Last post of the evening:

(With Friend Rat Wrangler looking over my shoulder, asking "Beer or caffeine? Beer or caffeine?")

At the bar, watching "Tyrannosaurus Sex" (a scientific program, swear to Frog, on how dinosaurs likely reproduced, and their parenting habits):

(Announcer) "The Megachomposaur, with its enormously toothy mouth, bites its mate on the neck to signal its interest. Unfortunately, due to the roughness of its skin and its useless, tiny arms...."

(Me, to RW) "Teeth, rough skin, and useless short arms."

(RW) "Sounds like your last date."

My fortieth year Zingsadoo list:

When I was a little kid, little enough that my own name came out of my mouth as Mawguk (and doesn't that sound like Cthulu's handmaiden? I started early), I had zingsadoo.

My zingsadoo for this year aren't as banal as "lose that 20 poundses, Precious" (although that is on my personal, non-blogged list). My zingsadoo are:

1. Plant a tree.

Littleton gives out trees every year, and sells other trees for way cheap in an attempt to beautify the prairie. The mission is questionable, but hey--if it gets me a free burr oak, I'm in. The best time to plant a tree is twenty years ago; the second-best time is today. Watch this space for updates as I try to figure out exactly where my sewer lines are.

2. Flash mob.

I've already signed up for the local flash mob group: it's healthy, given that we have something north of 50,000 college students in Bigton, just south of me. I wanna eat a banana or freeze in place! I can't dance, so the dancing mobs are out, but everything else? I'm into it.

3. Keep a journal.

Don't know whether this'll be personal or online (if the latter, I'll be sure to clue you in to ever-deeper forays into self-centeredness), but I want to keep one. This is the Year Of Living Singly, and it needs to be documented.

4. Get a damn massage, already.

I've been meaning to for two years; this should be self-explanatory.

5. Support other bloggers whose writing is worthwhile.

It doesn't matter if you're a dick; if your writing is good, I'm all over that bad boy. Look for changes in the links list in the weeks to come.

Unlimited Buffoonery in the Dark, Sunday Edition.

Ignore the picture. The song is good.

Sonnets: Unrealities III

ee cummings

it is at moments after i have dreamed
of the rare entertainment of your eyes,
when (being fool to fancy) i have deemed

with your peculiar mouth my heart made wise;
at moments when the glassy darkness holds

the genuine apparition of your smile
(it was through tears always) and silence moulds
such strangeness as was mine a little while;

moments when my once more illustrious arms
are filled with fascination, when my breast
wears the intolerant brightness of your charms:

one pierced moment whiter than the rest

--turning from the tremendous lie of sleep
i watch the roses of the day grow deep.

I have put on my eyebrows and pulled up my sparkly disco big-girl panties.

I'm goin' in.

Can't let those bastards scare me off.

Dammit.

Something's Gotta Give.

I woke up this afternoon two hours early with a horrible case of stomach cramps. I dread going in to work this evening.

It's not just the assholes I have to work with (and believe me, there are plenty more); it's the fact that I'm stupid at night. I make obvious mistakes and forget things and feel foggy. I am not safe at night.

Dammit! I'm a veteran nurse who's worked with this patient population for eight godforsaken years. This bullshit about being put on nights to develop time management skills is just that: bullshit. I should not, with the seniority I have and the experience I bring, have to work in an openly hostile environment with people who actively undermine each other. I resent that nobody's said anything yet, as far as I know, about the bullies and the racist bastards that populate the hours between 1900 and 0700.

I'm getting sick. I always feel like I'm getting sick. I can't eat, I don't want to sleep during the day any more, and I haven't seen the sun in two months. I'm sitting here typing this out in a fog, tears running down my cheeks, wondering if it would be worth it to get a written warning if I called in.

I need a cuddle. I hate sitting here sobbing, dreading going in to a job I used to love.

Things that make me happy, Friday morning just-before-bed edition:

Artichokes on sale, ten for ten bucks, at the local grocery store.

Walking into that grocery store at 5:30 ack emma and hearing Bare Naked Ladies, with commentary from somebody on the overhead speaker: BNL: "If I had a million dollars/I would buy you..." Bored employee: "Three thousand pounds of special house blend coffee!"

Buying new jeans two sizes smaller than my current jeans. During that aforementioned shopping trip, I damn near had to sing "Pants On The Ground".

Seeing my friend Lovely last night, who has the talent of not only calming me down, but putting things in proper perspective.

Snuggles with Max. "I know you're unhappy, so I'm going to run around the house chasing kitties, then fall over so you can RUB MAH BELLEH!"

Fresh mozarella combined with peppers, tomatoes, and cucumber and marinated in good Italian dressing.

Good tortillas. I managed to snag the last package of homemade flour tortillas from the local tortillaria this morning. It pays to get up early!

Finding a pair of earrings I thought I had lost.

Charming text messages in the middle of the night.

A non-sore knee.

Knowing that my folks got home okay, despite flooding in the part of Mexico where they spend their winters.

Knowing that my Beloved Sister is getting over her bout of pneumonia. That was scary times.

Driving over Lake Giganto on the way to Sunnydale the other day, with snow (SNOW!) on the ground. Grey sky, steel-grey lake, white snow, everything stripped of color, and a great blue heron and two coromorants flying past on the horizon.

Two brown thrashers and an adolescent raccoon in my back yard. Max on raccoons: "Um...I don't know what it is. It isn't a kitty. I can't play with it. Um....I think I'll just, you know, sit here and watch. Um." Brown thrashers on thrashing: "LEAVES! LEAVES! LET'S HAVE SOME FUN!"

A bed with clean sheets and a hot water bottle, freshly filled, just waiting for me. If anybody ever develops a body-pillow/hot water bottle, I'm first in line.

After that last post, I'm sure we could all use a puppy.

Max, being awesome.

Warning: extremely offensive, disturbing story. And for once, I'm not kidding. (Language and situational caution, too)

I work with a triad of jerks. All are members of that traditionally oppressed and demoralized class, the middle-class white male. All vote so far to the right of the Republican party that they're practically standing on *my* left (which is saying something), and none of them have any problems being bigots in public.

After hearing talk about "Indians smell funny, drive badly, and are taking all our jobs" and "Mexicans don't come here to work, those welfare-cheating bastards" and having to deal with some misogynistic crap that was directed at me specifically, I thought things had calmed down.

(Incidentally, my Beloved Sister's Husband, who is from India, responded to the "taking all our jobs" comment with "Yep! And we're taking all your women, too!" Which is why we love him.)

It's been a quiet week at Sunnydale. Nobody was showing me pictures of redheaded models in positions that suggested that they'd been brutalized and pointing out that the model, like me, is a redhead. Nobody was talking particularly offensive stuff about whether the White House was still, you know, white, har de har de har. Nobody told one single rape joke. I relaxed.

Bad idea.

Today one of the members of the Oppressed Minority showed me some of the funny, funny pictures on his iPhone. Most of 'em were of the Failblog variety--cars halfway off of docks ("Women drivers, har de har de har!") and cows in trees.

The last one he showed me was of a noose hanging in front of a hand-lettered sign that read "NIGGER SWING SET." (Yes, I used That Word. On purpose. Because the whole episode still feels like a kick in the gut.)

I'll give you a moment to get your jaw up off the floor.

Of all the offensive, brutally racist, entirely-inappropriate-for-any-situation things I've ever seen, this was right up there in the top, oh, one. I'm sure I've seen something worse, or heard something worse, but I can't call it to mind right at the moment*.

It shocked me so much that the anticipatory polite smile I was wearing for the next visual "joke" froze on my face for a moment before my jaw dropped (that's a weird feeling, by the way) and I said, rapidly, "Oh, no. No, no. That's not funny at all. What the hell. NO."

Because, really: What The Fuck Is Wrong With You, That This Is Funny?

I live in Texas. Our last lynching was in 1930, in a city called Sherman, up near the Oklahoma border. Well, our last "official" lynching--there have been plenty of people murdered in the years since by being, for instance, dragged behind trucks (remember that one?).

Our last lynching was well within the memory of a lot of the people that I work with on a daily basis. It was five years before my father was born. That puts it well inside my personal limit for "immediate experience". Yet you think that a picture of a noose combined with a racial slur and a reference to the murder of 551 black men (that's Texas' count) is funny.

This brings up two problems for me, one micro, one macro:

As I told my friend The Hurricane not too long ago, I'm not interested in changing these guys' hearts and minds--that's beyond me. All I want to do is to get them to shut the fuck up with their racist, misogynistic bullshit at work. There's only so much fighting one person can do against a cadre of ignorant people, and frankly, I'll call it out when I see it, but don't expect miracles.

If one of them does something jackholed, I can fight that one thing. I can resist, on a teeny-tiny scale, the sort of crap that they spew. After all, eventually this assignment will end and I'll be on the opposite side of the clock from them. Until then, it's worth a little discomfort to get them not to be threatening and horrible at work.

But the macro side of that problem is what disturbs me. These are three guys who are incredibly, incredibly privileged by virtue of being white, male, and middle-class.

They don't see that privilege, but again, unexamined privilege (though it drives me nuts) is a larger problem than I can solve in my one-woman consciousness-raising efforts.

What bugs me is the ignorance.

I'm sure they wouldn't hesitate to help a person trapped in a burning car, regardless of that person's race. I've never seen any of them refuse an assignment based on the race, sex, or sexual orientation of a patient. They treat the black, Indian, and Hispanic folks we work with with as much respect as they treat me (yeah, I know). Yet they have this worldview that, I don't know, the only good Person-O'-Color is the POC I work with, or something. The rest of those brown people are no-good, thieving, border-busting scumbags, present company excepted.

And it makes me wonder what they *really* think. If you're enough of a bigot to think a lynching joke is hi-larious, how do you *really* see all these people you're working with?

Again, as long as they don't shove it in my face, or think that they can intimidate me by making thumbfingered references to violence against women, minorities, and liberals, I'm cool with calling out the bullshit one incident at a time.

In the bigger view, though, it makes me feel like standing with my back against a wall for the entirety of the shift, just because I don't know what these dudes are going to throw out next.

It also makes me want to cry out of frustration, because some people are just so stupid.

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

*On second thought, I don't remember anything that's worse than that funny ho ho de har de har sign. I would continue to wrack my brain for something more awful, but honestly? I'm nauseated enough as it is.

A Beginner's Guide To Working Nights

(In that I am a beginner at working nights)

So: you just got your first assignment as a nurse, to work nights. Holy crapping monkeys, you say, what the hell am I gonna *do*? How will I live opposite the rest of the known world? What if I can't sleep? Auntie Jo is here for you.

Understand that some people are natural night shift workers, some can never adjust, and others can adjust fine but still hate working in the dark (I'm one of those last). If your preferred living schedule has you getting up at noon and staying up until four am, you're golden: nothing here will apply to you, and you can look forward to a long career of greater autonomy, bigger paychecks, and reverse commutes.

If you hate working nights and can't adjust, well, there's not a lot I can do for you either. Some people just can't do it; no shame in that. I have a number of colleagues who did their requisite two-to-eight months on night shift and were miserable the entire time. Some people just never do feel better about staying up until the wee hours.

But if you're determined to Make It Work, or if you're like me and can do nights with a little encouragement, here are some ideas:

1. Snacking is key. Seriously. Your metabolism is so whacked-out by going against your circadian clock that you'll probably pendulum between ravenously hungry and nauseated all night long. Don't expect to eat big meals; instead, take a variety of small, protein-rich, healthy snacks to work with you and munch. It'll help keep you awake, fast on your feet, and (if you choose beans rather than Bugles), keep you from gaining the dreaded Nursing Forty.

2. Sleeping is also key. Whatever it takes to get you to sleep during the day is fair game. For me, blackout curtains and a single beer put me down from nine a.m. to four p.m. Other people might need to add earplugs, white noise machines, or even prescription sleep medication: again, no shame. Do what you need to do to sleep.

3. Manage your expectations. A lot of new nightshifters try to "flip" on the days they're off--that means they try to maintain a normal daytime schedule after working nights. Most of them can't, and end up crashing around lunchtime. Keeping a regular schedule is important, especially if you get only a day off between shifts.

4. Get out in the sun when you can. I know this seems contrary to the previous piece of advice, but it's true: getting some natural light (not even sunlight, but natural, from-the-sky light) can do wonders for keeping you from getting depressed and frustrated.

5. That old saw about a fifteen-minute shower being equal to eight hours' sleep? Is true. Don't make any decisions about anything until you've poured a substantial quantity of hot water over your head. This goes whether you're working that night or not. It's amazing how far a little soap will go to make you feel Almost Human.

I'll be honest: I hate, hate, hate, hate, hate, loathe, and despise working at night. I have to, though, until a day-shift spot comes open. For me, the worst thing about it is the feeling that the crushing depression I've had to deal with in the past is just on the edge of returning. I'm snappish, bloated, grouchy, and weepy (Wow! Four dwarves at once!). I resent intensely having to be opposite everybody I know and miss out on stuff. I worry that my dog hates it, too.

Plus, it affects my brain badly, and thus affects my writing, and we can't have that. (The memory loss is a little unnerving. I hope it goes away as I get more used to this.)

But I'm doin' it. I'm doin' it by taking advantage of the small bursts of energy I *do* have. I'm managing to sleep all day, nap when I can*, and stay awake the rest of the time with B vitamins and caffeine. However long it takes, so long as it's not more than a year, I can manage. I may not like it, but I can manage.

I'll put it this way: working nights is less of a pain in the ass and frustration than having a sprained knee has been.

*The other night I had to go down to Radiology with a patient. The patient was getting an MRI that was scheduled to last 90 minutes. After the first half-hour, the MRI nurse (yes, we have one down there all the time) took pity on me and sent me off to the CT sled with a pillow and some blankets. I had an hour of blissful, lovely sleep while she watched the monitors for me. Thank you, thank you Emily, for that nap.

This morning we had a patient flown in from Nowheresville.

And I mean Nowheresville. "Where's Brokeneck?" asked my colleague.

"Somewhere," I said, checking Google Maps, "near Boondoggle. Looks to be just east of Drinkwater."

The flight RN came in with the patient after a cold three-hour fixed-wing flight. I remembered that TGIL had expressed some interest in flight nursing, so I peppered the FRN with questions for twenty minutes, and he was kind enough to answer them*, before I remembered that I really shouldn't be interested in what TGIL is interested in.

Sucks to have no memory.

*Three years post-graduate critical care experience at a minimum, trauma or med-surg ICU in a place like John Peter Smith, Parkland, or Methodist. Two years in the ED would be good as an addition. And be prepared to fly at a minute's notice, with no set schedule, in horrible weather, and to crash. This dude's crashed twice. You're welcome.

Do I have any Minions in Des Moines?

The Rat, damn her eyes, brought me a bottle of Bisignano's Italian Dressing hot off the plane from Iowa. She's got me hooked.

What I need now is for somebody to go get me about a dozen bottles and mail 'em to the depths of Texas. Any takers?

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

The cats, driven by Frog only knows what evil instinct, tore down two wall shelves in the office today and knocked a whole bunch of decorated Chinese take-out boxes all over the place. I showed them: I replaced the boxes on a new shelf, way up over the south windows. The boys stare and chirp and whine, but they can't climb seven feet up a bare wall.

All that means, of course, that the office/guest room/magic store is a freaking mess. And it has to get clean before I lose my mind. So I'm glad I'm awake at 3:30.

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

Prayers would be gratefully accepted in the matter of my moving to day shift. It's not that I mind working nights; I feel fine after about 10 pm. It's that I can't do a damned thing but sleep on my days off. I've emailed the boss; we'll see what he says today. If anything.

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

This damn knee is driving me crazy. I can't manage anything better than a moderate walk for about ten minutes before it starts to hurt, so working out at my usual balls-to-the-wall level is out of the question.

As a result, I'm grouchy, acne-ridden, and feeling pasty and bloated. If you'd told me ten years ago, or even five, that I would be grouchier *not* working out than doing it, I'd've laughed in your face. Now, all I want to do is sit on the couch, stare into the middle distance, and curse jumping jacks.

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

Two more HSV patients and another person who needs isolation because of bacterial meningitis means we simply do not have enough cobbled-together isolation rooms. This week (I'm working six days out of seven, thanks to a schedule malfunction) will be a real hoot.

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

Max just came in to communicate, through lip-flips and growls, that my popovers are done heating up. Time to melt some butter. And clean the office.

Good night, Joe Slobotnik, wherever you are.

Sunday morning mellow.

It's raining. Make some popovers. Make sure you bake them long enough, or they'll end up as Flopovers.

Mix:

Two eggs

One cup milk

A tablespoon or so of oil or clarified butter

A teaspoon of sugar

A half-teaspoon of salt

Grease:

A popover pan or muffin tin.

Preheat:

Your oven to 425*.

Now take your liquid mixture and add:

One cup of all-purpose flour. Beat until it's all incorporated and the batter is smoove.

Once the oven beeps (or after ten minutes of preheating) pour the batter into the muffin tin or popover pan. Bake for fifteen minutes at 425*, then turn down the oven to 350* and bake 15 or 20 minutes more, until they're a nice even dark golden brown.

Serve with scrambled eggs and bacon.

And listen to this:

Rules for Residents Redux

Actually, let's call this Rules For Everybody. Auntie Jo has some bones to pick.

Number One: I do not intimidate well. Please don't try.

The night supervisor threw a pissfit at two o'clock this morning because I was sitting in His Chair, using His Computer. Silly me; I had thought that it was just another computer at the station, and just another chair.

Rather than asking me to please get my ever-widening ass out of said chair, though, he went on and on about how he hates it when people sit in His Chair and use His Computer.

"All you had to do was ask me to move, Mark" I said.

"I hate having to tell people to move!" he said.

"You just did. About six times."

Shit like that wears me out. I am not cute when I'm tired. Save us both the trouble and don't get all puffy-chested on me, okay?

In other words: the queen of passive-aggressive taught me well. I can recognize that shit a mile away, and Mama don't play.

Number Two: If you don't ask the question, I can't give you the answer.

I don't care how stupid a question it seems to you, or how stupid it actually is. If you don't ask me, I can't help you. Whether you're embarassed about your ignorance or you don't believe that a creature as humble as a nurse could actually know something you don't, you're tossing a shoe into the works if you hare off on your own. Just ask me. I won't laugh at you, I won't get annoyed, I won't sigh deeply and roll my eyes before answering. We are all here for one goal: to get these gomers out of the beds and up the stairs; anything that helps you helps me reach that goal.

Number Three: Say what you mean. Mean what you say.

Who'd'a thunk working at a hospital could be so much like working in government or dating? Not me, but it is. I guess it's just people that make living on this planet so difficult. It doesn't have to be hard, though: if you want something, ask for it (see above). Likewise, if you want something specific, ask for it directly, rather than bumbling around and wasting time. A simple order should be just that: a simple order.

Likewise, if you mean something specific, say what you mean. This is not hard. If I fuck up, tell me about it clearly and specifically and simply. I ask this boon not because I'm any dumber than your average bear, but because it saves time and makes life easier. Avoiding bush-beating also ensures that I won't make the same mistake twice.

Number Four: Just because we worked out that little problem doesn't mean I'm not watching.

Nurse Jo is like Big Brother: always watching. If you're the resident that lied about my calling and charting to both my boss and your attending, then you know that we've already resolved the issues of your idiocy and inelegant behavior. Don't think, though, that you get a free pass from here on out. I am not a vengeful Jo; I am, in fact, slow to anger and quick to turn again. I don't hold grudges, in other words. But I am also not an idiot; I know that if you tried undermining me once, you'll likely try the same thing either with me or with a coworker.

So don't.

Number Five, and perhaps most important: Never, ever, ever lie to me.

You would think, wouldn't you, that helping sick people get well would kind of, you know, push the whole issue of ego and self-aggrandizement out the window.

Well, it doesn't.

There are still people--mostly doctors, I'm sorry to say, although there are some nurses in there, too--who think that being busy or getting stressed or being unable to accomplish something is a direct reflection on their worth. It is not. Let me say that again: everybody gets busy, stressed, and overwhelmed. If you didn't manage something, or some test didn't get drawn, or you fucked up inserting that drain, it's okay. Tell me you screwed up, tell me you didn't get X done by Y time, and I will bust ass to help you out and make you look good. I look better when you look good, so it's really all self-interest.

That said, do not lie to me. Do not lie to me about why you didn't do something, or why something else didn't work out as it was supposed to.

Example: I had a patient who was on pressors to maintain blood pressure. I wandered into work, yawning, to find that the patient's blood pressure was not only sky-high--totally out of parameters--but also that her pulse was off the charts. The reason was that the nurse and resident together had hung a bag of a particular pressor, but used the IV pump settings for another, less-intense sort of pressor. These things require two signatures for a reason: if your eyes aren't good enough, another set helps to catch any mistakes you might've made.

The nurse's reaction was "Holy shit, did I ever fuck up." The resident's reaction was hemming and hawing, denying that she'd ever double-signed the checkoff, and blaming the nurse.

The mistake was fixed without harm to the patient, but the stuff surrounding it sticks in my craw: a mistake is no big deal. Everybody makes them. Lying to me about it, though, and attempting to blame the nurse/the phase of the moon/your mother? This is another one I'll be watching.

It's funny how, when I started the whole CCU thing, I figured that it would be a closer, more professional, less fraught environment. On many levels, it is. I'd already earned the trust of a number of the doctors and nurses down here; most of 'em have expressed surprise that it took me so long to move to the CCU.

On another level, though, it's much like living with somebody you don't particularly like, or with a brother or sister you don't get along with in such close quarters. Ego and emotion come into everyday interactions to a degree that I frankly find uncomfortable sometimes; there are turf battles and irritating complications that could be resolved with a little plain talk. Some mornings I come home feeling like I've just spent a long night dealing with an old boyfriend.

I had hoped to work in a place where brains mattered more than hearts. I'm finding that, even though it's still neuroscience, hearts (and egos) play into the whole damn thing more than I'd like.

Cruel to be kind

I had a nursing student following me tonight. As I've said before, I love me some nursing students. I always feel bad when I ask them to do things like refill water jugs or do baths on patients, but I am *so glad* they're there. Nursing students make me a better nurse, in that I'm more careful, more cautious, and I bother to explain things--both to them and the patient. Plus, they can save my nursey ass from disaster by taking up the slack.

Anyway. Nursing student. Nice guy, works at County Giganto on the weekends. His wife was the one, coincidentally, who did my ultrasound during the great Maybe It's A Toomah Scare of 2009.

I taught him how to put down an NG tube. On a patient who still had a gag reflex, but who was aspirating anyhow.

Very traumatic.

For him, for me, for the patient. For some reason I still don't clearly understand, I tend to close my eyes during NG tube insertions and just go with the flow. Nine times out of ten, barring some weird turbinate action, I can get 'em down. I've not failed yet with one of the smaller, weighted tubes.

But this poor guy was a mess. I can understand nervousness about new procedures; I still remember how strange I felt the first time I jabbed somebody in the ass with a needle. He did really well, actually, not backing down or freaking out. He got the tube in with a minimum of blood and gagging, and the patient was fine afterwards. It didn't hurt that that patient has no short-term memory at all: she's totally amnesiac beyond about thirty seconds.

But it's still strange to realize that you're going to hurt people, to cause pain, in the service of getting them better. It's like the first time I ever really *thought* about what I was carrying when I was hauling samples to the lab (before I was a nurse)--I got a little faint, reflecting on the fact that I was holding comfortingly warm tubes of blood.

I got over it, and he will too. No matter how strange it seems, our job as nurses is to help people heal. Sometimes healing means unpleasantness or outright pain. Until you've worked in a unit that deals with post-op orthopedic patients, or a burns unit, you won't understand the degree of distance which a person can achieve with a little effort.

Sometimes being a nurse sucks. Having to hurt people qualifies. Having to stick somebody with a needle, or jam something into their nose, requires a certain sort of wicked (meaning keen-edged) sensibility that this, right here, is temporary, and that the benefits outweigh the costs.

In the last job I had prior to being a nurse, I had to deal with people who had been hurt by other people. That was harder than hurting them myself. Part of it is rationalization: I know that what I do has an eventual benefit....but it's still weird to contemplate.

Charlotte Gainsbourg had an MRI, and she is more talented than you are.

Well, that was an interesting phone call.

Dear Doctor Dipwad:

If I call you several times in the course of a night, warning you about subtle neurological changes that your patient is having, please don't blow me off.

Because, if you do, I will be forced to call your attending at oh-damn-thirty and let him know that the subtle changes you blew off have become something truly horrible. By that time, of course, the patient will be already on the way for a stat scan, and I will have alerted surgery. 'Cause I'm good like that.

So when your patient (whose changes you ignored) is going to surgery for an emergency skull-chop, and your attending isn't happy about that, and I'm running mannitol much faster than it probably ought to be run, and there are intubation trays all over the place, just remember: dealing with it now means you'll have less to deal with later.

And, dear Doctor, once it's been established that you were indeed a Dipwad about things, please please please don't try to blame it on me. Don't tell your attending that I didn't notify you when things started to go pear-shaped. Don't tell my boss that I failed to catch the subtle changes that I called you about four different times. There's this little thing called charting that I do that will put paid to your story. Also, the page operator has a computerized record of all the times that I tried to make you see reason.

All that being a further Dipwad will do is make my boss call me in the middle of a nap to make sure it's okay that she accesses my charting. I'll say it's fine, and you'll be sitting there in a conference room with my boss and *your* boss, and I'll be on speakerphone, and then things will begin to get very depressing for you.

I'm just sayin'. You interrupted my nap like I interrupted yours, but the consequences were very, very different.

(The patient will be fine, by the way.)

My loss of sleep is your gain in posts.

2:39 am and I can't sleep.

Night shift is completely messing up both my circadian rhythms and my typing. I wake up at odd times, I fall asleep at odd times, and I keep having to backspace constantly.

It kind of sucks.

I wonder about the patient with the belly bleed from last night. I wonder about the sweet little girl with the huge herpes infection.

I wonder why I already miss That Guy I Liked, whom I dumped over the weekend because he didn't like me. Knowing I can't just email him sucks, even though he never emailed me first.

Maybe the girl who went wonky on me the other week will get sent to rehab soon. She's much better; following commands and speaking spontaneously, but she still has that bunch of infections.

Maybe if I were sweeter, not so snarky and sarcastic, he would've liked me. His best friend told me that the woman he does like is really sweet. I guess that might be it.

Maybe now he'll read that book I gave him. Probably not, though.

I wish I could kick some of these docs in the head a few times. Just because you think about ordering a morning CT scan doesn't mean that I'll pick up on your mental transmissions; you actually have to *do* it. They yell at me for their mistakes sometimes, or order stat CTs at five in the morning, when things are already insanely busy, what with rounds and labs coming in.

It was stupid of me to like him. I thought he liked me; I made him laugh, and he said he liked my cooking. Oh, well.

I wonder how that patient with the belly bleed is. Maybe his crit's come up and he can go to the floor in a couple of days. I have never seen an ammonia level that high; Nurse Ames and I figured it out when we saw the way he was breathing, so we ordered a stat ammonia. It was through the roof. That was a nice win for the two of us.

Those herpes and meningitis patients are going to be a bitch to deal with. I hope we don't get any more from Incompetent Hospital Corporation; we've already got every single negative-pressure room filled up, and we had to create two more with plastic sheets and blowers and vents.

It kind of sucks to realize that you've been used as a pacifier by somebody who's addicted to drama queens. It's really humiliating. I can deal with a bruised ego, but humiliation is something worse.

Oh, damn. We're starting that new stroke study next week, and I haven't finished the online training for it. I'll need to do that next time I work. It's really kind of cool: it's a study to determine the outside limit of time at which TPA will actually work for a clot.

I need to pay the electric bill. I wish they didn't charge five bucks to do it online.

This week I have got to get that plywood up to the attic. Maybe Matt could help me. I think I can do it, even with a bum knee. That knee got bonked last night in the scrum around Mister Belly, and it's kind of swollen right now. Ah, the joys of aging. And of doing ill-advised stuff with your trainer.

I sure hope I don't need surgery. Probably will; there's a torn meniscus or something nasty in there now. Damn.

It doesn't really matter. Not really. I mean, yeah, the blog gets a hundred thousand page views a week, but he doesn't read it any more. I don't know why not. Maybe he's just too busy.

Notamus got tangled up in a reusable shopping bag at one o'clock this morning and went tearing around the house in a panic. That's what woke me up. Poor guy knocked over two trash cans and was all agley afterwards. He needed many head-rubs to feel better.

Yeah, so. I can't sleep. And this is the last beer in the house. Hi, Mom! Hi, All Of Mom's Friends! (Hi, Lawyer Guy I Met Last Week Who Told Me About His RAP Theory! In case you didn't notice, that one went over like a lead balloon! Probably not a good thing to tell a raging feminist! Just sayin'! Thanks for the whiskey!)

Maybe I'll go sew some curtains. That's a good use of time. As Queen Elizabeth said, one must be patient, and let time pass. All it takes is time, right?

Right.

The stupid: It BURNS.

This has been One Of Those Weeks. The level of Stupid has gotten to the point that, if somebody doesn't do something soon, the Stupid will all roll together into one big ball of Damn That Was Dumb and there'll be a cataclysm.

For instance, Doctor Fuquad, you should probably not put a luer-lock access on to an arterial line. (For you non-medical types, an arterial line is just what it sounds like: a big IV-type thing that goes into an artery in your wrist so we can monitor your blood pressure directly during surgery.) For one thing, if you're monitoring pressures with an A-line, the luer-lock access will screw things up and make it look like the patient is running a blood pressure of 264/264. For another, and here is where I start to get all-cappy, YOU ARE NOT SUPPOSED TO PUT ANYTHING INTO AN ARTERIAL LINE EVER EVER EVER AND PUTTING AN ACCESS ON ONE MIGHT CONFUSE PEOPLE.

Let's make it simple, Doc: arterial lines are to be flushed only with pressure bags through pressure lines and are supposed to be directly connected to whatever they're going to. Luer-lock IV accesses are only for intraVENOUS access and are meant to allow you to shoot drugs through them. YOU ARE A MORON.

Gracious. Was that a rant? I think that was a rant.

*ahem*

Okay, boys, second thing: If you've done belly surgery on a patient, and that patient has developed a rigid abdomen and a sharply falling hematocrit about two hours after surgery, please don't keep that patient in the CCU for eight more hours to see if the bleeding will stop on its own.

(Yes, I just said that. And I just put my head in my hands In Remembrance Of Things Stupid.)

Ten hours after surgery, things were going.....badly for that poor bastard. Dr. Fuquad's brother, Dr. Diqhed, looked with some surprise at the lab values that were incompatible with life. A hemoglobin of five-and-a-half and a pH of seven-point-one? (For you non-medical types, these lab values are both fatal and entirely preventable. If you're not STUPID.) Well, then! Let's pour eight fucking units of blood into this guy using pressure bags, and if we don't have enough pressure bags, let's have Jo just stand there and squeeze!

And let's watch the blood we pour into the patient pour straight out into his already board-like belly!

Dr. Diqhed stopped by the unit after his patient's second surgery and expressed surprise at how well the patient looked. I couldn't stop myself--I hate this guy; he's an attending who should be weaving baskets--and said, "Yeah, it's amazing how great people do ONCE YOU STOP THE BLEEDING." (YOU MORON)

Uh, oh. Ranty again. So very sorry.

*koff*

And, finally, Manglement At That Other Hospital? It doesn't matter how sick your immunocompromised patient is with his widely-disseminated herpes simplex: you probably shouldn't put him into a unit meant for people who are seriously immunocompromised. Because if you do, all those poor bastards will be showing up at Sunnydale's CCU, medevaced in with screaming disseminated herpes simplex infections. It really doesn't matter how much negative pressure you have and how much your nurses scrub; that shit will travel.

Herpes encephalitis is bad enough. Herpes encephalitis combined with a cutaneous herpes outbreak bad enough to obscure major anatomical landmarks is worse. Like, if I can't see the person's navel for the blisters, that person is fucking SICK. And, if not for the level of MORON at your fine establishment, this could've been prevented.

*rubs eyes*

Every morning between three-thirty and five I get a little shirty and short-tempered. This week's been worse. I only cry when I'm angry or frustrated, and today I found myself sitting in the locker room on a bench, facing the wall, trying to decide whether breaking my hand by punching that wall was worth it, or whether I should just sacrifice my mascara to the Stupid.

I ended up having some Gatorade and a chicken sandwich and going back to work. Sometimes there isn't enough time to get upset about The Stupid; you just have to try to fix it.

A sideways love letter: West Texas

There's a point, driving east in West Texas, where the long series of ridges vanishes into the horizon. On an overcast day, you can't tell whether you're heading over another hill or into the clouds; only the trees serve as a reminder that you're still on the highway, still fighting sloth-driven campers and double-trailer trucks.

If the wind's at your back, you can maintain an easy 75 all the way to Parker County without using much gas. At the Parker County line, things slow down. Their cops are known for zero tolerance of speeding and their courts impose heavy fines. Too, going east, things get more civilized. By the time you've turned south to get back to Bigtown, everybody is going pretty much the speed limit, even in the left lane.

Not so heading west. You climb and climb over a series of ever-steeper hills. Just east of Ranger, a little nothing town, there's one huge last hill. Your car, if it's a four-cylinder like mine, will act like it's fighting a headwind all the way up. At the top of that ridge, the post oak and cedar are replaced by leafless mesquite and prickly pear lining the barbwire fencing, and you're really on the high plains. The speed limit is taken as a gentle suggestion, and you can move at eighty mph all the way through and past Abilene, without a care in the world.

Where I live there are small hills, mostly topped with burr oak, live oak, and carefully-manicured grass. There are more people than there are free acres, so things are nicely controlled. Head west, though, and you confront miles of empty space, fading radio stations, and the knowledge that (if you should get into trouble) some old cowboy in a truck will stop for you within five minutes, because trouble out here means Trouble. The nearest rest stop is more than a hundred miles behind you, and all you have is rolling hills, tumbleweed, stands of trees all bending to the south, and hawks riding the thermals.

West means little bars where it's a good night to get knifed. East means women with big earrings and hipster girls with blackwork tats. West means barbacoa and tortillas; east means a subtle mix of herbs with your king crab and mussel stew. West means freedom. East means civilization. West means hoping; east means reality.

I should've kept driving.

As promised, for Mingus Thurber, Esq.

Valentine's day for geeks.

This is worth listening to. It's seven minutes and a few seconds long, and it's one of the most heart-stoppingly wonderful things ever.

Ann Druyan talks about falling in love with Carl Sagan and a gold record.

And, for those of you on the other side of the fence, this:

Live in a swamp and be three-dimensional.

Good advice at any time, but particularly now, when "be oblong and have your knees removed" sounds really, really good.

The original title of this post was "*thud* POP! AarghFUCKFUCKFUCKAARGH", but I decided not to go with that, as it didn't get to the real heart of the matter: the fact that I sprained my right knee during my workout with Attila last night.

Yeah. Sprained knee. Not badly sprained, as I can walk on it, provided I keep it wrapped up tightly with an ACE bandage, but sprained. It's not exactly painful, but it's a weird feeling, not being sure whether or not the lower half of your right leg is going to shoot off in some random direction without warning. I'm walking like I'm eighty and taking my own weight in naproxen sodium at the moment. If things don't improve markedly by tomorrow, it's off to the Doc-In-A-Box I go, for better bracing and a note that says that yes, I can work, really and truly.

Friend Suzie, who seems to have lots of time while wrangling rats and pigs to think up bons mots, asked me in a concerned tone, since I'm reaching "that age," if I was sure I hadn't broken a hip. I would kick her, but I can't manage that much movement with the bum leg.

For the first time, I am truly grateful I'm still on the night shift and in the CCU to boot. Were I still on the floor, I would have to chase around five or six rooms, move people, help them out of bed, and generally be active. With any luck, my assignment this week won't involve a lot of gymnastics.

Before I sprained the knee, I had plenty of gymnastics going on. One of my patients, who has the deep misfortune to have a number of bacterial and fungal infections going on in about six different places at once, suddenly became unresponsive the other morning, just before the docs started rounding. (I suppose that's more convenient than three ack emma, but not by much.)

She had been fine all night. Ten minutes before, she had been fine. Then, as I was walking past her room on the way to pick up some drugs from the pharmacy, I heard her snoring. My first thought was, "Thank God she's finally getting some sleep". My second thought was, "Um....that doesn't sound right. At ALL."

I went into the room to find her blowing spit bubbles, eyes rolled back in her head, and not moving anything, even to pain. Her pupils were uneven and oval--and that's a bad, awful, panic, horrible, hair-on-fire, Jesus Christ you stupid lazy nurse you missed an earlier neuro change sign.

Somebody called the resident. Somebody else called the radiology guy and woke him up from his nap (sorry, Scott!). I had the fun job of calling the family, and of having an audible code called while I was on the phone with them. We never lost a pulse, but we did end up intubating her, as we couldn't trust her to protect her own airway.

Thirty minutes later, she was back to neurological baseline. Was it a seizure? I have no idea. A cardiac issue, caused by heretofore unknown vegetations on her heart? I would think so, but her enzymes stayed fine all day. Hydrocephalus? Pneumocephalus? Maybe, but neither one of those do what whatever-it-was-she-had did. Plus, her CT was totally clean, totally unchanged.

The upshot of the whole trauma-drama was this: both the intensivist and the neurosurgical attending agreed that I had not missed anything prior to The Event. (This was a huge comfort; I had broken my own rule earlier in the day and had stayed up worrying about her rather than going to bed.) The attending confessed with a shrug that he had no clue what had happened. The intensivist opined, in his heavily-accented way, that sometimes strange things happen. Coming from a fellow nurse, that's nice, but coming from a six-foot-four Sikh with a blue turban, it's comfort.

We'll probably never know what really happened in her brain to make her go bad like that. We'll probably never know what happened to make her come back, just fine, and be extubated a bare six hours after she was intubated. All I know is that, the next night, when I asked her to show me two fingers and she grinned and flipped me off, it was the best feeling ever.

For sale, cheap: (and an addendum to the DMV)

Two feline juvenile delinquents.

I returned from the DMV/grocery shopping/etcetera to find that Notamus and Flashes had opened a three-foot by three-foot by eighteen-inch box full of packing peanuts and spread them all over the house.

Nine hundred square feet doesn't seem like a lot until it's covered with fine drifts of packing peanuts.

I cannot *wait* until the weather stays stable enough that I can build them their outdoor kitty-cat run. (Yes, I am a crazy cat lady. Crazy because that's what they're making me.) With cat-killing dogs in front of and behind us, I don't feel safe letting them out. Instead, I'm going to build an eight-by-eight cube of 2 x 4's and screening that will allow them to climb, run, leap, and generally raise hell. It'll be accessible through a cat flap in my bedroom window (what, incidentally, that box contained).

Oh, and the DMV?

The website is wrong. The local office accepts only cash and checks. Personal checks. Not cashier's checks, not money orders.

Head, meet desk.

Fear not, America.

I have been weeding.

Spring is not far behind.

*#^&$ Seven-Layer Dip. *#$*@ being awake at night...

Grrrr.

Obviously, I have the night off. Also just as obviously, I've not managed to flip days and nights successfully on my nights off. This would not be a problem, except that the DMV opens after my bedtime tomorrow morning, and I have to get my license renewed.

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

So I'm looking up recipes for Seven-Layer Dip and pondering the breakfast I had this--well, yesterday, now--morning.

Fellow Intern Anna and I met up for breakfast at a place where, no kidding and no exaggeration, the pancakes are a foot across and an inch thick. An omelette with all the fixings (potatoes, biscuit that's the size of a half a loaf of bread, gravy) will run you twelve bucks, but it's three meals.

Anyway, as I was plowing through a quarter of one of my pancakes, she told me about a minor procedure she'd screwed up the night before. It's one of those things that they didn't cover in the internship. The screw-up was tiny, not harmful to the patient, but got the resident annoyed and made Anna feel like a dope.

Turns out it's covered in the CCU protocol.

"There's a protocol for that?" I said.

"There's a protocol for everything, apparently." she replied.

"Well, that's a good thing to know. Better late than never. Where are the protocols?"

"Nobody knows."

I wish I'd been surprised. "You mean we have protocols somewhere in a three-ring binder, but nobody knows where it is?"

"Yep," she sighed. "And the CCU protocols are supposed to be online as well, but every time you click the link to the practice and protocol pages, it lands you on the page that asks for a password, then tells you that yours is invalid and kicks you back out. Nobody can access it."

"Seriously?"

"Uh-huh. *And* the only official protocols are the ones online, so even if we managed to find the binder where the old protocols are, we couldn't use those."

"Well," I said, "It's nice to know that there are standards of practice and ways of doing things, even if we're not allowed to see them. Makes me feel all warm and fuzzy inside."

Anna stirred her coffee and stared into the middle distance for a minute. "I wonder if my mom kept that decoder ring I bought from the back of a comic book when I was eight. Maybe *that* would get us in."

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

This is, of course, Texas. The idea that anything associated with state government could actually work well (or at all) is pretty foreign. I mean, you're working in a research institution, you're trying to access the rules set forth for your practice by that State-funded institution, but you're not allowed to. That's pretty much how it goes here.

When I called about renewing my driver's license, the state DMV people told me that I had to bring a money order or cashier's check for the fee. They don't take personal checks any more; it was too hard for them to track down hot-check writers. Not enough information in their database, they said.

Rainy Thursday Twosome.

The problem with the CCU.

They will not let you die.

That, right there, is the whole problem with critical care.

Regular readers here at HN are thinking, "Dude. Death again?" I say, yeah, death again. Because, let's be honest: it's not the people who get better and take two turns around the floor with the help of physical therapy that send you home at the end of the shift to stare at that six-pack in the fridge.

It's the purpose of a hospital to help people heal, and mostly we do pretty well. I'd say 95% of the people I've cared for over the years have gone on to have decent-to-exceptional recoveries, and that's coming from a nurse who works in one of the strangest branches of medicine. When something goes wrong with your brain, a whole lot of other things tend to go off the rails a bit, and when we get those fixed, well, there's still something wrong with your brain. Ninety-five percent is good odds, given those limitations.

And when you're used to seeing most of the people you work with get better, the ones who don't hit you particularly hard. Every death is a failure. Some are more FAIL than others; it's harder, naturally, to lose a patient who's younger than average, or nicer than average, or who just had a run of crappy luck.

Which is where the problem with critical care starts.

Critical care is, by definition, critical. Like, "anything could go wrong, so I'm going to be particularly paranoid" critical. Like, "let's hope this thing in your head doesn't bust loose all of a sudden" critical. Like, "we've tried everything, but the rare and aggressive blood dyscrasia that's killing your 25-year-old wife won't go away, so let's put her on three pressors and pressure-bag some fluids in and put her on a ventilator" critical.

That last is where my own personal sticking-point is. Sometimes, people have to die. I hate it as much as the next nurse, but I come from a background of watching people die on a fairly regular basis and mostly being relieved and happy for them when it finally happens. It's not a big, scary horrible monster for me, and mostly it's not an admission of failure by the time it comes about. Instead, midwifing somebody through the process, letting them take the lead while still responding to their needs, is a tricky, thoughtful business, and one I'm glad and proud that I can do well.

But the folks in critical care (especially the oncology guys, because really, that's a tougher call than seeing a black brain on a CT, right?) don't see it that way. Death is something that *can* be beaten, and *will* be, no matter the cost to the doctor, family, or patient.

So we keep the patients alive, no matter what. A nasty case of sepsis can be fought. A stroke or brain injury can be fought. Multiple broken bones and pneumothorax can be fought. Those things are reasonable and logical--the person with the problem will likely go on to make at least a partial recovery, so you're not wasting your time or torturing them.

But the ones who simply won't get better, who've used up all nine of their lives? Those ones bother me.

Honestly: if we have you on three different drugs to keep your blood pressure up and your systolic won't come up out of the sixties, or if you're so damn sick that you've got three different central lines running six different antifungals and antibiotics, and you're still not improving, it may be time for us to give up. You've probably left the building long ago and are waiting impatiently for the chance to get on with things.

It's hard to make that call, and I respect that doctors don't want to judge too quickly. We've all heard about or seen miraculous recoveries (or at least, unexpected improvements). It's not up to anybody to determine, actively, when another person's life should end.

Still, it leaves me with a nasty, metallic taste in my mouth that has nothing to do with the drugs I've been running into someone.

I wonder what it's like for the person in the bed, the patient. I can begin to appreciate what it's like for the family; I've fielded plenty of tough questions even in this short time. I know what it's like for us: a colleague of mine is getting the hell out of nursing and going back to accounting so she doesn't have to be sad every day.

Maybe we should be more accepting of failure. Maybe we should turn our attention to the whole situation, and realize that sometimes, that small failure in losing a patient can mean a huge comfort for the people who are left behind. They won't have to think about, late at night, whether they caused more misery than they prevented. And it would be better for that person in the bed, sometimes, to just up and say, "Look: we can bring her back, but it would mean that her intestines would be dead, that she'd be comatose, that she'd be dependent and in a nursing home for the rest of her shortened, sickly life. Is that worth it?"

We have amazing technology and incredible understanding of the body and the brain. Sometimes I wonder if our humanity isn't lagging a bit behind our understanding and technology.

I love my dog so much it's stupid.

Note: Nursing-related posts will return later this week. This is just too damn cute not to share.

Max is a big dog. Like, a hundred and fifteen pounds big. He's also silly, and gentle, and very much enamored of things he finds on the floor. If it's something interesting enough (a sock, a stuffed animal, the cork from a wine bottle), he'll bring it to me, sticking out of his front teeth, with his neck arched like a horse's and do the "I found something on the FLOOR!" dance. It's hilarious to watch a dog almost as big as I am, lengthwise, do something so damn *cute*.

Max does not chew the things he finds on the floor. He simply takes them outside, lays them down, and looks at them. Then he goes off and yells at the mailman.

This morning, I returned home to find that the cats had partially opened a box I got yesterday in the mail. There were three foam packing peanuts on the living room floor. I looked at those, shrugged, and went to let Max in for a minute to say hi.

Max disappeared into the living room and returned to the kitchen with a strange expression on his face. I wanted to keep him in, since it's starting to rain and he (despite his size) is a Delicate Flower, but he kept looking at me and looking at the door. With this strange expression.

Finally, after I refused to let him out, he did the "I found something on the FLOOR!" dance.

And spit out, with a "bleah" worthy of Snoopy, one small unharmed foam packing peanut.

After which I got a series of disappointed, vaguely depressed glances from His Majesty.

Because, of course, one styrofoam peanut is worth taking outside to the rain and simply looking at for three minutes.