An old-fashioned bitch session: What not to do if you are a patient of mine.

Remember the halcyon days of HN? Back before I was on this higher dose of antidepressants, when every little thing used to bother me, and I would expend insane amounts of electrons on complaining?

Those days are back.

Herewith, then, a list of things you Should Not Do if you are one of Jo's patients:

1. Please do not have bitchy family members.

Really. I'm doing all I can. I cannot make the patient suddenly remember that the left side of the universe exists, or that words have form and meaning. I can relieve pain, manage emergencies, act in therapeutic ways far beyond your puny imagining--in short, I am your only hope, and I am helping the fuck out of you--but I cannot work miracles. So don't be nasty. If you're nasty, I may forget that the economy is in a hole and respond in kind.

2. If you are simultaneously over six feet tall and over eighty years of age and have extinction of one side, please do not throw your remaining leg over the bed rail in an attempt to get up.

Because, honestly? That's the last thing I need. Your attempt to get out of bed without taking one side of your body along will lead to a whole lot of running around and me pulling a muscle in my ass that I can still feel two days later.

3. Don't abuse your elders.

Again, this is a tip for the family rather than the patient, but don't families make most of our problems? If you abuse your elderly aunt or mother or whatever, I will take you down.

Seriously.

I had one situation I tried to solve in the Manglement-Approved Way. Now I just dial a nine and a one and a one on the phone and go straight to the cops. You really, *really* don't want to deal with Bigtown's cops. They're used to crackheads and college students and other folks who are not amenable to reason, and they will put the hurt on your lousy geriatric-starving ass before you can blink.

4. Don't abuse me.

I am helping you as much as I can. (See point one, above.) The food service, doctors' rounds, and way the room is decorated is beyond my ability to control. And yes, I am making bank taking care of you.... .... ....which is the only thing that's keeping me, right now, from strangling you. I am here to be the last, best defense against mistakes and complications that might harm you, as well as to help you heal. If you're nasty, I'll notice a sudden dimunition in my enthusiasm. I'll still do my job, but I might not be as happy about it.

5. Don't smoke weed in your room, or consume large amounts of hydrocodone cough syrup, or otherwise fuck with your care.

I cannot tell you the number of otherwise intact people I've had through my hands in the last eight years who've done something really, really dumb that interferes with their care. From the woman who used to bring back homeless people for parties (and the homeless folk in the Miracle District are hardcore) to the weirdo who pulled out a crack pipe during his assessment, I have officially Seen Most Of It.

If you have to ask me when you can go back to snorting coke or taking large amounts of meth, there is a problem. I don't care what you do post-discharge: just please don't ask my advice or do anything stupid while I'm with you. Okay? Thanks.

Thus endeth the trip down memory lane. Coming soon: The Ballad of Pinky Prosthetic and Fun Links To Read!

I need help remembering the title of a book.

It's a children's book, illustrated with gorgeous pastels. It's about a paleontologist who works in a museum, and suddenly the dinosaurs in the museum displays come to life, or some dinosaurs show up, or something (I can't recall, exactly). The paleontologist adopts them and takes care of them.

The two things I remember clearly are these: First, that the paleontologist is a short little woman with grey hair and round glasses (you never see her eyes). Second, at the end of the story, she's sitting in a rocking chair, reading a bedtime story to the dinosaurs ranged around her. The stegosaur has a blanket over his back, through which you can see his spine plates, and the tyrannosaur is sitting in the corner, I think with a teddy bear in his little-bitty arms.

Does this thread any beads in anybody's mind?

Yeah, dammit, I'll get back to nursing later. It's Spring.

Last night I let my Geek Flag fly, and lo, it was good.

Somehow, a group of coworkers who are not at all nerdy decided to all come along to a definitely nerd-focused event at a local museum. Among them was The Cute Neurosurgeon, who paid me the biggest compliment I think I've ever gotten:

As I was listing titles of hard SF books I like, he yanked out his cell phone. He was noting down titles, like Asimov's Before The Golden Age. The Cute Neurosurgeon was taking interest in what I like to read, guys.

Just looking that sentence makes me nod my head, smile, and think about ordering that Starfleet uniform tunic (Science Officer, of course). Although a Security tunic would allow me to leave a party early without anybody noticing or caring....

Two cats for sale, cheap.

I woke up this morning at one o'clock to the sound of the cats going insane. Why were they going insane? Because it was windy overnight, and wind is apparently one of those things that your average kitty-brain Simply Cannot Handle.

Wait.

Make that SIMPLY CANNOT HANDLE. As in, we must ricochet all over the place and scream and hiss at one another and bug the dog and generally make life hell, and when we're done with that, we'll launch ourselves onto unprotected parts of your body with claws out.

So I laid there for a few hours, unable to get back to sleep (wall wall wall wall ceiling ceiling ceiling other wall wall wall) and finally got up about four, ate some soup, and texted Attila to ask please can we reschedule today's workout for tomorrow?

Then I showered and went to the grocery store and generally did all the things that normal humans do, except not usually at six ack emma, and played around online for a while and tried to make head or tailio of this thing that the PTBs at work want me to do, and generally ignored that I felt like crap.

Then I took a nap. And woke up, still feeling like crap.

What do you do when you feel like crap? Why, you take apart your secretary and then clean house like a maniac. That's what you do. Later, perhaps after I eat something more, I'll wash down the secretary with TSP and degloss it and generally get it ready to paint. This is a wild hare that I got last week, but now I've got all the fiddly little bits and bobs and hinges and escutcheons off, and I kind of have to follow through.

Otherwise I will have nowhere to store my tax paperwork. Or the cats. I'm going to put the cats in the drawers of the secretary, then PAINT THEM SHUT.

Wish list.

A bidet. A real bidet, not one of those Toto toilet-seat ones.

A heated towel rod.

Living somewhere that winter really means *WINTER*, not just six inches of snow atop four inches of ice and then it's gone by Wednesday.

Bonus to the above: Max was *so happy*!!!11!!ponies!! when it snowed this year, he could hardly stand it. His arthritis didn't bother him a bit.

Learning Capoeira, or whatever that Brazillian martial art that requires lots of upper-body strength is.

Singing again. My singing voice went from okay (pre-surgery) to fucking fantastic (six weeks post-surgery) to fucking bloody awful (today) because of the reaction of my head to the prosthetic palate.

Radiant heat under my wood floor, varnished trim with white walls, and a set of doors that are all a foot wide and as tall as the room, that I can open to let the air in. Curling up on the world's weirdest cotton mattress, under a down comforter and a fucking REINDEER SKIN, in Denmark, with the door open so I could watch foxes run past in the back yard of a suburban house, is one of my favorite memories. The tea they had for breakfast, not so much.....but the foxes? Pure bliss.

"Oh, there's a fox" Renate said. "A fox?" I thought. Apparently foxes are not that big a deal in Birkerod.

Not having to think about my palate.

A new palate. Please, God, let somebody design and make a new palate that works like the old one, some time within the next twenty years, so that I can have my palate back.

No more cancer.

A date. Seriously.

Max would like a week free of his collar, a new chewy bone ($14.95 at the local grocery), and nails that don't need to be trimmed by the Horrible Trimming People Of Doom at the vet. He would also like a neighborhood free of the ice cream guy, but only because he's getting tired of chasing him.

Spring: it's what's for dinner.

This morning I had a pleasant (yeah, right) workout with Attila, who has agreed that my current workout plan isn't working out, so we're going to heavier weights and less cross-training. Then I mowed the back yard and groomed Max.

It's gotten hot here earlier than usual, so Max-Zoats is blowing his coat earlier than usual. Since his undercoat is white, it looks like an American Eskimo has exploded all over the back yard, and every bird from sparrow through robin to hawk is sporting a Mark Twain moustache as they pick up fur to line their nests.

Which, speaking of hawks, is kind of a weird deal. There was a sharp-shinned hawk overwintering in the neighbors' pecan tree (at the very edge of its Southern range) this winter. She was driven out by a breeding pair of red hawks, who have built a nest in the tree. . .yet the other birds and the squirrels who live there seem positively blase about having a pair of carnivores in the same house, was it were. The red-cockaded woodpeckers are back in their old spot, above the first crook in the branch, where one big limb is semi-dead, and the squirrels have squirrel babies in part of the tree, where the limb fell last winter during that big storm we had. It's like a condominium filled with adherents of two different political philosophies: I keep wondering when the massacre will start. Maybe, for the hawks, it's like living next door to a restaurant?

Tomorrow I simply MUST go buy tomato plants. Even though I don't have a decent garden plot this year, as garden plots in Texas have to be started in October and I was a little busy, I have to grow tomatoes. In my family, the unwillingness to plant tomatoes means you're going to be in a little plot of ground yourself before too long. The only time I worried about my Sainted Mother was when she told me she hadn't bothered to start a garden one year; the situation has since been remedied, and she now grows enough tomatoes for all of Seattle. It doesn't matter if you get them in too late and they don't set fruit (as mine didn't year before last, as I'd bought from a place up north); the point is that putting tomatoes in the ground means that you plan to be around to eat them on home-made white bread with mayo in a few months.

My tomatoes, by the way, will be going in the front beds, amongst the Russian butterfly bush and the American butterfly bush and the rose bush and the oregano and rosemary that are, despite a hundred-year drought, going strong. The back beds I'm mulching now in preparation for fall crops; I'll just have to buy my zucchini and pickling cucumbers at the farmer's market.

Which reminds me: There is only one thing I dislike about living in Texas at this time of year: raspberries.

My grandparents (Mom's parents) had what they called the "North 40" but was actually a plot of land that adjoined their back yard that they'd bought, far-sightedly, when they built their house up in Missouri. Granddad used to grow raspberries along the fence line. Mom would throw me out of the house early in the morning and tell me to get breakfast from the garden, so my foraging instincts were sharply-honed from an early age, and one of my favorite things was to go out after a morning walk with Granny and Granddad, before breakfast, and eat raspberries from Granddad's canes.

You can't do that here. Blackberries, yes--they grow like freaking weeds, and hide snakes of all sorts and produce fruit like there's no tomorrow. Plums go crazy. Herbs of any sort grow like it's ancient Greece and they have a walk-on role in one of Homer's plays. But raspberries? Grow like crazy, then fail to fruit because it gets too hot too fast. Whereas, in Seattle, you can (as I did two summers ago) buy a flat of raspberries at the farmer's market for five bucks, then turn to your mom and ask, "Are you getting any for dinner tonight?"

A sun-warmed, ripe, musky raspberry is better than sex, better than being cured of cancer, better than eternal salvation--and combines elements of each.

Raspberries and hawks nesting and Max barking in the back yard without his collar on and a brown thrasher in the compost pile: proof that God loves us and wants us to be happy.

Gratuitous Ingrid Michaelson:

Thursday Morning Remedy:

Shamelessly stolen from Jezebel:

BABY ELEPHANTS IN A KIDDIE POOL OMG.

Edited to add: If that's not doing it for you, try this: Fifty Photographs of Basset Hounds Running.

March extra moneygrubbin': Y'all know how I feel about the critters:

http://japanearthquakeanimalrelief.chipin.com/japan-earthquake-animal-rescue-and-support

This broke my heart:

via The Daily What (Which reports that both dogs are now in a shelter and doing okay; but what of the rest of them? What if it were the Max-Zoats out there, looking for his kitty-friends? and now I'm crying again...)

Answers to the Further FAQs....

1. Parathyroid and thyroid issues: I know absolutely smurfling nothing about that thing in your neck that runs your metabolism. I'm sorry. I know I should remember more than Circumoral Tingling Is Bad, but honestly? I haven't dealt with anything thyroid-related in years and years and am therefore highly underqualified to say more than Circumoral Tingling Is Bad.

2. Work shoes: Right now I'm wearing the same pair of MBTs I've had for omigawd has it been six years? with Birkenstock insoles. Basically anything with Birkenstock insoles is what I'll wear to work. My only requirements for work shoes are that they be sturdy, closed all the way around, and not made of plastic.

3. The best way to chill a beer quickly is to put it in ice and add water until the mixture is slushy. Leave it in its container, of course. The best way to chill a beer slowly is to put it on the bottom shelf of your fridge and leave it alone for several hours. Please do not ever pour beer over ice. Thank you.

4. Head positioning for various types of strokes:

For bleeding in the brain, you want the person's head *up*, so stuff that's not supposed to be in the brain, like free blood, can drain. A bed angled so the head is up at least 45 degrees will also help decrease intracranial pressure. This rule is, of course, subject to the usual caveats about exceptions and modifications and ventriculostomies and pressure-monitoring bolts.

For a stroke caused by a clot, you want the person's head *down*--no more than, say, 30 degrees or so above horizontal. This is because you want the area around the clot to stay well-perfused so that damage is minimized. If you have a patient whose embolic stroke has converted to a hemorrhagic stroke, as sometimes, happens, then you have a nice little juggling act between watching their neurological status and keeping their ICP stable on the monitor.

5. How the hell I got here in the first place:

I had planned, after nursing school, to get a job working general med-surg for a couple of years and then head back to school to become a nurse practitioner in women's health. I applied for the job at Sunnydale on a whim, never imagining that they'd actually hire me. They did. In fact, they offered me the job before I'd left the hospital after my interview.

Then I discovered that I really like brains. I like the things that they do when they're healthy, and I like the weird ways they behave when they're not. I like spines, too, and all the jacked-up stuff that can happen if you partially or completely transect them. I also like all the things that can go wrong with peripheral nerves, or demylenating disorders, or crazy-ass injuries to tiny bits of people's heads. I stuck around for more than a couple of years. Now that Sunnydale's got that portrait of me up in the attic, I think I'll be sticking around a little longer.

6. I get a lot of questions, not just in the comments, about dumbass coworkers and eyerolls. In answer to the emails and the comment questions, I have this to say: I'm lucky to work with only a couple of people who raise homocidal urges in me. Those people I avoid as much as possible; it's the only way to make it through the day. It helps that I'm not alone in my avoidance, as nobody else can stand those folks either.

If you're stuck working with somebody who drives you 'round the bend, it's important to remember something: You Are An Asshole, Too. You Make Mistakes, Too. You are sometimes that person that nobody can stand. It's important, then, to treat even nutso coworkers with respect and kindness when you can't avoid them completely. I'm not sayin' here that I'm perfect, that I've never yelled at anybody--but I am saying that I'm learning (slowly) from my fuckups.

I try to kill people with kindness, especially if I really dislike them. Then I come home and I blog. Perhaps, if your work situation is really awful, you should start a blog!

7. The story about the neuro attending was, sadly, true. I should mention here that ever since then we've gotten along famously. Apparently all he needed to behave decently was a little bite-back.

8. On woodchucks chucking wood, and a formula for determining amounts of wood chucked:

Obtain one woodchuck. Allow said woodchuck unlimited access to a given number of linear feet of wood for twenty-four hours. Measure, at the end of that time, the amount of wood chucked by one woodchuck. Extrapolate from that number the amount of wood chucked by a group of woodchucks, controlling for variables such as size of woodchuck and number of teeth per animal. Divide that result by the sine of the number of angels that can dance on the head of a pin, and you have your answer.

The *tough* question is the one posed by Calvin to Hobbes: "How many boards would a Mongol hoard if a Mongol horde got bored?"

The identity of illness.

As I was leaving work last night, I ran into somebody who took care of me after surgery and whom I'd not seen since. She squealed and we hugged, and she said what everybody--even my surgeon--says: "You look so *good*!"

Everybody says I look good. The people I've known longest, since before I grew my hair out for Beloved Sister's wedding, look at my buzzcut with satisfaction and say that I'm the Jo they knew "before".

I am the Jo they knew Before. I'm also the Jo that's here After: after diagnosis, after surgery, after PET and MRI scans and Dilaudid PCAs and the long-to-me-but-actually-short recovery.

I look good, if good is still the forty-pounds-overweight, silly, rubber-faced me that you've all grown used to. I feel good--better than I did before surgery, that's for sure. I take more care in what I eat and what my habits are and how hard I work out, and I have a lasting (I hope) gratitude for things like sunny days and unexpected afternoons off. All in all, things haven't changed that much.

(That is, by the way and parenthetically, the weird thing about a diagnosis like CANSUH. You expect that your life or your *self* will change in some way, but it really doesn't. Not in any way that you can put your finger on, anyhow. Which is kind of disappointing, and kind of reassuring. The human animal is immensely adaptable.)

But now, added to all of the stuff that Jo was before, is Jo the Cancer Survivor. That's an identity I'm not completely comfortable with for two reasons:

First, mine was a baby cancer. Compared to people who had to have radiation and chemo or who lose their hair for real or who fucking DIE, mine was the sort of cancer that slumps along and doesn't do much. I don't feel like I can really claim a Survivor Badge, because what I went through? Really wasn't all that bad.

And second, and this is the hard part, the five-year mark means nothing with PLGA. It's most likely to recur in years seven through twenty...which means that it's most likely to recur just when the plans I'm making are finally coming to fruition, or after I think it's gone for good. I try not to be pessimistic, but I wonder: am I celebrating too early? Should I be making plans for the day when the rest of my mouth is gone?

Cancer is gonna be a part of me from here on out. Even if everybody I work with changes jobs, even if I move, even if I shut the blog down and delete six years' worth of posts, I'll still have it in my head that I've had cancer. I'll have it in my head that it could come back.

I'm not sure how to integrate this illness into my identity.

All Play And No Work Puts Jo Behind The 8-Ball.

I have three deadlines to meet and no clue how to meet them.

However! This weekend I ate huevos quatro quesos with Pal Joey from Montreal, scratched a pony on his neck in such a way that his winter coat started to blow and he stretched his neck waaaaay out, loved on a number of Greyhounds, one of whom was a twin to the late lamented Bucky, and tapped my feet to Irish fiddling.

I also trimmed a tree with a pole saw (yay me) and chopped down several feet of brush. I drove all over Bigtown, got lost only once, and managed to get Aforementioned Pal Joey to the airport after a long weekend of driving, mojitos, more driving, and traffic from hell. It was like a Jedi mind trick: You Must Go South To Go North.

I also hung out with three-quarters of the Fearsome Foursome, met the biggest damn dog I have ever seen, and ate much Fair Food. So it was okay.

Especially the tree-trimming part. I am much more capable than I ever dreamed I was.

Jo FAQ

Welcome, readers from ScrubsMag and beyond! I seem to have some new followers these days and am getting lots of emails into the bargain, so I figured I'd do the triennial FAQ, version 3.whatever, to introduce you to the wonder/trainwreck/amorphous thing with flagellae that is Head Nurse.

Who are you?

I'm a middle-aged grouchy critical care nurse somewhere in the heart of Texas.

Where do you work?

Not tellin'.

No, really. Dallas?

Nope.

Houston?

Nope.

San Antonio? Austin? Bridgeport? Del Rio? Tyler? Pine Bluff?

No, nyet, nope, nay, and that one isn't even in Texas. Give up.

Are the stories you tell true?

About my animals, always. About my patients, usually--but I've changed dates, switched sexes, obscured and obfuscated diagnoses and treatments, and generally anonymized them to the Nth degree.

Who are all these other people you talk about?

You might've noticed that HN has a recurring cast of characters.

Nurse Ames and Pens are two of my best pals in the world. Stoya is a coworker who resembles (physically, not habitually) the porn star of the same name. Dr. Heron is a neurologist I work with; Dr. Crane is my own mouth-obliterating surgeon. Dr. Elf is the guy who makes the prosthetics I wear. Der Alter Jo is my namesake, opposite number, sounding board, and friend.

Beloved Sister, Sainted Mother, and Honored Father ought to be self-explanatory. Max, Flashes, and Notamus are (respectively) a very large dog and two brother cats with attitude. Attila is my trainer. The Brother In Beer and Abilene Rob are two close male friends. Rob also has a blog; if we're all very good and mind our manners we may get another post out of him someday. The Man o' God and His Lovely Wife, and Matt and Beth, are my neighbors. I think that about covers it.

What exactly do you do?

Brains, spinal cords, and peripheral nerves. My main focus is neurology and neurosurgery, with a special emphasis on degenerative motor neuron disease and stroke.

What do you do for fun?

I stand in one place and lift heavy objects over and over. I cook. I garden. I go out with friends. I play with Max and the cats. I drink good beer. I read. I sing loudly and off-key in the shower.

Oh, my God. I can't believe you wrote X about Y. I would hate to be one of your patients. You suck. I hope you die horribly.

That isn't a question. You're aware of that, right?

Look: If you're expecting unadultrated sweetness and light from a nursing blog, you've got the wrong blog. There is no other job, except maybe working with abused children/elderly folks/animals, that will make you hate humanity faster. There's also no other job that'll make you love individual people more deeply, or be more grateful to be doing what you're doing.

However, I'm not gonna lie and say that I love everybody or that I'm perfect all the time. If it pisses you off, go elsewhere: it's a free Internet. Please don't waste time sending me nasty, threatening, or abusive emails, especially if you can't spell. Thank you.

Are you married? Boyfriend?

No and no.

Oh, so *that's* your problem.

That's not a question either.

Will you post an advertisement/review for my shoes/scrubs/weightloss product/sex toy?

Head Nurse is an ad-free and paid-endorsement-free zone. Any product reviews I do I do either because I've bought the thing I'm reviewing myself or because I've worked out a deal to donate any moneys from the review to charity.

What's up with the fundraising links and moneygrubbing, then?

Those got their start shortly after I was diagnosed with oral cancer (see September 2010's posts through December of the same year for details). It became obvious that people with oral cancer were sometimes unable to afford treatment or equipment that they needed, so I decided to hit up the readers for cash. The response was amazing: we as a group raised more money than was really practicable for me to keep track of, so I took the PayPal link down.

Since then, several individuals (Tashi and Wash, whose blog is linked above) and organizations have come to my attention who need dinero. I post links to worthy causes or people as I see fit. Everything here is my own fault.

Got any further disclaimers to make?

How kind of you to ask!

Please note that all content on Head Nurse that is not otherwise licensed is licensed under a Creative Commons agreement. What this means is that I don't mind if you repost or borrow things as long as you check with me first. If you repost my work as your own or borrow things, Kharma will get you. All patients, doctors, and nurses are fictionalized to within an inch of their lives. What *that* means is that if I write about something that happened "yesterday", it could easily have happened last week or last year or eight years ago. This blog is not intended to be used for, and the author of this blog will not give, advice on medical matters. If you have a problem, see a professional instead of some schmo on the Internet. If you don't like things that are tongue-in-cheek, you should go somewhere much more earnest.

Everything here is mine unless otherwise credited. If I've fucked up and quoted you without attribution, please let me know and I'll rectify it ASAP. Likewise, if I manage to make a real howler either in spelling or information, tell me. That means that everything that I get wrong is my own damn fault, while everything that turns out okay is entirely due to the goodwill and grace of other people.

Any other queries? Ask 'em in the comments.

Is she outside-in or inside-out?

I've been thoughtful lately.

Not the sort of thoughtful that sends flowers for no reason, but the kind of thoughtful that explores ethical problems.

If you were taking care of a patient who'd specifically asked--when he could talk--for certain things *not* to be done, and you'd heard a doctor promising his wife that those certain things, if done, would only last for a couple of days and give that patient a chance at recovery, and you knew that statement was a bald-faced lie, what would you do?

*heavy sigh*

Here's the deal: a nice guy, about my age, came in with a nasty infection secondary to a recent bone marrow transplant. It was a MUD, not that that matters; what matters is that he and his wife had agreed on what was appropriate in terms of heroic care and what wasn't. He was able to talk for the first two weeks of his hospitalization, so we had a number of discussions about allowable things and dis-allowed things.

The poor guy took a nosedive a week ago. When I say "nosedive", I mean nosedive in the sense that only somebody with a platelet count of fifteen (not fifteen thousand) and a white count of two (not two thousand) can take a nosedive. It was sudden, unexpected, and horrible. I watched as the docs intubated him nasally because he was too jacked up to intubate in the usual way, then spent hours suctioning him so that he didn't choke on the blood he was oozing from every orifice.

That was something he and his wife and I had agreed wouldn't be done. Yet, because his doc said Oh, What The Hell, We Do This All The Time And People Are Better In Seventy-Two Hours, his wife gave the go-ahead.

I knew the doctor was lying at the time. I've never seen anybody get better after they've been intubated in this (much more complex than I'm telling you about here) situation.

The textbook response would be to schedule a meeting with the family and the doctor and lay out your concerns there. The textbook response never, in my experience, works. The Manglement response would be to involve Manglement, but again, Manglement never responds in the way you might feel is best for the patient.

Years and years ago, I had a guy in who was obviously actively dying, yet his docs (the same doctor, come to think of it) weren't willing to let him die. They kept pumping in fluids and pulling labs and running antibiotics, and it took me having an actual shouting match with a resident (me as a new nurse of less than a years' experience!) to change the treatment plan.

I'm not any less willing to shout now, and I'm not any less sure that what Dr. X is ordering is a bad idea, capital B, capital I. It's just that, in a critical-care unit, the stakes--no, the expectations--are different. You can't let people die with dignity in the CCU, because it's seen as a defeat. On the floor, where people die more often without the sort of technological insults they sustain in the CCU, they see dying differently. At worst, it's a neutral ending to a battle that's been hard-fought with honor. At best, when you have the privilege of laying a hand on a patient's chest to feel their heart stop, it's a victory over cruelty and unreasonable hope.

If I ruled the world, things would be different. People would still die, but it'd be seen for what it is: a transition in the same way that birth is a transition. I've talked before about midwifing the dying, and that still holds true: dying as an active process is just as much work as is giving birth. It's the lying there intubated with drips going and a tube in your nose and a tube in your bladder and more tubes here and there holy shit that deprives you of the chance to do your work.

And that, friends, is the problem with critical care: we do not allow things to take their natural course. There are some things we can intervene in, and should: brain tumors, spinal problems, you name it. The trouble comes when we start keeping people technically alive when they shouldn't be.

I do not know what to do. For the first time in my practice, I am at a loss. This is a bad feeling.

In which Jo feels rather more optimistic. (Now with improved spelling!)

Cancery McCancersons update! Well, not really. More like Evil Space Creature Obturator Update:

The interim obturator is GO. Dr. Obturator Elf is fitting me for a functional tracing later this month, and then the traced device will be casted in acrylic, and I'll have an entirely new roof-of-mouth.

Now, for the preceding in English:

When somebody like Dr. Crane comes along and removes the top of your piehole and most of the back of your throat, things change. Chief among those changes is your subsequent inability to talk without sounding like you're stuck at the bottom of a well with both a cleft palate and a sprained tongue. Seriously, I sound better without the prosthetic than I did just after surgery, but I'll never be able to be intelligible without it.

Also, because the throat is made up of a number of layers of muscle which heal at different rates and adapt to the obturator/speech bulb combo in different ways, there have to be different devices (I love that word: device. Sounds like an evil 1950's scientist is working on me) to cope with those changes.

The first obturator, the one that looks like a big pink bug, is called the surgical obturator. The second, the one I'll be fitted for in a couple of weeks, is an interim obturator. The big differences between the two are materials and size. The first obturator was/is made out of a softer material, to help coax the musculature in the back of my throat into the shape it'll need to be in to handle the later prosthetics. It's also freaking HUGE, because, well, there's a big ol' hole in the back of my head.

This second obturator is already smaller, and will be made of clear acrylic. It's not porous and will therefore be much more hygienic in the long term.

The interesting bit, though, is how the whole fitting process works. Check this out:

The back of your throat is really mobile. It changes shape when you talk, eat, swallow, sneeze, or even turn your head. Even going from sitting to standing changes its shape a bit. Therefore, you can't have a solid, smooth piece of plastic sitting back there; the muscles wouldn't "grab" right, and the plastic would slide around. You'd have leakage through your nose and sound, again, like somebody with a badly stuffed up schnozz who's at the bottom of a well.

Unfortunately, because you're making something that has to last for months or years, you can't have a nice, smooshy lump of, say, Silly Putty atop the obturator. It has to be rigid. The way it gets fitted, then, works like this: You wear the preliminarily-shaped obturator with a thick layer of wax on it for a number of hours, going along in the noiseless tenor of your way, and the wax shapes to the average configuration of the surgical deficit (or "big ol' hole").

In a way, it's like any other prosthetic: you take the average of all the activities that the device will help you with, and try to incorporate those activities into the device's finished shape. The difference is that this prosthetic is much smaller than an arm or a leg.

During the last appointment, Dr. Elf made a general outline of the big ol' hole with thermo-reactive plastic mixed with diatomaceous earth. (Why diatomaceous earth, I don't know; I think it has something to do with stabilizing the plastic, kind of like cornstarch thickens gravy.) The mixture that got globbed atop the base of the obturator and shoved into my mouth tasted just as lovely as you might imagine, but we ended up with something that sort of looks like the back of my throat, but about fifty percent smaller than it was just after surgery. The wax that Dr. Elf then used to make a preliminary functional tracing thankfully has no taste at all--and showed that the angles where my throat muscles come together have closed substantially in the last few months. The new obturator will be about half the size of the old one.

This is exciting as hell. I'll never be able to function without a prosthetic palate, but at least it won't be something that needs its own seat on an airplane. It also explains why my voice quality went from okay to fantastic and then back to sort of nasal and gurgly: the old prosthetic (the one I'm still wearing, the pink space bug) is now too big, and gets knocked around by my toned, rippling throat muscles. I have the equivalent of a Fitness America contestant in the back of my throat.

The weirdest part of all of this is how it's changed the shape of my face, to talk with this obturator widget. For a while, I had an even bigger set of lips than normal, because talking took a lot of work, lip-wise, to enunciate properly. Now I've got a sizey lump of muscle that looks a bit like a double chin, since it takes more tongue-muscle at the moment to talk/swallow/whatever. Dr. Elf assures me that all of this will fade back to normal as the process continues.

I'll post pictures of the two obturators compared and the second one in process if he'll let me photograph them. It's really cool.

And that, Chickadees, is why I feel vaguely more optimistic these days about this whole shebang.

March Moneygrubbin: Help a woman in need.

More than half of the women who have abortions in this country already have kids.

A whole bunch of women don't have the money either to have more kids or to have an abortion. Hell, a lot of 'em don't even have money for birth control (or bus fare to get to the Planned Parenthood in the next town that has free condoms, but which closes at three o'clock during the week).

Texas Equal Access is a fund that provides small grants--from fifty to a hundred bucks--directly to clinics that perform abortions, with the agreement that that money will go toward reducing the cost of a woman's abortion. It's only given after the woman in question has had a pregnancy terminated, so it's not like the clinics are rolling in money. Said women also have to satisfy certain conditions to demonstrate financial need.

(Side note: if you do a real-terms comparison of what it cost to get an abortion in 1980, when the only clinic in my county opened, and the cost in 1999, when it closed, then you'd see exactly zero profit. This is the norm for abortion providers in this country, the majority of whom are small, independent practitioners, who do reproductive health work as a sideline.)

There may be no worse feeling in the world than sitting at work, waiting for a call from your partner, hoping that he's been able to get the money you need out of the bank or from friends or relatives, because neither of you have a credit card. The woman whose partner isn't able to find the cash will be helped by your donation, so she won't have to shout "FUCK" across her workplace when it looks like she'll be pregnant for another two weeks, and go to a different clinic, and have a different, more involved procedure, to get rid of a pregnancy she'd tried to prevent and never wanted in the first place.

It's ridiculous that women have to go through this to obtain a safe, legal medical procedure.

Help a woman. Being pregnant when you don't want to be is like being an animal in a trap; chewing your own leg off is an understandable and reasonable reaction.