All in favor, say "Aye".

Wrong-Way-Ray gave us our start/He said, "Don't listen to your heart"/"Instead, please follow these instructions/Towards the path to self-destruction"....

Unlimited buffoonery in the dark...

We'll do this 'till we die. All in favor....say "Aye".

Big holes

Sometimes, they leave big holes in you.

The people who die--that is, the patients you can't save--generally leave little holes, the sort that punctuate a baby Swiss cheese. If you gave them any more space than that, you wouldn't have a soul left.

But one time in a hundred, you get a really big hole.

The patient had a big hole in her. She was split from breastbone to pubis, and from one side of her ribcage to the other. They'd had to take out both of her kidneys and most of her large intestine, and a few bits and bobs in her mesentery, as well. What had been gut was now Gore-Tex. What had worked--however marginally--was now gone, and she was going to be on dialysis for the rest of her very short life.

"I think I'm going to die", she said, and I checked her color. It was good--her cheeks were pink and her eyes were bright. "I'm okay with that," she said, "I'm just scared of pain."

So I hit the button on the Dilaudid pump and prepared to listen.

The one thing nursing at night teaches you is listening. For some reason, patients are more prepared to talk about their fears and hopes at two a.m. than they are at any other time.

We talked about dying. She talked about her family, about her husband, with whom she'd shared forty-one years. It hadn't always been easy; she had secrets she'd kept from all of them that she told me that morning, in the quiet space between lab draws and rounds. Sometimes you're the nurse. Sometimes you're the confessor.

She died. She ended up dying. She passed. She coded, and we couldn't bring her back.

She left a big hole in my chest. As bad as things are, I wanted to tell her, they are still better than they could be; you have somebody at the side of the bed who loves you. You have your faith--with that, you ought to go to Heaven. You have children to remember you, and grandkids who will remember you, too, without the static of discipline and daily life to complicate their affection.

Put bluntly, without sentimentality or the rosy glow of blogging, something cut loose in her belly. She bled to death internally, probably experiencing a fifteen- or twenty-minute period of intense pain. We tried to bring her back with artificial respirations and chest compressions, but that only made the bleeding worse and hastened her death.

A fifteen- or twenty-minute period of intense pain would be welcome right now, as I contemplate the hole in my belly that matches hers. You can't always catch everything. You can't prevent every complication. You can't be enough.

She was mine, and she's dead, and I wonder what I missed, what I lacked.

Sometimes, you are not enough. It's an interesting process, to learn how to live with that.

Hey, Eloquent Anon, Classmate of Snurse8....

Dammit, I wish I had a way to do this rather than a generalized shout-out, but would you please email me?

Link is to the right under "Speak".

Many thanks.

Especially for the students: The bully professor

An astute Anonymous Minion commented on my bully post below that she'd/he'd had trouble with bullying professors in school. I don't particularly want to go back and find the quote, as I'm currently recovering from a FABULOUS alcohol-and-food-soaked weekend, but it was along the lines of "Dude. Totes not the case. My nursing professors are snacking on the bodies of students even as we speak."

Except more eloquent than that.

I don't know if I've told this story before, but the first day of finals in my first semester of nursing school, I had to put down my beloved, beloved dog. She'd been sick for a while and had taken a sudden and awful turn for the worst, so I skipped a clinical exam with the assurance that I would and could make it up the next day.

When I went to the professor who was administering that exam, (who, by the way, was fine with me making it up) she told me the following thing:

"You know, you're going to have to learn to prioritize what's really important."

My clearest memory of that encounter was thinking, "I could put her up to the wall and nail that gorram bow on the back of her head to these lockers."

Later, I had a professor who told us quite bluntly that all nurses were codependent, bitchy, and mentally ill. Even later than that, I had a third professor who used her position to advance her own quite odd ideas about health care--believe me when I tell you that a "Vitamin C cleanse" was the least weird thing she brought up in patho--and go on political rants unrelated to the course.

It wasn't until I had been a nurse for a couple of years that I realized that all these women had one thing in common: they hated nursing as a career. They'd gotten *out* of hospital nursing because they either couldn't manage the speed and intensity of floor work (the first professor was quite frank about that) or they were depressed or disgruntled by, you know, actually having to conform to things like protocols and policies.

The instructors I had who were still working as nurses, on the other hand, were fantastic. They were, thank God, in the majority--and they were, as a group, some of the toughest, strongest, most skilled women I have ever met in any profession. They were nurturing in the best sense of the word: emphasizing strengths, correcting weaknesses, and not afraid to admit when they didn't know the answers. They were realistic about the weirdos we were likely to encounter, and gave us tools to deal with them. They demanded respect not by being autocratic, but by showing us students what good nursing really was. Some of them would express frustration with doctors or hospital policies or the nursing world in general sometimes, but that frustration was always tempered with the lesson that some things that frustrate you nonetheless have a purpose.

As a result of that experience, and as a result of working with dozens of other nursing professors from other institutions over the years, I look at nursing professors with slightly narrowed eyes now. Honestly, if somebody's still working a floor job or an ICU job on weekends, I tend to take them more seriously--that's my personal prejudice, and I own it.

The point of this is that, if you have a professor who's a bully--belittling, negative, angsty about nursing in general--you should look at where they're coming from. It's not necessarily going to help you solve the bullying problem, but it'll at least give you an insight into their psychology. It might even help to keep you from getting too depressed.

Of the nine professors I had through school, three were bugnuts insane. Of the probably three dozen professors I've worked with in a clinical setting, there have been five I was very, very concerned about. The rest of 'em, whether in my own school or in the hospital, have ranged from good to awesome. They're out there, the good instructors--it's just that the way the typical nursing school is funded and run makes it hard for the good ones to be obviously good. They're too busy grading and running committees and publishing.

My advice? Look for the good 'uns. Make an effort to get to know those professors who you could see as solid mentors outside of class. Use them as buffers against the bugnuttery. Polish your Crazy Detector, and keep it active during your first year or two as a nurse.

And do not despair. Corporate culture varies greatly from hospital to hospital. The culture can even be changed from the inside (but that's another post for another time). If you find yourself in the alligator pit, the beauty of nursing as a job is that you can always find a less-reptile-infested place to work.

And, if you can find a good 'un or two, to bloom.

If you're one of the students I precept, I will do my level best to make you less frightened of what's coming. You and me, we're in this thing together, and you can teach me as much as I can teach you. Provided I don't go bugnuts from this weekend's mashed-potato-and-wine overdose.

Mellow, Musical Monday:

One of my favorite songs ever.

When What's For Lunch Is You: Dealing With Workplace Bullies.

Nurses eat their young.

Bullshit.

Nurses don't eat their young any more than electricians do, or bookstore clerks do, or lifeguards do. There are bullies in every profession; the thing about nursing is that we're expected to be all warm and cuddly and friendly and healing angels of peace yadda yadda. So when "horizontal violence", or bullying, happens, everyone clutches their pearls and has a little crinoline-lifting moment.

Still, if you have to deal with a bully at work, things can suck hard. I deal with three on a regular basis. Two I've dealt with fairly successfully up to now and the other I've ignored. Here, therefore, are the three types of bullies you'll encounter most frequently and the ways I've come up with to handle these people. More suggestions in the comments would be welcome.

(Nota Bene to new nurses: If your manager is the one who's determined to clean your bones, get a new job. There is no winning with a bullying boss, unless you're willing to spend a whole lot of time and effort to get them reprimanded repeatedly and then fired. If you're new, quite frankly, you have better ways to spend your time. Get the hell out and leave the crusade to older nurses who don't have to worry about ruining their future careers through one bad apple. Seriously.)

Bully Number One: The Know-It-All.

This person just wants to help you. Yeah, right. They know more than you do (debatable) and are better at their job than you are (extremely debatable), and are determined to let you know it every single time you two work together. It's wearing and exhausting to have to listen to unsolicited advice when you're trying to get something done, and a lot of what the Know-It-All does involves criticizing (ever so subtly!) the people who taught you how to do those things in the first place.

How To Deal With Bully Number One: Speak Up.

This is the hardest sort of bully to work with, though he's often the least damaging to you personally and professionally. Bullies in general are easily recognized by other people that you work with; it's likely that this guy has a reputation that preceeds him. Still, he can make you (meaning me) freeze up and screw little things up when he's got you under the microscope, no matter how much experience you've got.

Therefore, the only way to handle such a person is to be frank. You have to tell them--sometimes repeatedly, in a variety of situations--that you're doing fine, thanks, that yes, you understand that X, Y, and Z lead to Q, and that the way you're running that line is just fine with your preceptor, manager, and the attending.

Doing it respectfully is the key. Doing it without losing your temper is critical.

Oh, and by the way: Never, ever, ever ask this type of person for help. They'll likely defer to the patient care aid, the charge nurse, or Santa Claus before actually being useful.

Bully Number Two: It's a bird! It's a plane! No, it's Off-The-Handle Man (or Woman)!!

This sort of person can be nurse, doctor, or aid. Or respiratory therapist or X-ray person or whatever. The thing that distinguishes this sort of bully is that everything will be fine for some time.....when suddenly, they'll blow up at you over a situation or problem over which you either have no control or weren't involved in in the first place.

There's usually shouting involved. There's also usually hand-flapping, eye-rolling, and perhaps some loose spittle here and there. It's scary and can be enraging, but like the Know-It-All, the actions of OTHM, while disturbing, really don't make much of a lasting difference to anybody.

How To Deal With Bully Number Two: Employ Heavy Weaponry.

This is another sort of situation you gotta deal with immediately. It's fresh in my mind because I just had a mild, drama-free showdown with our local OTHW the other day, and here's what I did:

I waited as calmly as possible until she finished screeching, and then I said, "There's obviously a problem here. Let's take it to Boss Lady as soon as she gets in."

OTHW backed down immediately, saying that oh, no, that's not necessary, but--and here's where the heavy weaponry part kicks in--I would not let her off the hook. She'd yelled at me for something completely beyond my control, made some remarks about my parentage and my personality into the bargain, and scared hell out of a student I was precepting.

So in the morning, off we went to see Boss Lady. As we walked into her office, I said, "OTHW got very upset with me this morning, and so we need a mediator. I'll let her talk first." And then I sat down and made myself comfortable while she ranted.

This is, again, crucial: you must let the nutjob spew gaskets and bolts all over before you respond in a reasoned, logical manner. Not only will it make you look like a fair person, but it's golden for getting your point across in such a way that showcases the other person's wackiness.

Not only, then, do you show your boss where the problem is, but you do something equally important: you let OTHperson know that you are on it, you are down with it, and you are not afraid to bring it to their doorstep (as the kids say). Not being intimidated is what makes these bullies leave you alone.

And finally, Bully Number Three: She Who Must Not Be Named.

I have no good name for this person. If there's a nurse that eats her young, this is the one: passive-aggressive, condescending, subtly critical, and prone to complain about other nurses to residents and attendings. This is the bully that you have to watch out for, as she can be damaging to your reputation as a nurse and your standing with your boss and the people who aren't there all day (like doctors).

How To Deal With Bully Number Three: Get Ready For The Long Haul

Unfortunately, like all things toxic and explosive, this person is the hardest sort of workplace bully to handle. You can go about it two ways: ignore what's happening and just keep your head down, or write everything down and make a near-Federal case of it when you have enough evidence.

You know how everybody always tells you, "Write everything down", right? Well, it's true: it does give you ammunition when and if you want to confront SWMNBN in the boss's office. (Don't ever do it alone, without a senior person there. That way lieth disaster, verily.) You'll need to be as careful at recording what she says or does as you would be in documenting the care of a very ill patient with litigation-happy family: that's the only way to keep yourself from becoming mired in she-said/he-said Hell.

Try to mitigate this person's actions and words by forging close relationships with the doctors and nurses (and everybody else) you work with. In dealing with our unit's SWMNBN, the reputation that I've developed--carefully and consciously--over the last eight years has been invaluable. You may not have that depth of experience, but it's never a bad time to start building respectful, open relationships with your peers.

And, if it comes to the point that you have to say something to your boss (it might not; often this bully's teeth are pulled when you ignore her or him), it's usually best to meet alone with the boss and show them the evidence you've compiled, then let him or her take it from there. The more ammunition you have, the better--and the higher quality ammo you've got, the better. If a doc reports that SWMNBN told her that you'd not done some vital thing, ask the doc to write that down for you, and keep it with your other documentation.

I wish you luck in dealing with this particular bully. I was fortunate that, when my unit's bully complained to an attending about the care I supposedly hadn't given a patient, she chose an attending with whom I'd just discussed that care, and with whom I have an excellent working relationship. The doc basically nipped that particular bitch in the bud, and I've had no problems since, but it was pure chance that it happened that way.

Tell your fellow Faithful Minions and any new Minions out there how you deal with bullies in the comments, please. And thank you.

The kids across the street are having a party.

After an hour of yowling from a woman who seemed to think that elliding her notes was akin to sounding like a drunken Sara Jaffe, the music stopped.

The band went away, to be replaced by a Celtic-mash group on acoustics, who, if I'm hearing it correctly, are playing the Who's "Boris The Spider" with three-part harmony on the "BOOORRRIIISSS THE SPIIIIDER" part.

Nice fiddle work.

Hair of the dog

"Hi, Ginny," I said, as I walked into the room, holding a syringe with heparin in it and a couple of pills in a cup.

Ginny looked up, looked alert, but said nothing.

The guy in the bed was relaxed. Ginny stayed with him twenty-four hours a day, helped him walk around the halls (this was back when I was still on the floor), and generally helped with his treatment. She had even stayed in the CCU with him, contrary to hospital policy, overnight after he'd had his cervical laminectomy.

The guy in the bed stayed relaxed, answering questions about how he felt and whether he had had a return of the numbness and tingling in his hands. He took the heparin shot in his belly without complaint, though Ginny looked narrowly at me as I approached him with the needle. I didn't think she'd do anything, but I didn't want to get into a scrum with her: not only was she intelligent, observant, and devoted, she had twenty-two teeth to each jaw and was faster than any human I'd ever met.

Ginny was a chocolate standard Poodle. She lived with her master/soldier/friend as ballast against the worst effects of PTSD.

When he walked the floor, holding the pole on which his IV pump hung, Ginny would scan around the corner before he got there. When anyone came in the room, she would give him warning before we knocked, so he wouldn't panic at the loud, unexpected sound. Ginny had been trained to bring him his phone when it rang, always on the vibrate setting. Ginny did a lot for him that we couldn't do.

Ginny hated hospital food just as much as her human did.

At the same time we had the guy with the cervical lami in, we had a woman on the opposite hall who rescued dogs and trained them to be helper animals. She had a side business making organic pet treats. I brought Ginny a couple of the woman's peanut-butter biscuits, which she gratefully accepted as a break from dry kibble and awful hospital food treats.

Ginny was a celebrity in the hospital. With her yellow Animal Assistance vest on, she looked quite stylish. Her coat was trimmed close, except for the typical Poodle puff on top of the head, and her nails were short. She didn't need a leash, and would ask politely to go outside by coming to the nurses' station, raising up on her hind legs, and staring fixedly at the unit clerk, who would then jump at the chance to take her out.

Sometimes I wonder what happened to her human, my patient. I don't worry as much about him as I do about other people who don't have a Ginny: it's easier when you know somebody is watching after your patient when they head home, even if that somebody has four legs.

Musings, and where the magic happens.

So I'm at the grocery store today when this song by a group called "Train" comes on. I've heard it once before, as the music behind a "Nurse Jackie" teaser. There were four of us in the health-food aisle when it came on, and we all started dancing before we thought about what we were dancing to.

After some discussion with the two guys and the woman in the aisle with me, it was decided that you cannot name-check Mister Mister and claim to be "thug" and "gangsta" and have an "untrimmed chest" all in the same song.

The ukulele spoke in the group's favor, but the idea that a skinny white guy in his forties would try to sound cool sank that prop right away.

Still, it's a good hook. I mean, if you listen to it without context, and don't pay attention to the words, and most especially don't watch the video:

Also, where the magic happens: When I look up, I see the top half of a secretary that was passed down to me through my parents from my great-grandmother, for whom I'm named. I've stuck a lot of stuff up under the wood divider over the glass doors. For instance:

That's the HN logo, yes. The other side has pictures of the Patchwork Girl of OZ and a poster of the entire "House" cast with the caption "It takes a village to kill a patient."

I have no clue why this is still sideways. Blame Blogger.

This is what I see when I glance up from downloading bad music videos (cute dog, though) and posting about work.

0530 Monday morning...

...and all I want to do is take a blood sugar.

Instead, I get into an involved conversation with the patient about the aftereffects of his brain surgery.

It's as much of a conversation as you can have with somebody who has expressive aphasia; the tumor has left him unable to form complete sentences without a whole lot of effort, and he's still having trouble naming objects. Still, you can tell when something's bothering somebody, right? So I stuck around after I stuck his finger and let him fumble-talk.

We went through what to expect in terms of his recovery. He'll get his speech back--there was no permanent damage to his speech centers. What he said next surprised me.

"I don't want to die."

In one complete sentence, with no pauses.

"I...don't...know...not...good..."

There was a long pause. He finally looked at me, rolled his eyes, and sighed out one word:

"Catholic."

"Oh," I said, "I get it."

"I...don't...know...what's...in...store..."

"You don't know what's going to happen to you when you die?" I asked.

"Yeah."

Then he said, "...Want...to...die..."

"Give me more" I told him.

"Want...to...die....Wife. Daughter. Other daughter. Forty...forty-three...have...own...things...not...be...like..." and he stopped. He waved one hand, taking in his body in the bed, the drains coming out of his skull, the lines and cords around him.

"You don't want to be a burden to them." I said, more certain of this than the last one.

"Yes" he said, definitely.

I was stuck. Theological discussion of what happens after death is not one of my skills. Four years at a Christian college left me with a complete uncertainty of who's going to hell and who's going to heaven (with a few notable exceptions) and totally unprepared to coax out the threads of the fear of God out of a man who could barely say his own name. Likewise, I couldn't be certain that he wouldn't be a burden, in the sense that we usually understand burdens: I couldn't assure him that he would be able to talk as well as he had in the past, or that he wouldn't need help, later on when the tumor came back, with such things as dressing and peeing.

He went on. I was going to stay at his bedside for as long as this took. There are more important things than checking blood sugars on somebody who's needed no treatment for them for a week, after all.

"My...wife. Saint. Never...not...doesn't...angry. Not a cusser. I...cuss." Again, the hand-wave.

Cussing is not, as far as I can tell, a problem for God. But cussing is not what this is about, not really. Cussing is a stand-in for all the things he's screwed up, all the times he had to kill somebody during his time in the Marines, all the things he could've done better. I know this, and I feel my heart break a little for him. There's so much in there that he wants to get out, and right now, at this time when it's so important to be able to confess his sins, his speech is tortured and elliptical.

I tell him, "God speaks in metaphors and without words. You don't need to have words to talk to God, and I don't believe that you've done anything worth going to hell for."

Then I remember: his wife told me how he still has nightmares about the man whose throat he cut, years ago, in some other country in some other conflict.

"Don't...know...what...He...will...think."

There were other things I said. I remember most of them, but they're not important to put down here. Some of them were funny. Some of them weren't.

Why, I raged at God, do You put me in these situations? You know I don't have the answers to why You do the things You do. You know I can't just sum up everything with some pat theological answer. You were the One who made me question every-damn-thing You do, and yet you present me with somebody who needs solace? Fuck you, God. Just... fuck You.

I drove home that morning with Neko blasting as loud as I could stand her, wondering if I had enough beer in the house to make a difference.

Yeah, Dude. Whatever.

"You're really going to take all that? You don't need to take all that. You can always hang the bag up there, you know. Let me show you how this works. This bed turns in the middle, like a tank, so you don't have to haul it around. You're really going to do that? Why don't you do that this way instead? Here, let me show you how I tie the tourniquet. It'd be easier if you did this *this* way, rather than the way you've been doing it for nearly a decade. By the way, my way is always better than your way, and I am smarter and more attractive than you into the bargain."

And on and on and on, all the way to the basement. At which point, I heard the second-sweetest words ever:

"I guess you just want me to shut up, huh?"

I said, "Yes. Yes, I do."

You'd need three words to say anything sweeter.

"You're cancelled."

God, I love that. I especially love it when I've already accomplished everything I wanted to do tonight (organize utility room shelves, wash and rehang curtains, finish laundry, vacuum, clean bathroom) and have had dinner besides, so the rest of the night is gravy.

And it's raining, to ice the cake. And it's supposed to rain all day tomorrow, too.

Max is indoors on his bed, snoozing damply and waking up with the occasional *boof* when he hears the neighbor dogs bark. You can, if you look closely, then see the wheels turning in his head: is it worth it to go outside in the wet and pretend to be Braveheart, or should he stay here inside, in bed? Bed wins.

The guy I took care of for the past two nights, the one with the crazy electrolyte imbalances (potassium of six, anybody? Calcium of three-point-eight? You go!) has transferred up to the floor. The other guy, the one who had his entire throat rewired, will be with us for a day or so more, but at least I don't have to be the one checking four pulses with a Doppler every hour and hoping the flap stays viable.

I feel so sorry for people who have complex head-and-neck dissections, or folks with really complex plastic surgery. It's never for a benign reason that you get a flap; it's always because you have to have a breast or two removed, or (God forbid) your entire tongue, and you get some new architecture on your face into the bargain. No matter how good we get at plastic surgery, a jaw that's rebuilt from leg bone will never, ever look like the one you were born with.

Add to that pain and fear and general anxiety that you've got a nurse coming in every hour on the hour, smearing light-blue conduction gel on your new face or new chest and checking for the swish-swish of a good pulse, and you've got hell on wheels. There is not enough Ativan in the world to make me willing to go through that, yet I ask if of my patients every night. They can't even *sleep*, for the love of Mike, and yet we expect them to get better.

You can, eventually and with enough support, get used to not looking like yourself. I imagine you can get used to having tattooed-on nipples (though I'd hate to have to) after a while. It's what we put them through in the meantime that kills me a little every day. I want to let them sleep, to feed them decent food rather than the weird stuff from the hospital kitchens, to touch them without gloves. I'd like to touch them without hurting them once in a while.

People go through hell before they heal.

Sometimes I wonder if the advances in surgery and technology really make it worth it.

With all of that, and with the continuing revelations that the people I work with on nights are ka-ray-zee, I've decided to take the job in the new neuro unit. It'll be back to all brains, all the time. I have to cast back six years to the last time I did brains and spines exclusively, and it seems at this distance to have a nice rosy cast to it. I'm sure there'll be parts that suck, but at least I'll be doing things that are less painful and invasive.

One of the unit managers came to me last night, envious that I'd gotten the offer to work on the new unit. Apparently, my current manager doesn't know my long-standing reputation as a rabble-rouser/pain in the ass, but everybody that does is excited that I might actually have something to do with how the new unit's laid out and run. As the other unit manager said to me, "Make sure you work it so we can see all the beds from the desk, okay?" Like I'll have anything to do with that, but it's nice that she has confidence in me.

One of the newly-minted neurology attendings asked me if I planned to take the job on the neuro CCU. When I said yes, he sighed "Thank GOD."

I guess it'll be okay. If it's not, there's always the general CCU to go back to, or I could conquer my mental block about telemetry and go work for CVCCU (note to self: cute male nurses on CVCCU! Wahoo!). We'll see.

In the meantime, I have Fritos to eat and a dog to scratch. *Boof!*

Saturday Night Duet:

Saturday Cephalopod

As some of you might know, I have a deep and abiding passion for octopi in all their forms. From itty-bitty ones on plates in schwanky restaurants in Montreal (so cute! so tasty!) to big ones in aquariums in Seattle (it's looking at me!), I love octopudlians.

In fact, during college I had a passionate semester-long affair with an octopus who lived in the basement of the science building, next to an extraordinarily bad-tempered alligator.

So when some poor scuba-diving schmo had his camera stolen by one of our eight-legged brothers, guess who I was rooting for?

octopus steals my video camera and swims off with it (while it's Recording) from Victor Huang on Vimeo.

Amateur Night, or: This Ain't How We Do It

Note to surgeons universally: if you're a general surgeon in some little teeny town in the middle of nowhere, it is not a good idea to experiment with neurosurgery on your locals.

Seriously, dude. Leave it to the experts.

Because what will happen, if you decide to fuck around with somebody's brain, is that you'll screw something up. Even if you're doing what would be (in the hands of our guys) a fairly benign procedure, you'll almost certainly screw it up.

There's a method of embolizing aneurysms that involves shooting dozens of little tiny platinum coils, like itty-bitty Slinkies, into the aneurysm. That causes blood flow to slow down, pressure to drop off, and eventually the thing clots off and collateral circulation forms, solving the problem. Although it's a fairly simple procedure, things can and do occasionally go wrong, even at Sunnydale.

Things go wrong much, much more often outside of Sunnydale.

For one thing, playing around in the vessels of somebody's brain is a high-risk proposition. For another, you have to have a good idea of how blood flow behaves in an aneurysm before you start putting things into it or clipping it off. For a third, you have to know that there are some aneurysms that can be coiled, and others that cannot.

A nine-millimeter-diameter torturous enlargement of the posterior communicating artery probably should not be coiled. If you try, you'll end up shooting coils all over the brain's posterior circulation. And somebody will have to go in--that somebody being one of our boys or girls--and get the damned things out before they cause more problems.

That said, it's interesting to see imaging of your patient's brain and note the little teeny cute coils ALL THE HELL OVER THE PLACE.

Jesus. *rubs eyes*

In other news, I'm going to start wearing safety glasses when I mow the lawn. The nice man who came in this week didn't, and ended up with a piece of yard waste embedded in his eye. Which wouldn't've been a problem, except that that bit of yard waste contained some sort of particularly virulent fungus. And that fungus contaminated his whole eye. And spread. And eventually necessitated the removal--and here I wish I were making this up--of half his face.

Jesus. *rubs forehead*

I have the world's worst neckache. Sadly, I wasn't having any fun when I got it; I was busy wrangling leeches.

Leeches suck, no pun intended. They're fast-moving and aggressive, and they can change shape to an alarming degree. Picking them up with tweezers is an exercise in futility. If you want to preserve the little bastards, pick 'em up with your hands. If you don't care if they live or die, try a pair of ring forceps. (I keep a pair of ring forceps in my bag for just this occasion. Don't tell the OR that I stole 'em, okay?)

Leeches tend to get full fast, then fall off of whatever they're sucking on and start crawling around. This means in practice that if you start with half-a-dozen leeches and end with five, you'll spend forty minutes scouring the damn room for one freakin' leech before you find it attached to your leg just above the ankle.

No kidding. People, I do not lie when I say I had a miniature internal mental breakdown.

Luckily for me, the patient had nothing infectious that I could catch through sharing a leech. But holy Christ on a crutch--finding a peacefully sucking leech about a centimeter above your sock will cause you to freeze, stop your thought processes entirely, then make you think calmly and critically about your situation before you grab the tweezers and alcohol and a little cayenne pepper. (Cayenne pepper stops bleeding; it gives the blood something to grab hold of and clot on.)

Leeches do not hurt, by the way, but their anticoagulant spit is powerful. We use it in drip form for folks who need to be anticoagulated fast but who are allergic to heparin.

Jesus. *rubs ankle*

It's four ack emma and I have four hours before I can go to bed. It's going to be a long, long four hours.

Jo versus the Collection Agency Guy: An Epic Saga

The telephone rang early this morning, awakening me from a very pleasant dream involving Dr. Teeth and about six pounds of ice cream.

Me: *gronk* Hullo?

Collection Agency Guy, cheerily: Good Morning! May I speak with John Lastname?

I have what's about the third most common last name in America. I also have a very common first initial. My first initial and last name are how I'm listed everywhere, including in the phone book. This has been the source of problems, not least of which is the tendency of collection agencies to call.

Me: Sorry, you have the wrong number.

CAG, cheerily still: But you know John Lastname, right?

Me: Nope. Can't help you.

CAG, less cheerily: You don't know John Lastname?

Me: Nope.

CAG, getting snarly: But he gave this number as a contact number. You've got to know him. Let me speak to John Lastname!

Me: You. Have. The. Wrong. Number.

CAG, outright fang-laden: This is John Lastname's number! He gave me this number!

Me, through my teeth: Bullshit. This has been my number for the last six years. At no time has anyone named John Lastname ever lived here. Furthermore, I do not know anyone named John Lastname. I also do not know anybody named Jane Lastname, Juan Lastname, Justin Lastname, Joe Lastname, Jeannie Lastname, or Jack Lastname. I do not know any of those people, those people do not live at this number, and you cannot reach ANY of them at this number. Especially not John. Fucking. Last. Name. You got that?

CAG: ... ... ... ... ...

Me: Hullo?

CAG: Wow. You must, um, get a lot of these calls.

Me: Yes. Yes, I do. Have a nice day.

CAG: Um... you too?

Finis

Single: The Pros and Cons.

I've been purposefully single for a year.

(Note: Even if TGIL had liked me back, I still would've insisted that he get his head together and be single himself for a year. Independence and clarity of thought are the two greatest gifts one person can give another.)

Here is what I've learned so far:

The Pros

1. Sleeping in the middle of the bed. Nothing compares to starfishing in the center of the bed after a long night/day at work.

2. Really fucking long showers. Running the hot water heater out by myself is a pleasure I hadn't had in a long time.

3. Time to be with my own self. The running commentary that another person in the room introduces, even at the level of private thoughts, is taxing after a while.

4. Obnoxious self-examination on a psychological level. Again, interacting with another person in the same space blunts introspection. Getting to the root of things (see mental clarity, above) is an interesting and profitable exercise.

5. Walking around naked. It's neither advertisement nor suggestion when you live by yourself; it just means you're too lazy to put clothes on.

The Cons

1. Leftovers. How often can I eat biriyani without being tired of it? About twice. Since my recipe makes a ton, that means I get tired of it fast.

2. Cold feet. A hot water bottle mitigates this, but it's not the same as putting your freezing feet on somebody else's warm ones.

3. Not having anybody that has your back. Seriously, this is the biggest problem I have with being single. I'm lucky in that I have fantastic neighbors and friends who do what they can and do it happily, but it's still not the same as knowing that, if it storms, there's somebody around who will comfort Max in his fear of hail and thunder. When I'm on my back under the kitchen sink, it sure would be nice to have someone around who can hand me the damn pipe wrench rather than me having to unfurl to find it myself.

4. Nobody's there to bounce ideas off of. That's the flipside of being introspective; there's not another person to pull you out of a black hole of thoughtfulness. As I told The Brother In BFE the other day, I don't have enough sane friends left, so I have to cherish the ones I've got.

5. Back scratches. I miss them. I will not lie: getting your back scratched is the primary reason to get married; all else is gravy. Romance, a martini waiting for you and a meal in the oven when you get home, and sex are all secondary to getting back scratches. The cats try, but they just can't match another human.

That's what I've learned in a year. I wonder what I'll learn next year: I'm purposefully single until at least April of 2011.

W00T! Wait, what?

My boss, who is a good sort, has offered me a different job.

I'm not sure what to do. Well, no: I am sure what to do, and I've told Boss Lady what will have to happen for me to accept the new job. I'm just not sure she can make it happen.

Sunnydale's CCU has become less neuroscience-focused and more everything-surgical over the last five years. For me, this is bad: I like neuroscience, and I like working with patients who have weird stuff wrong with their brains. A good day, for me, is brain worms and undiagnosed CNS disorders and a couple of glioma resections. A fair day is a fresh head-and-neck dissection. A bad day is freaking kidney resections and freaking gut resections; I've had a lot of bad days lately.

Because Sunnydale's historic focus has been on research and neuroscience, the change to Big Al's Surgi-Mart has been bad for the hospital, as well. There simply aren't enough CCU beds to accomodate folks with brain problems.

So Sunnydale is opening a new critical care unit, focused strictly on neuroscience. I have been offered the chance to be one of the very first nurses on that unit. Clinical trials would take place there; we'd see brand-new strokes; people with weird shit would be in there all the time.

It sounds great. It's a daytime position, and it's just what I want to do.

The problem? The start-up budget is zero. There are cannibalized beds and pumps all over the new unit, and some of the rooms have only portable monitors in them. We don't even have a dedicated EEG monitor. There is also no dedicated moolah for nurses; my wages would come from a combination of general funds and the current CCU budget.

I've told Boss Lady that three things have to happen in order for me to take the job:

First, I have to be guaranteed hours. As I told her, I do not have two incomes in my household; I am sole support of myself and three hungry animals. No hours, no bueno.

Second, if the opportunity arises for me to go back to a guaranteed daytime shift in the CCU, I want first dibs. Not third, not second, not "Let's wait and see what happens". First dibs. It's job security I can't afford to be without at this point, especially as Sunnydale's last try at a secondary CCU petered out after a few months due to lack of funds.

And third, if the job goes away (see petering out, above), I get moved to CCU on days, period. At full-time hours. No excuses, no exceptions.

Boss Lady came in seventy-two hours before my one-month deadline for finding a solution. For that I give her full marks. I'm just hoping that she, and Sunnydale's army of neurologists and neurosurgeons, can make this new CCU work and grow.

The chance to shape the care of neuroscience patients in a critical and acute-care setting is absolutely phenomenal. I have *lots* of ideas about how things should be done, starting with things like how soon we start physical and occupational therapy and continuing on to how the damn place should be set up (hint: it's nice to be able to see all your patients in the CCU, not have some of them stuck back in what's essentially a closet). I would love to be part of a research team again and to work on clinical trials. We've got a double-blind coming up that sounds fantastic.

Any prayers, positive thoughts, and general good kharma anybody feels inclined to send out will be gratefully accepted. This could be the start of something absolutely magnificent; it just has to get rolling. And get money. And get patients.

Wednesday Top Predator Snorgles:

Okay, I know the story of this: Luna the orca was separated from his pod and imprinted on humans. (Luna died in 2006 after efforts to get him to go wild failed.) It's not surprising that an imprinted wild animal would go with what he knows, right?

But what the heck is up with this one? This is a major predator. It eats, you know, meat. And things about the size of humans. And has lots of big, sharp teeth with which to dismember you. It's cute and cuddly, yes, and I'd love to snorgle it....but I would be very aware of the teeth behind the lips.

(I note that the woman in the video is not touching the seal except to make kissyface at it. I would be hard-pressed not to give it back-scratches. Seriously. This is why I am someday going to be typing with my toes.)

Tuesday Meditation: On Prayer

The Man of God (my neighbor, Pastor Paul) and I were talking about prayer. I mentioned to him that my Brother In BFE had said that he was trying to pray more; that he felt like he didn't pray enough (or maybe at the right times).

I told TMOG that my first thought in response to that was, "What? You don't pray as you breathe?"

And TMOG pointed out, quite rightly, that I am fortunate in being able to do what Buddhists call walking meditation, and what I call prayer while breathing.

I am not much of a Christian. I'm still not down, Dawg, with the primary tenets of the Christian faith, chief among them being Jesus' divinity. I studied comparative religion in college and so learned about a donkey-headed half-man, half-god who was nailed to a tree and raised from the dead three days later. I have too much doubt to call myself a Christian, though I might call myself, on a good day, a follower of Christ. (Paul-the-Pastor says that Christian disciples go all the way up on the cross, while followers stop at the bottom of the hill. I'm down here, at the bottom of the hill. Join me! I have cookies!)

And yet I pray. I pray intercessory prayers, for people I work with who are sick or hurting. I pray intercessory prayers for my patients. I pray intercessory prayers for myself, because there are things that I want to change.

Most of the time, though, the prayers are wordless. They come out of me as simply as a breath and as regularly. What began as a conscious effort when I was in school has evolved to a very simple state of being, in which weeding the garden is a prayer. Dusting the bookshelves is a prayer. Dealing with the be-damned cats is sometimes not so much a prayer as a florid curse, but I'm working on that one.

There are times when words simply won't do. Those times happen most often when I'm confronted with a person so sick, so beyond my help, that I can't even comprehend what on earth I'm supposed to be doing here. It's in those times that a still, small voice (there is a little cloud/it is like a man's hand) tells me to do the simplest thing first. I consider that an answer to a wordless prayer.

I would not be here, talking about this, were it not for the work I do.

In the main, I am a scientist. I look dispassionately on what works and what doesn't; the idea of a double-blind study is like crack. But there is a part of me that prays with every step as though I were counting the beads on a Buddhist rosary: one hundred and eight, with subsidiary strands: enough to get lost in the process.

We are all dichotomus. The friend who has been seeking Christ finds he doesn't pray enough. I, who have never sought Christ but instead raged at God and cursed Her less-understandable ideas, am the one who prays as naturally as breathing.

From Brother Cadfael's Penance, by Ellis Peters:

If it was the sharp, clear cold of frost outside, it was the heavy, solemn cold of stone within the nave, near darkness, and utter silence. The similitude of death, but for the red-gold gleam of the constant lamp on the parish altar. Beyond in the choir, two altar candles burned low. . .Now he had now true right to mount the one shallow step that would take him into the monastic paradise. His lower place was here, among the laity, but he had no quarrel with that; he had known, among the humblest, spirits excelling archbishops, and as absolute in honor as earls. . .

. . .He lay down on his face, close, close, his overlong hair brushing the shallow step up into the choir, his brown against the chill of the tiles, the absurd bristles of his unshaven tonsure prickly as thorns. His arms he spread wide, clasping the uneven edges of the patterned paving as drowning men hold fast to drifting weed. He prayed without coherent words, for all those caught between right and expedient, between duty and conscience, between the affections of earth and the abnegations of heaven. . .

Back when I was a kid,

My dad had preseason tickets to the Cowboys games. He got 'em from a colleague of his at the university, and would take me on the days when neither of us had much to do the next day (it was a long drive for a six-year-old) and his colleague wouldn't be there himself.

The seats were in row TT, for Tippy-Top. You could look down from where we sat and see pigeons flying underneath, through the windows set into the walls of the stadium. And because preseason games are generally in August and heat rises (regardless of how large the hole in your roof is), I remember mostly being extremely hot, uncomfortable, and wondering how the peanuts and Cokes the guys were selling tasted.

The first time I saw Texas Stadium, I was amazed at the size of the thing. It hovered on the horizon like an enormous egg. Dad pointed out that we were still a good five miles away. Then we were a mile away, walking up from our parking space, and I was fascinated by the steel girders you could see on the outside of the building. I had never seen construction like that, being only six, and it was the coolest thing ever.

Those were the days of Too-Tall Jones, Harvey Martin and his grin, and Tom Landry's hat. I have what's probably a false memory of looking waaaaaaaay down through Dad's binoculars, which I never quite got the hang of, and seeing that famous hat. I do recall quite clearly seeing Too-Tall make one of his field-goal blocking leaps, though Dad had the glasses at that point and what I saw was no more than a tiny man downfield who suddenly was much taller than everyone else.

Texas Stadium is officially gone now. The next time I drive to Dallas, I won't have to crane my neck and risk rear-ending the car in front of me in order to catch a glimpse of that inhumanly large hovering egg, though I'll probably do it out of reflex anyhow. I never did get to eat any peanuts or hot-dogs (at least, I don't think I did), but I did get to see Too-Tall's jump.

And maybe Coach Landry's hat. Just maybe.

And a Sunday Camelid Extravagaaaaanza! (for Joey)

Years ago, when I was still married, El Erstwhilo worked with a guy who had a llama ranch.

Llamas are a big money-maker, apparently; these folks worked year-round to keep their champion show llamas in top form. A groomed, buffed-up llama is a lovely sight. A shaggy, muddy llama after a winter of being out in the field is less so, but still charming.

A few facts I have llearned about llamas over the years: (primarily about female llamas, as male llamas are assholes and should be avoided lest you get kicked or barfed upon)

1. Mmama llamas are intensely curious and protective of their babies. If you wander into a field with a bunch of llamas, you will soon be surrounded by quiet, tall creatures with no upper teeth who will then solemnly investigate your ponytail, your shoelaces, and the collar of your shirt.

2. Baby llamas are cutest when they're about the size of a greyhound. Mama llamas will let you pet and look at their babies, but don't ever try to grab one.

3. Llamas of any age will attempt to chew your ponytail off, under the excuse of seeing what it tastes like. This is especially true if you have red hair; red is one of the few colors llamas can see.

4. Llamas are no respecters of personal space.

5. If you find yourself in the middle of a llama convention, you'd best hope you're more than five feet tall. If you're not, you'll find yourself doing a sort of desperate semaphore in an attempt to get the people who are with you to notice that you are surrounded (see number four, above) by llamas who would like nothing better to chew your ponytail, your shoelaces, and your shirt collar, cuddle up next to you, and use you as a tool to scratch the itchy bits on their sides. The baby llamas, meanwhile, will be busily engaged in repeated attempts to remove the back pockets on your jeans using just their lips and noses. Llama spit is viscous and does not come out in the wash.

6. Llamas do not smell. That is, they don't stink like horses or smell like dogs; they are quite odorless. I assume they smell in that they can perceive odors.

7. Llamas all poop in the same place. Llama poop looks like larger rabbit pellets, and because they are essentially neat animals, they have communal poop spots. Makes walking the paddock a hell of a lot easier.

8. Llamas are excellent guard animals. Here, people use them as guards (usually along with Anatolian shepherds or donkeys) for everything from goats to chickens. If a group of Mmama Llamas sees a coyote come through the fence--and here, remember that our coyote crossbreeds can reach upwards of 60 pounds--they will surround the coyote and stomp him to death.

9. Even so, llamas do not have hooves. They have big soft smooshy feet with huge calluses on the bottoms, like sandbags.

10. They chuckle and make deep, resonant sounds, almost like a purr, when they're happy. You can hear that sound most easily when you've dug both hands into a winter-roughened llama coat and started scratching, pulling out handfuls of loose hair. That activity, given the softness of llama wool, combined with the noises they make, is incredibly relaxing and pleasurable.

And that is all I know about llamas.

Sunday Stevens; Sunday Sonnet

Crank it.

From Rickety Contrivances of Doing Good:

Bed 1.1

Right now I feel less holy than a head
of cabbage. It’s too early for a break --
I’ve only seen three patients -- so instead
I’ll choose an easy room (I hope) to make
this stretch less draining. Ah, one-one’s asleep;
that worked out well. He’s middle-aged and gaunt,
cheeks sunken, forehead bloody, clothes a heap
beside the bed. He twitches. Spirits haunt
his dreams: distilled, I think. Oblivious
to wailing from next door, he snores in peace,
hands pillowing his cheek. I’m envious.
I practice seeing Christ in him, release
my anger at the mom, note mocking doubt.
So easy to be loving when they’re out.

Middle of the night note:

I just returned from the local grocery hut, the one that has a sign on an aisle directing the shopper to "asceptic juices" and "bubbling, pure, and still waters".

They have a large Caribbean food section.

In that section was a mix for Cock flavored soup. (Dude. Chicken.)

You have *no* idea how hard it was for me to put that packet down and pass it by. It would've been a perfect gift for almost everyone I know.

The comfort of other nurses (and nursing students)

Nursing is hard. (cf Barbie, "Math is hard!") It can be lonely, overwhelming, frustrating, irritating, enraging, satisfying, thrilling, scary as hell, and sometimes hilarious.

Nurses need nurses. Back when I started nursing, I was so burned out on the whole "talk about nursing all day/dream about it all night" thing that I'd done in school that I made friends who weren't nurses, on purpose. Then, about two years into the deal--about the time I started the blog, not coincidentally--I realized that there was a shortage of people I could talk to who would really understand what I did for a living. In one sense, it's like being a veteran or having lived through a natural disaster: explaining the backstory for everything that happens would take too long for a civilian audience, and dilute the power of the stories.

Once you've had somebody die with your hands on them, or brought somebody back to life with a combination of chest compressions and epinephrine, your life changes. Your worldview is never quite the same, and you never have a truly bad day again. After all, you're vertical, right? And you're not in the bed. And there are no tubes in your bladder or throat, so it's all good.

There are very few people who really *get* that. Most of 'em are other nurses, or nursing students who have seen a few things.

Abilene Rob has a brilliant description up on his blog just now about what it's like to watch a heart bloom in the cath lab, once the dye is injected and goes through the heart. Watching a brain bloom like that is what made me first believe seriously in God. (Sometimes that belief gets tested, as in cases of GVHD, but that's another post for another time.) He and I have had some nice chats about watching doctors tear open an incision line with their hands in order to evacuate clots that were cutting off important avenues for blood and air, or folks with such serious jaundice that they're dark orange.

Other nurses have consoled me when they've sensed that I've been less-than-myself. They've sent emails, or funny e-cards, or just let me know that they're thinking about me after I've, say, lost a patient in a particularly brutal way.

Sometimes I get an email from a civilian who says, "My mom was a nurse, and what you talk about is what she talked about at dinner when I was a kid. It makes me feel closer to her to read about what you do. Thanks for doing it." That helps immensely, knowing there are non-nurses out there who really get it.

We need to take care of each other. We need to take care of the students who depend on us to learn not to kill people. I'm incredibly fortunate to work in a place where nurses don't eat their young, but those places still exist. Cannabalistic nurses need to be called on their behavior and told it's not acceptable; new nurses need to be nurtured and toughened up and cut some slack. Students need to be shown all the cool shit we do, and how vital even the most boring stuff is, even at the same time they're shown why we still smile after years when we say "I'm a nurse."

Never say "I'm just a nurse." What we do is trench work: difficult, dirty, sometimes heartbreaking, occasionally dangerous. It requires skill and brains and an ability to deal with people that is tested every damn day on the job. We--you--are not "just" anything.

Be careful out there. Watch each others' backs. And pat your own for the job you do. I'm proud to call you a colleague.

Musical Friday

Make that "Punchy as Hell because I've had two hours of sleep in the last twenty-four and just lifted really heavy, plus I've got leftovers from Louie's in the microwave" Friday:

Or maybe it's "Yeah, it's a new dress; makes my ass look great, doesn't it?" Friday. Or perhaps "Thanks; my neighbor cut it last Monday" Friday. Or, on the offchance, "Quit hittin' on me; I can see that picture of your wife in a yellow dress on your iPhone" Friday.

Oh, I see: it's Fierce Friday.

Oh! And before I forget...

A revised version of the classic "Fashion Tips For Nurses" has gone up at ScrubsMag.com.

The article, if you really feel like reading it (and there's no new ageless wisdom there that hasn't already showed up here, sorry) is here.

ScrubsMag is one of the few, really-truly nursing-focused websites I visit on a regular basis. Not too silly, not too earnest: just right.

Heh.

Definitely worth clicking on. (Girls With Slingshots)

The sheets that glow in the dark, by the by, can be had from Garnet Hill. Look in their children's bedding section.

Oh, and a question...

There is a set of sheets I want.

It costs over one hundred dollars.

BUT!!

It has glow-in-the-dark Martians and flying saucers on a dark blue background.

What do you think? Turn-off, or turn-on?

Don't tell anyone, but...

I'm kind of adjusting to nights.

I know, I know.

Several Faithful Minions gave me excellent advice that was backed up by the not-natural-night-shifters I work with. I try to get at least twenty minutes of sunlight a day, flip when I'm off for more than a couple of days in a row, and don't get stressed out about not sleeping: resting is enough.

And I take multiple short naps during the day.

And then I get up and go to the grocery store at about 1 a.m., which affords me the opportunity to see the shelf-stocking guys doing a synchronized dance to some song I've never heard, and hear Yes on the overhead radio. Yes? I'll be darned.

And, of course, I cook.

Auntie Jo's Extra-Cheap, What's On Sale This Week Italian Bean And Sausage Soup

(modified, believe it or not, from the Weight Watchers website)

Take three turkey Italian sausages, or a half pound of the chub stuff, whatever's cheaper, and either squeeze it out of the skins or squish it out into a pan.

Saute over medium-high heat until it's mostly browned. Drain.

Chop a medium onion and three cloves of garlic. Dump it into the reserved sausage grease and saute until soft.

Dump onions, garlic, sausage, and a big can of tomatoes (on sale for 57 cents!) into a big pot. Add two regular-sized cans of white kidney (cannelini) beans and some water, or some chicken broth, or a mixture of both. Or you can use about three cups of cooked dried beans, but I don't keep white ones around.

Add whatever seasonings you like. The recipe calls for sage, but I hate sage, so I used more oregano and some red pepper.

Simmer until it's all combined, about as long as you want to wait plus ten minutes.

If you could get frozen artichoke hearts on sale (rare) or frozen chopped spinach on sale (common), I would bet they'd be good in this. Likewise a sprinkle of Parmesan or some small pasta, if that's your thing.

Oh, and the Annual Spring Shearing has happened. The sweet hippie chick from across the street came and cut eight inches of hair off my head; it's now jaw-length and extremely curly. I look sort of like an angora rabbit who's been on a bender and is beginning to have regrets.

And now it's time to find a decent recipe for flatbread. The roti recipe I posted didn't work for me; be warned.

"Ronnie," I say, a little louder than is natural, "Ronnie, I'm going to brush your teeth now."

Ventilator-associated pneumonia is a big (in the words of Joe Biden) fucking deal. It can be prevented with careful deep suctioning and good mouth care. And good mouth care is what I'm doing now.

Once during the shift, I use a toothbrush connected to suction. Twice during the shift, I deep-suction and swab.

This patient is younger than I am, with no risk factors for laryngeal cancer. The surgeons had gone in, expecting to take a biopsy, but had ended up having to take her whole larynx. She was a singer, before. I was a singer, before.

I shake off the associations and continue. I've already turned up her paralytic drip so she won't bite down on the brush. "Ronnie, here comes the brush. I'm just brushing your teeth, okay?"

I hate it when nurses end their sentences with the word "Okay?" I prefer statements: We're doing this, NOW. You're going to get out of bed. I am going to brush your teeth. But this time, I say, Okay?

She grimaces, but she doesn't have the coordination necessary to bite down on the toothbrush. For a long two minutes, I scrub: it's important to get the mouth bacteria off the teeth before I suction, to make sure they can't migrate past the endotracheal tube cuff and into her lungs.

"Ronnie, I'm going to suction you now. If you cough, that's okay; I can take care of that. Go ahead and cough. That's right; good cough. Give me another."

I suction under and behind her tongue, then grab the suction connected to the ET tube to suction down further, where her cough might've brought up some garp.

There is a boom-box in the corner playing her favorite music. She was a contralto, unlike me: I sang early music, with the occasional foray into Britten and the moderns. She sang the Magdalen in cantatas and led her church choir's alto-section woodsheds. I sang songs that nobody really knew the rhythm to, they were so old. She sang songs that had been written down long after the ones I sang had passed on.

They took her larynx, and left her her life. Whether or not it's a life she would want, not being able to sing, is not my problem. It is not my problem. I shake off the associations and move on.

There's a lot of crap in her lungs. I get a whole load of it out, then give her a break. I turn up the Versed, so that she won't remember any of this, and get the hell out of the room. I don't sing to my patients any more; they're generally not sick enough.

Back in the day, when I was in school, I sang to premature babies. It was my last semester, and I was constantly exhausted. The nurses would find me a pair of twins, or a baby who was so premature he looked like a monkey, with hair all over, and I would button them or him into my uniform top and lie back in a rocking chair. I'd sing them to sleep, and myself to sleep, with songs from "Jesus Christ Superstar" or "Fame" or the things the troubadours sang in the 1300's.

Since then, I have sung once, to one other person, outside the hospital. "Oh, wow, man/I ain't complainin'/Only thinking out loud/My life would've been different/If I knew then what I know now..."

I hope she can turn her singing voice into something else.

Enough with the sweet sentimentality. It's time for some bitching.

1. When a nurse charges, we give them little phones to carry around. That way, we can reach them when something like a code or a respiratory-team response happens. If you are a charge nurse, please carry your phone so we can reach you, and some gooberhead like me doesn't have to respond to RTRs with a little box and a befuddled expression.

2. If you smoke before rounds, Doctor, please flap your coat around outside so you don't choke the rest of us with your putrid cigar smoke. Or smoke better cigars. Please.

3. You're going to get a bath. I don't care what you say. You're in the ICU, you get a bath. If not now, later. Seriously. If I can smell you from the door, you might get two. Believe me, it's not fun for me, either, but it does help cut down on infection rates.

4. Neuro-breath may be the worst thing ever. It's not due to intubation--non-intubated patients get it too--and it has nothing to do with overall oral hygiene. It's a weird, awful bad breath that people who've had bleeds get. I do not know why, and I'd like to, so that there might be some chance someday of some bright person solving the problem.

5. Delicate-featured, pale redheads should never wear as much makeup as you're wearing, Doctor. Trust me on this. If you're leaving smudges on your own labcoat by turning your head, you've got too much paint on.

6. While I'm at it, can every owner of every beauty and fashion blog in the world please get over this putting-eyeliner-on-the-inside-rim-of-your-eye kick? It looked like crap in 1983, and it looks like crap now. Not only do you end up with irritated eyes and black eye boogers, you look like a tired old whore. Or at least I do. Because I believe in truth in advertising.

7. The time to schedule every single elective aneurysm clipping in a three-state area is not the week that our main CT develops some weird software problem and has to be taken apart.

8. And while I'm at it, the time to mention that oh, yeah, I forgot, I *do* have some metal implants in this arm from when I broke it as a kid is *not* as I'm sliding you into the MRI. Especially when it's a stat MRI. Perhaps especially-especially when the resident on call has already dragged his exhausted ass out of bed and come up here to admit you, and he's already cranky.

9. If your six-hundred-pound mother-in-law has just had an extremely risky gastric bypass surgery, she is not allowed fried chicken to eat. Please don't try to smuggle it in under your shirt.

10. Likewise, when we've just had a huge scare regarding Fifth's Disease and immunocompromised patients (and pregnant nurses) is not the time to attempt to smuggle your small baby into the ICU in a tote bag.

There. I'm done now. You can expect more sweet sentimentality and wide-eyed wonder next week.

Saturday Song:

Gaga!

Happy Pony Express Day!

One hundred and fifty years ago today, at about 0715, the first rider on the Pony Express left St. Joseph, Missouri on a ten-day trip to California. He carried, in addition to a pistol, letters that cost $5 at the time to send: about $100 in today's money.

The Pony Express lasted a bare 18 months, before the telegraph made communications speedier and more reliable. Still, the PE has a place in American folklore and especially a place in St. Jo's history.

St. Joseph is a medium-sized town these days. Because of the confluence of rail and river back in the day, there are a number of brick and stone houses dating to the time when brick and stone were expensive to move. There are rowhouses in varying conditions for sale, most of them in the network of streets named for St. Jo's founder's children. Any native (including my parents) can name off the streets rapid-fire and in order: Messanie, Angelique, Sylvanie, Charles...and so on. Any native can tell you how the numbered streets run, and where you can cross between Edmond and Felix to get to Fish Galore. Everybody knows where the YMCA is.

The Pony Express Museum in St. Jo is one of the more interesting museums I've ever been to. There are, besides the usual dioramas of riders and horses crossing the mountains, stuffed examples of the wildlife the riders might've encountered, including a bobcat over the door to one of the exhibits. It's a strange little dark vaguely rickety museum, but the people who work there are passionate and have fascinating stories.

After your trip to the museum, you can head over to Jerre Anne's, a venerable cafeteria which my mother swears still has the same line ladies as it did in the 1950's. You can still get merengue-topped pie and liver-and-onions there if you want, or macaroni and cheese, or string beans cooked to that classic cafeteria point of no return. Jerre Anne's website says that they'll ensure you a "memorable dining experience", and I can attest that every time I've been there, it's been memorable.

You could also go to the state mental institution and check out the Glore Museum, in which you can find exhibits tracing the history of the treatment of mental illness. It's something to see: department-store mannequins repurposed into the ice baths that schizophrenics used to be put in to calm the voices.

My family didn't do that; we kept our crazies in the attics. Now we keep them out on the street and in the living room.

St. Jo, to me, is early-morning walks with my grandparents, who always carried a bag of dog biscuits for the dogs on their walking route. It's the taste of raspberries in the North 40 (what we called an extra parcel of land Granddad used for gardening) that were warmed by the sun. It's the smell of my Granny II's attic and the joy engendered by back stairs and speaking tubes. It's the feel of the shade from the pine trees around the country club, or the ice-cold water in the Moila swimming pool, and that damned high-dive I finally conquered. It's the bone-deep pleasure that comes from knowing that my family built a whole lot of stuff here; I come from (as the man said) a long line of brick and stone.

Happy 150th anniversary, Pony Express. Happy anniversary, St. Jo. I promise to eat at Jerre-atric Anne's when I next come back.

Addendum to Friday Night Fabulous: the one post anywhere on the Internets....

....that always makes me tear up.

Yes, you are.

Friday night Fabulous

Check out the dude in the tiger suit on audience left:

*Totally* my kind of dancer.

The President gets to look at awesome stuff.

Not sure how I missed this, but Animal Review gets a thumbs-up tonight.

This is the coolest semi-origami I've seen in a very long time. Click the blue bar to the right-lower side of the page to print.

Eats! Nom nom nom the roti.

Last but not least, the only condom commercial in the world that will make you misty-eyed. Totally safe for work and Mom.

An announcement:

I'm leaving nursing.

This has been coming for a while. Over the last eight years, I've experienced a lot and learned a lot, but it's time I go back to my first love.

For that reason, this blog is going to transition to a static site between now and May, when I re-enter school to get a degree in sports turf management from the University of Mississippi. It's going to be a difficult readjustment, but I really think it's for the best.

The nursing experience will continue to serve me well, especially in dealing with mower-related injuries.

It is, really, all about blood.

There was blood on my front door. There was blood on the pedestal of the toilet, from a cut on her leg. There was blood in the sink--less blood than you might expect, but enough to stain it. There was blood on a door frame, where she'd richocheted off in coming through to the bathroom, where I put cold cloths on her ruined face.

An old friend of mine went looking for a beating and got it. Or maybe not; maybe she was looking only for resolution of the awful telephone calls her ex-lover had been making, and she didn't think he'd actually get violent again.

He did, and she showed up on my doorstep late at night, her face a mass of bruises and blood and snot, all mixing with her tears and her inability to speak.

I had never seen the damage one person could do to another, not up close without warning or intermediary. I've always seen it a couple of days after the fact, or in the clean environment of a clinic or shelter. It's never invaded my house and my peace before, not like this.

There were phone calls after that, and a conversation with a very nice cop with a twisted sense of humor, then trips to the police station and the emergency room. I found myself at home at two o'clock in the morning, making unanswered phone calls in an attempt to decompress. Eventually, unable to sleep, I called Nurse Ames, who I knew was working, and met her for breakfast a few hours later. Nurse Ames is sweet, soft-voiced, unflappable, and the toughest bitch kitty I know.

I got home to an email message from Land's End. Apparently, Sane Me had taken over and ordered Freaked-Out Me an entirely new set of bathroom towels. I needed them anyhow; the old ones are ragged and literally coming to pieces, even if they hadn't been spotted with blood.

There wasn't a lot of blood, but it wasn't blood I was prepared for or shielded from. It was blood that was born of a series of really, truly, amazingly bad decisions on the part of somebody I'd hoped would be smarter. It was blood that I didn't want to have to deal with, that should never have dripped on my floor, gotten smeared on my wall. There were myriad better ways to handle this that would've never meant bloodshed, and all those myriad ways got ignored. That left me to deal with the aftermath and the consequences and the public records and the police statements.

I am angry, and I am sick. I'm sick because the person who did the damage was methodical, almost scientific in his application of fists. I'm angry because the person to whom it was done knew better. She crawled back to the tiger cage after the tiger had taken off her leg. Nobody, ever, anywhere, deserves a beating--but you have a responsibility to your own self not to place yourself willingly into that situation when the alternative is easier.

There was no need for this. From start to finish, there was absolutely no need. I've had trouble sleeping since that night, and I've had trouble finishing both meals and sentences. I don't know what happened to my old friend; my first reaction--and I think it's a good one--was to offer help, and when that help was refused, I cut off contact. I don't need that brand of crazy coming around. Willfully putting oneself in harm's way without a larger purpose is not something I can support. Especially not when everyone around you has been campaigning against it for a year or more.

Things tonight are quiet. The dew has already risen; it's humid out, and we'll have storms in a few days, but for now everything smells fresh and new and, most of all, clean. The salvia is getting ready to explode in that way that it does, out in the front beds. Tomorrow I'll buy tomato plants and lavender and basil, scrub the remaining blood off of the grout in the bathroom, and change the sheets. In the afternoon I'll mow and plant and then lift weights.

I used to be annoyed by the amount of hair that my boys shed. Between Max and Notamus and Flashes, there's a lot of hair balling up and rolling around my floors. Now, though, I'm grateful that I can turn on the vacuum and have it be out of sight, out of mind, and gone.