I got the honor of letting a pregnant woman hear her fetus's heartbeat for the first time after she came out of anesthetic.

I have commuted more miles than I care to count and gone up three scrub sizes. I've made a lot of friends, some of whom were patients and some of whom weren't. I haven't made, I'm glad to say, too many enemies.

I've fallen out of love, in love, out of love, in personal life has been like the drive thru at an In-N-Out Burger. 

I held one cat while she was dying and welcomed two more fur-suited terrorists into my house a few months later. I re-acquired a big shaggy loveable dog, the only thing I missed from my marriage. 

I bought a house, helped ChefBoy rebuild the bathroom, painted everything in different brilliant colors, and am getting ready to do the painting thing again. 

I've reviewed beers, mascaras, toothpaste, frozen pizza, and shoes. 

I've sprained my ankle once, had at least three bouts of stomach flu, two cases of flu-flu, and gone up on my dose of antidepressants. 

I've gotten off the Pill. 

I'm facing dating again at nearly forty.

Five years ago, after I'd been a nurse for not-quite-a-year, I still prayed every day that I wouldn't kill or injure anyone during my shift. I don't do that any more. Instead, I pray that somebody, at some point during my shift, will feel like I made a difference. Once in a while my prayer gets answered, when a patient tells me that I gave her hope, or made him feel better, or believed her when she said she hurt.

I have more wrinkles now, and more pounds. I'm cynical and twisted and bitter sometimes. Occasionally I give up hope for a few minutes. Very occasionally you might see me leaning my head against the cool marble facade of the lobby, praying that I can make it through the rest of my shift and still want to come back in the morning.

And I still love what I do. I said a couple of posts ago that I felt like a fish finally dropped into water, and that's true today. I opened a tiny bottle of very good champagne just now and am celebrating five years of loving what I do, both work-wise and blog-wise.

This blog would not have survived as long as it has, and I would not have survived as long as I have in this business, had it not been for people who read, emailed, commented, and sometimes ranted at me or corrected my mistakes. Thank you. I can't say any more than that: you guys are the reason I am still here.

Monday, May 04, 2009


Fuck passion.

Oh, for cryin' out loud.

Some well-meaning person told me yesterday, after I excoriated him for using a toothbrush on an incision, that I must have a real passion for my work.

No. I do not have a passion for my work. I have a commitment to it, and a love for it, and I felt like a fish finally in water for the first time in my finny life when I got to nursing school, but I do not. Have. A passion. For nursing. I have a deep, consuming dislike of people who scrub incision lines with toothbrushes, though.*

I certainly do not have a passion for people who use the word "passion" as a positive term.

"Passion" is like "artistic". People who are artistic tend not to show up for work on time. They tend to be a little ADD. They tend to freak out and need a certain level of excitement in their lives that normal people can't tolerate. In short, they're drama queens. "Passionate" people are the same way: try to live a normal life with one of 'em and you'll find yourself on the receiving end of invented crises and tearful midnight phone calls as they attempt to keep things off-balance enough to make themselves happy.

A patient's wife told me the other day, as I was tranferring him to the ICU with a raging case of bacterial meningitis, that he had ignored two cerebrospinal fluid leaks following surgery because, you know, he's an artist. He has a mind above such things, don't'cha know. He had apparently ignored the clear, yellowish fluid running out of his nose in favor of demolishing old car parts, or whatever the hell it is he does for art, until the headache and nuchal rigidity got to be so bad that he couldn't stand up. The pus leaking from his incision should've been the first clue, but oh, you know these artistic, passionate people--he felt he simply had to finish chopsawing that radiator to get his Vision out into the world.

My ex-husband told me, after he and my best friend had started screwing like rabbits, that he'd done it because he missed the Passion in our Relationship. Uh...dude. Passion, with a few exceptions, does not last for fifteen damn years. If you're lucky, you can build a good, strong, solid, deep-rooted something that outlasts passion and over-reaches it. You were not lucky. You were, in fact, a drama queen asshole, which is pretty much what I told him after I finished laughing. 

See? Passion bad. Workhorse good. Boredom positive. Excitement debatable. Butterflies early, good; butterflies late, a sign of needing to up your Xanax.

I am sick and tired of artists and passionate people. Give me a good, strong, not-too-brilliant workhorse of a surgeon any day rather than the passionate, artistic guy with a gift who tells patients to shut up when he's talking and is prone to fits of the sulks. Give me the uninspired, hardworking nurse who shows up on time, doesn't miss details, and gives a decent report rather than the one who feels drawn by some Higher Shiny Cosmic Power to the field. The ones who are so very drawn to this marvelous, wonderful, fulfilling thing are the same ones who either end up in management, fucking things up for the rest of us, or who go back to accounting or truck-driving or whatever it was that they could actually pay attention to and be good at.

Give me a nice, good, workhorse of a boyfriend, while you're at it. I don't care if he bradys down into the 50's when he's relaxed; it'd be a nice change from constant tachycardia. If he spends days silent, punctuated by the occasional grunt, so much the better. Keep your Jack Russell terriers and your people in search of something all-consuming; I want somebody dull and reliable and not prone to causing crises for the sake of excitement.

Which is why I love my dog. Max is passionate about one thing only: bully sticks. Even then, he won't bite my fingers taking one from me, or stay out in the yard with one when it's raining. He's my new benchmark for sensible behavior.

*And while I'm bitching, what is it with you people scrubbing your incision lines with a damn toothbrush? Doesn't common sense tell you that that is a bad idea of the first order? Don't you think about things before you do them? What posessed you to...oh, wait. I'm getting back into excoriation mode. Sorry.

Sunday, May 03, 2009

Margaret vs. Pauline

Two patients, both with problems.

One is on Medicaid. She was hit a couple of years ago by a drunk driver in a big SUV; her youngest child died. The older two survived. She was paralyzed from the belly down. She has Brown-Sequard Syndrome, which means her touch sensitivity and her movement ability are both completely out of whack and she has constant pain, even from gentle stimulus. She had to come back for a revision after surgery to repair a bone-deep bedsore didn't work out well.

The other is a privately-insured patient with money to burn. After years of plastic surgery and expensive beauty treatments, she decided to get her lower back pain fixed with a lumbar laminectomy. She has an inch-long incision in her back, private duty nurses around the clock, a Dilaudid pain pump with a basal rate, and a husband who waits on her hand and foot.

Guess which patient was more willing to get out of bed this morning? Guess which one cried and moaned and complained about having to have physical therapy today? Guess which patient refused to walk in the hall, while the patient next door would've given her eyeteeth for the chance?

*** *** *** *** *** 

You're the one that I still miss

She has vascular dementia and doesn't remember that her husband died three years ago. Her kids kept reminding her of that until I told them to stop it, that making her go through that grief again and again was cruel and unhelpful. She still asks where John is, though.

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

Can't give up actin' tough; it's all that I'm made of

One of the new nurses asked me tonight how I managed not to burst into tears every time something sad or pathetic happened. I replied, half-joking, that it's because I'm cynical and bitter. Looking back, that answer made more sense than I realized at the time.

It's not that certain things don't break my heart; they do. It's just that you learn a certain distance over time that allows you to keep working, to keep doing unpleasant things to pleasant people and not obsess about it later.

I used to obsess all the time. Occasionally I still do. Mostly, though, it's out of anger at a person's situation rather than from grief.

I told the chaplain once that nurses believe in God primarily so that they'll have somebody to blame. This is still true.