Congratulations, new graduates! You'll be fine.

Really.

You won't kill anybody.

No, I mean it. Seriously. Just remember Jo's First Rule of Nursing:

If you have to fuck with it, it's wrong.

This was brought home to me in a big way just yesterday, when I had a patient with one of those don't-stop-it-or-they'll-die drips. The pharmacy sent a bag with a certain concentration of drug, and that matched the doctor's order, but the pump....was fucked. I couldn't make the drug dosage on the order match the drip rate in the pump's library, no matter how much I fucked with it.

So I stopped. Because fucking with it until you can't remember exactly how you got to where you are means it's wrong. I got another pump, with a different drug library, and I reprogrammed that pump, and everything was fine and dandy.

Advice for the new nurse, graduate nurse, or intern, gleaned from five minutes' worth of actually paying attention over the last decade:

1. Do not freak the fuck out.

There will be time to learn everything you need to know. There will be people who are willing to answer your questions, and people who will have your back (even if you don't know it at the time) and people on whom you can call when things hit the fan. You are not doing this on your own. Everybody has been where you are; sometimes we feel like we're right there with you once again.

2. Actually killing somebody means that a lot of things have gone wrong.

Therefore, it's extremely difficult. With any medication or procedure or what-have-you, there is a string of quality-assurance checks that happen that are meant to ensure that you, New Nurse, will not make a mistake. Trust the procedure, but verify. Which brings us to:

3. Be sure to ask for help or advice when you're not feeling confident.

I ask for help every damn day, and I have been doing one thing for eight years. How many of you have done one thing for eight years? Show of hands?

Yeah. That's what I thought.

The point here is that the human body, even independent of doctors' orders, can do crazy shit with very little warning. Don't bully on through if you don't feel good about it. It's worth it to look like an idiot, or to take the extra five minutes to verify a policy or drug dosage.

4. This ain't no party; this ain't no disco; this sure as hell ain't no fucking Grey's Anatomy.

Don't sleep with your coworkers.

I don't care how cute that nurse is: you're asking for trouble if you have a horizontal relationship. Ditto the resident, the intern, the attending, the other nurse's boyfriend. Just don't. If you must have a relationship with another nurse--a decision which might lead to endless arguments about who had the worse code that day--make it a nurse you don't work with directly.

I, and your other coworkers, thank you.

For this one, Rob, I'm looking at you:

5. Don't work too hard.

There is time. Coco Chanel said that there was time for love and time for work, and no time for anything else. If you adhere to that philosophy, you'll be a crappy, burnt-out nurse in no time. I know you have loans to pay off and an electricity bill that's two months overdue, but you can't kill yourself the first six months out of school. Any knowledge or insight you gain will be overwhelmed by stress hormones.

Take some time to rediscover what you loved before you started drinking from the firehose that is nursing school. Remember what it's like to wake up in the morning (or evening) with nothing to do all day (or night). Read for pleasure. Go catch a movie. Spend a couple of hours doing nothing but daydreaming and petting the dog. It'll not only help you stay healthy, it'll make your brain more able to retain information, true fact!

You're done. You've walked the stage, you're about to take the NCLEX (and you'll pass, I swear), you're getting ready to start a hell of an adventure.

Congratulations! And I look forward to working with you.

I'm really looking forward to a week off.

It will come as no surprise to anybody that people can be stupid.

I wonder why it still surprises me sometimes. The level of inexcusable, inexplicable, unbelievable stoopid I've encountered lately has left me looking forward to having holes punched in my belly. At least I'll get a nap, and at least I'll be at home for a week.

People, please:

If we tell you Papa mustn't drive after his stroke, that means Papa must not drive. Not "not drive long distances" or "not drive a Toyota" or "not drive to the store." It means that Papa now lacks decision-making ability, part of his visual field, and most of the use of one side of his body, and Must Not Drive. Even a big car, even for short distances, even in town.

This is a hospital. It's in the inner city, on a busy street. People come in and out and through on a regular basis. Some of them have business here, while some are merely cutting through our lobby in order to shorten the trip from point A to point B. We can't predict who's going to be coming in and out. Therefore, it's a very bad idea to leave your computer, your iThingy, your purse (no, I am not kidding), your children, *whatever*, unsupervised for long periods of time in the ground-floor lobby.

Likewise, if you choose not to reveal that you have valuables on your person (which means I can't inventory them and lock them in the safe), I am not responsible if your aunt, cousin, ex-husband, or daughter takes those valuables away while you're laid up in the bed. It says so right there on the admission sheet.

No matter how long ago you had that reaction to that drug, it's still an allergy. If penicillin made your face swell up and your breathing get funny six months ago, it's likely to do the same again. Please tell me these things. While we're at it, tell me if you have a food allergy. Some things I can predict, like that the guy whose rabbi visits twice a day might not want bacon on his breakfast plate. Other things, like that you're allergic to nuts, are not immediately obvious.

If Mama is ninety-plus years old with multiple medical problems and occludes the big arteries in her brain, then converts to a hemorrhagic stroke, it might be time to let her go. I do understand that this is a horrible shock to you and that it's tremendously difficult, but please: you are not doing her any favors by leaving her on a ventilator and pressors and a tube feed for three weeks. There is no Mama in there any more.

Check a blood sugar before you give insulin to your patient. That way I won't be trying desperately to start an IV in a stenosed, disappearing vein that belongs to the person with a blood glucose of 20. (Jesus H. Creeping Roosevelt: how many times do I have to say this?)

And, finally: I know I am strong. I know there's a certain amount of noblesse oblige that comes with being stocky and squat and able to lift heavy things. That doesn't mean, however, that if you ask me to "help" move your patient from the bed to the chair, you can stand by quietly as I lift your patient bodily, pivot him (with only toe-touch to the floor on his part), and place him in the chair by myself. Although I am so feminist that I glow in the dark and kill noxious weeds at twenty paces with only a glance, I will be doubly pissed off if you're a man and bigger and stronger than I am. Help means help. Picking up a person and slinging him over my shoulder means my back hurts today.

Do you suppose, if I stay under general anesthesia long enough, that the collective IQ of the planet will have gone up a few points by the time I wake up?

I just won five bucks.

Although I doubt Laura-Loo will pay, because she wasn't all that keen on the bet in the first place.

We had a patient with symptoms of psychogenic origin (English: crazy as a pet raccoon) discharge home the other day. I bet her that the patient would call within forty-eight hours with either a problem or a claim that we had failed to return some of their (controlled substance, held in a lockbox) prescriptions.

I returned all of the prescriptions on discharge, and made sure I saw the patient put them into their suitcase. I even noted that in the chart.

They called today, claiming we'd lost a bottle of controlled-substance drugs.

We're never accused of failing to return antibiotics or hormones or other non-formulary drugs without a significant street value or abuse potential. It's always the amphetamines, Oxycontin, and Fentanyl lollipops we lose.

Of course.

Random, and updates.

Dr. Crane emailed me on Tuesday with a single line: "MRI looks good. No tumor."

That was fucking amazing, guys. I wasn't aware that anybody was even looking for a tumor. I just thought they were, you know, getting a baseline for my new skull configuration.

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

If you wake up from your afternoon nap totally blind, it's probably not a good idea to wait a full twenty-four hours before you go to the emergency room.

On the upside, though, it gives me a chance to see a really nice case of cortical blindness in action, along with temporal lobe edge-sensing and a lack of confabulation. The patient's hypothalamus got hit in the stroke as well, with the effect that they seem to be unable to regulate body temperature.

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

Likewise, if your spouse has had a stroke, it is not a good idea to allow them to drive. Home. From the hospital. Just. Sayin'.

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

And finally, let me make this perfectly clear:

We Can Tell If You Are Cray-to-the-Cray.

If you insist (par example) that you have to have an MRI because of some whacked-out set of symptoms that correspond to no possible hit in your brain to me, then insist that you *can't* have that MRI because of some whacked-out implant that nobody has ever heard of to the doctor, we will treat your case with what's known as a "high level of suspicion."

I still do not know, nearly ten years later, why people think faking neurological symptoms will somehow fool neurologists and neuroscience nurses. We have seen it all before, including things that hadn't been described before we saw them. I, personally, me, Little Jo The Neuro Nerd, have seen two things that weren't named before the patients showed up on our doorstep, and one additional thing that our most experienced neurologist had never seen, but only read about. He told me I could retire happy after that one.

You can't get past us. We are the Cerebrus of the medical system. Just give up, already.

Please note that here I am not describing conversion syndrome, which is a positively hellish disorder in which your body basically takes over your brain. I am talking about hydromorphone-craving malingerers. Dilaudid's a great trip; I'll give you that. But it's not worth four days in a CCU, with me standing over you like an angel of Hell.

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

In other, more personal news, my GYN thanked me today for being the easiest, least emotional, most logical and productive surgery consult she'd ever had.

Yes, Animal is being evicted. On July 7th. I have yet to tell my boss.

My GYN, whom I'd thought was seven feet tall and as impressive as Michelle Obama, actually turned out to be a rather short, fragile-looking woman with huge eyes and a ready grin. It's amazing how one's perspective changes when there's no speculum involved.

Animal is roughly the size of, oh, I dunno, a starling's egg? A robin's egg? Say, four cee-em one way and three cee-em the other? And, thankfully, there was no indication of malignancy on this super-de-duper microsonic amazo-sonogram. Teeth and hair and possibly some waxy substance (me thinking "WAXY BUILDUP" from the commercials), yes, but not anything scary.

So not big, but big enough to torque, which would be a fucking emergency. So we're going to take it out. Not that there was any question, mind you: as long as I'm still relatively young and healthy, and have met my deductible, why not go in for another $13,000 nap?

It'll be laparoscopic and will involve four band-aids to my belly. Worst-case scenario, which neither Dr. Impressive nor I think is likely, would involve the ONC/GYN staff coming in to do a lavage of my belly and take out both uterus and tubes. More'n likely I'll get out in under an hour.

My recovery nurse, whom I've already lined up, is named Tiffany. So is my surgeon. All I need now is a gashog with the same name and we'll be set.

Remember when we all were kids, and we were told "Girls can do anything they want!"? That time is now. I'm a middle-aged woman going under the knife with a female, black surgeon and a female recovery nurse, and probably a female anesthesiologist.

Wow. Things sure have changed since the 70's.

Things that made me cry today.

I don't usually cry. I'm not a crier, unless you load me up with bourbon or give me a sick kitten.

But today?

The tornado in Joplin. Der Alter Jo is from there, and some of her friends are still practicing in the triage centers set up after the tornado destroyed the hospital.

Prison conditions in California.

The woman who sat down next to me at Dr. Elf's Prosthodontic Wonderland, who'd had the right side of her jawbone taken out three years ago and had been unable to eat or swallow since. Her three wishes were to go out in public without being self-conscious, to be able to talk on the phone and be understood, and to let her grandchildren see her smile.

I was so excited for her when she walked to the back of Dr. Elf's office. She was starting something that, while it may not make her perfect, would make her whole.

And this:

My jaw dropped and I leaked tears on the way back from Dr. Elf's.

Early Sunday morning listening:

*whew* *sigh*

No grabbings so far this week. No screaming family members with threats of suing and retribution, no codes called for patients who get out of control, no fires in the rooms, no weird semi-recognizable things in the cafeteria waving up from the steam trays.

Something's bound to happen soon, but I'll take calm and cheerful where I can get it.

This was an unexpected day off. I'm not quite sure what happened in the surgery department, but for once we didn't have sixteen more brain surgeries than beds, plus nephrectomies, plus belly resections and Whipples, so they called me off at five. At nine I called my charge nurse and asked, quaveringly, "Do I have to come in?" She told me to stay home. It was wonderful. Laundry was did, dishes was did, and soon my hurrr will be did as well--it's growing out into that unflattering Giant Q-Tip Look I try to avoid.

All of which leaves me tapping my fingers a bit.

This last year has felt a bit like Limbo. The feeling's been especially strong since about Christmas, when it became clear that I wasn't going to have to deal with radiation or further resections or anything like that. The CCU is up and running, though we still don't have the number of patients I'd like to see. The unit itself is mostly stable, though. I'm not sick, I'm not in danger of losing my job, the animals and house are running themselves, just as I set them up to do. . . .

I'm thinking of going back to school. Maybe for a BSN and maybe not, and certainly not this year, as I still have this prosthetic and one more to pay for. One prosthetic equals a semester of employer-subsidized work at one of the local universities, and my priority has to be speech. Nothing stops me from being a bookworm, though, so it's off to Amazon I go for texts on things like pathophysiology and organic chem--things I've gotten rusty on since the last time I was in school. And Texas government and English and Poli Sci and all the other subjects I could test out of to earn higher placement in a program.

Meanwhile, it's time I fed the dog and took the clippers to my head. This is the bi-weekly night of buffing, razoring, clipping, waxing, scrubbing, and tweezing, all the while hoping I don't uncover something Much Worse than I already have.

Limbo, limbo, lim-bo. It's a bit like brownout. It's also a little bit like the Doldrums in The Phantom Tollbooth.

Well! That hasn't happened in a while!

Today a patient grabbed and shook me as a terrier might shake a rat. Although I am, in my own opinion, prettier than most rats, and most terriers I've met--Jack Russells included--are saner than this guy was. Baseline asshole, cray-cray secondary to Versed. I put the flat of my hand on his chest, pushed him back, and hissed "Lie the fuck down and shut the fuck up and don't do that again, asshole" as the surgeon behind me went wide-eyed and silent.

It had already been a long forty-five minutes. I'd discharged all of the patients from the neuro CCU, so I was down in surgical CCU to help out. Five minutes after I walked in, a patient came rolling up from surgery, having had something complex done to a carotid artery. We were all settling her in--the Mankiller, the Manhandler, and I--when something odd made her monitor go "bonk bonk beeeeeeeep." I figured it was me, since I was futzing with the cords and unplugging things, until I heard people in my immediate vicinity shouting the patient's name.

Oh.

God, I hate it when that happens.

Shortly after that, CrazyPants rolled in, and so I was tasked with calming down a shouting, punching, shaking patient who'd just had a throat resection.

Right now I've got something obscenely cheesy baking in the oven and I am drinking white wine. My sister sent a hand-me-down in the shape of a gorgeous blue-green dress that I was born to wear, and a cute little hand-knitted uterus with Fallopian tubes. I am going to watch Dr. Who again until my head explodes and then check my upper arms for bruises.

Lock up your sons, lock up your daughters, lock up your husbands....

...'Cause they conferrin' degrees on ERRYBODY up in here!

We got Abilene Rob graduated, on time and in good standing, and he'd better not fail the last final he has on Wednesday. If he had comments enabled on his blog, I'd suggest you go over there and offer your congratulations, but he doesn't. So just head over there and hang out for a bit, or something. Have a drink. Dust some bookshelves.

I drove the Endless Hours (tm) to Abilene in a dress, expecting a day of sightseeing with him and his family, whom I had not met. It's important to make a good first impression, especially when you have the sneaking suspicion that every tale involving yours truly has hinged on roasted gopher and long runs from the Law. Rob's a good friend, but he's entirely too honest with his mother, so I was expecting the worst: the patented Mom Side-Eye as she tucked her wallet behind her and attempted to steer the conversation away from prison conditions and the regulation of tattoo parlors.

Instead of Side-Eye, I was met with Windex.

When I knocked on the door, a dark, intense, pretty woman immediately hugged me and introduced herself as Rob's Aunt. She then shoved a bottle of all-purpose cleaner into my paw and instructed me to get started dusting down his bookshelves. Those of you who have lived through nursing school know that some things, like basic home maintenance and personal hygiene, tend to slide. Those of you who've travelled through or lived in West Texas know that dust is a part of life. The two together had prompted all of the relatives who'd gathered for Rob's graduation to do a home makeover of the Extreme type on a tight budget and short notice. So I changed out of the dress and did my part for Dust Abatement.

Rob's mother is relaxed and friendly. His older aunt is, as I said before, dark and intense (but friendly). His younger aunt is blonde and bubbly. His uncle parallels my uncle in spooky ways, down to the name and profession and fondness for toys. They are all, as you'd expect from the family that spawned him, brilliant and funny and talented. It was a little like hanging out with my own family, but without the alkaline snarkiness and puns.

And he graduated! For real! And he has a job all lined up!

I cannot remember being more proud of a friend of mine. I had no doubt that he could do it, and do it well. And he did.

And the commencement ceremony was a hoot. West Texans have fewer inhibitions about whoopin' and hollerin', and graduation is the perfect time to show off that between-the-teeth whistle you've been perfecting for years, out with the cattle. At first it was a little jarring (well, a lot jarring), given that I come from a family of Uptight Academics Who Wear Their Caps And Stoles Correctly. Then it got to be fun. Plus, the college has one very talented singer-slash-organist, who should sing the National Anthem at every baseball game forever, in perpetuity.

Then dinner and drinks, then bed, then up early the next day for a session on the porch with coffee, then a party, then more drinks and dinner again and bedtime.

I am so proud of him. He's a brilliant, talented, funny, kind person with a good heart and an excellent brain. This feels a little like I've shepherded somebody through something, even though I didn't do anything but link to his blog and occasionally bug him with emails during finals weeks. He is going to be...wait, no: He is already the kind of nurse I would love to work with, and whose name on the schedule would prompt a sigh of relief.

Rob, dude, you are awesome. Business will continue, I am sure, to be good.

Love,

Yer pal,

Jo

Bad-ass Good Boy! of the day:

The dogs that work with forces like Navy SEALs have their canine teeth (their four fangs) capped to prevent or repair the damage that can be done to a working dog's teeth. Those canines wear down fast, especially when you're training a critter to do things like bite body armor.

So they get their fangs capped. With titanium or stainless steel. Gold and amalgams aren't strong enough to withstand the bite force of a big dog.

Who's a good boy with beautiful white teefies? Who's a gooood boy? Who is? You are!

(I, for one, welcome our titanium-toothed canine overlords. I hope Kong has a toy for this.)

Limbo, limbo, lim-BO

Quick Animal update:

Animal is two inches (roughly) long and some undetermined measurement the other way. Nobody has any idea what he is, but everybody agrees that for now he's not a big deal. Don't ask me how that works.

Re-sono in three weeks, with the doc in the room, then everything will get decided.

Meanwhile, I'm going to go do some dishes.