Wednesday, November 26, 2014

This is not Thug Kitchen.

However, I have a roll recipe for your motherfuckers that you are gonna love.

This is what I bring to every holiday gathering, and have brought since forever. It's a soft, white, not-too-sweet, not-too-salty, buttery bread that you can make into loaves, or into rolls, or into a braid. It is incredibly easy, even if you've never made bread before. It's also high in fat, totally devoid of nutritional value, and should therefore be eaten only once or twice a year.

Check it out: you will need. . .

one package of regular yeast, or quick-rise/bread-machine yeast, or a cake of yeast, if you roll that way. (For newbies: these packets come in threes in the US. You will need only one. It's about two US teaspoons of yeast.)

two and one-half cups (590 ml) of lukewarm milk. I use whole milk and zap it in the microwave for a minute, just to get the chill off.

one tablespoon (~15 grams) white sugar

one teaspoon (eyeball it) salt

one stick (half a cup, or 4 ounces, or 120 ml) of unsalted (very important!!) butter, melted and cooled slightly. (Salted butter will make the dough both too salty and make it brown unevenly.)

Mix all that stuff up. It'll make a nasty, semi-lumpy, unpromising mess.

Now stir in, about a cup at a time. . .

six (more or less) cups (~150 grams per cup) of plain white all-porpoise flour (not bread or cake or semolina flour)

. . . until you get a sort of sticky, shreddy dough.

Now dump some flour onto a clean surface. It doesn't matter if it's a bread board or a counter or what, as long as it's clean.

Begin to knead. If you've never kneaded bread before, this is a treat: the dough is such that it's not hard to manipulate, and you'll know when it's done by a foolproof method I'll lay on you in a minute.

To knead, take your lump of unpromising flour-goop in the middle of your floured surface. Grab the top edge and bring it toward you. Using the heels of your hands, shove the top edge gently into the middle of the lump. Give the whole shebang a quarter-turn and repeat.

It's not hard, I promise. The trick is to stretch, rather than tear, and tuck, rather than hammer, the dough. Although you really can't go wrong. Add more flour if you need to; it's really hard to fuck up.

The dough has been kneaded enough when it's smooth, relatively elastic, no longer lumpy, and --here's the secret trick-- no longer sticks to the surface, even without extra flour.

Now. Take that dough, butter it well all over (I soften a lump of butter in my hands) and stick it into a buttered bowl. Cover it with a damp dishtowel and stick it in a warm, out-of-the-way place, like the top of the fridge, and forget about it for an hour or so (less if you're using rapid-rise yeast).

Make a mental note of the volume of the dough when you pop it into the bowl, so you'll know when it's roughly doubled in size. When it's at that point, put it back on to your clean surface and shape it into whatever form you like. I make two-bite rolls, about an ounce to an ounce and a half each, and I think I got three dozen? today.

Once you've shaped your dough, stuff it into whatever container you'll bake it in. Strangely, butter will not work for greasing your baking pan. Use solid vegetable shortening instead, okay? Throw your damp towel back over the container(s) and stick it/them back into that warm place you used earlier.

Nota bene for first-time bakers: give your dough some room. You want it to be able to grow and expand and breathe, so use a pan a smidge bigger, or leave a bit more space than you'd expect between pieces of dough. Crowded dough can't rise properly and will make heavy, unhappy rolls that don't fulfill their potential.

Allow that shit to rise until it's doubled in size again. The beauty of this step is this: if you want to take a long nap, like I did today, you can leave the dough in a relatively-cool place to slow its rising. Hell, you could even stick it in the fridge overnight! The possibilities are endless. You do you.

When the dough is nice and puffy, preheat your oven to 425F/220C/gas mark7. If you're making rolls, they'll bake for about 20 minutes. If you're doing a loaf, you might want to turn the oven down to, say, 400F, and give it forty minutes or so.

The bread/rolls/carbohydrate portrait of Nathan Fillion is/are done when they're that golden brown that you only see on TV commercials about bread, and when it/they smell done. At that point, remove your product from the oven and turn it out onto a cooling rack. This is important. No cooling rack = sad soggy bread and disappointed eaters.

Americans love these. Canadians love these. Indians and Filipinos love these. Mexican-Americans from Laredo practically fucking riot over these rolls, since they're very close, apparently, to something served in the Laredo school system in the 1970's. Italians love these, but only for dessert. Nigerians love them, as do all the Egyptians and Lebanese and Moroccan people I've tried them on. I have yet, in short, to meet a single person who does not like these rolls. Even skinny white girls like them.

Starch: the Universal language of Peace. Do your part for understanding and tolerance today!

Thursday, November 13, 2014

This was my week:

On Monday, my Sonicare toothbrush bit the dust. I'd been limping it along for months, and it finally coded and couldn't be revived.

Today, I had a decision to make: I had money in the budget either for a new Sonicare or a bottle of Laphroiag.

I chose Scotch. Oral care, I am not up in you right now.

And this is why:

On Tuesday, I was minding my own business when I saw a coworker hurpling cheerfully down the hall with what looked like a liter suction container full of bile. I shook my head and blinked twice, and damned if it wasn't a liter suction container full of bile.

Now, normally when one is faced with a quart or more of straight-up digestive fluid that has to be removed from, say, a patient's room, one gets a bottle of this nifty fluid-solidifying stuff and takes it in to the room where the straight-up digestive fluid is. One then dumps the solidifying stuff into the container of SUDF, waits until it solidifies, and tosses it into a biohazard bag.

One does not bop down the hall, hugging the still-liquid, suctioned-out contents of a stranger's stomach.

So I stopped the coworker, and took her into the storage room, and grabbed a bottle of solidifying stuff. And then told her how to handle the liter of green corrosive goo, and what to wipe down, and where to throw it all away.

And she argued with me. She wanted to take it into the nurses' breakroom and deal with it there, because you can't deal with that stuff at the sink in the clean utility room. She argued, and continued arguing, until my hero the unit secretary came in and laid down the law.

Wednesday was a blur. I think it had something to do with more than one bottle of wine, consumed such that I maintained a happy glow throughout vacuuming and napping and cooking dinner. I know there was some Doctor Who involved. (Does anybody else get a creepy vibe from Danny Pink? I sure do.)

Today that same coworker, who is a nurse (well, a nurse who hasn't been a nurse in, like, twenty years) but who has a non-nursing job, approached me with a sunny smile. Here is what she said, verbatim, with no prelude:

"As soon as the car arrives, they can go to rehab!"

What car? I asked. And who, and where, and how?

Turns out she was talking about a patient she'd been rounding on and case-managing for *for a week.*

Dude has a dense hemiplegia and is globally aphasic. He's also incontinent, has no truncal control, and requires frequent suctioning. He's a max assist with two people to sit edge of bed and can't tolerate an hour in a geri-chair.

And she wanted to send him to a rehab four hours away in the family car, with only his wife and son (no suction, no help) to watch him.

And she argued when I said we needed an ambulance.

Unfortunately, the Hero Unit Secretary wasn't working today. I was forced to say, "You are out of your effing MIND" before she would stop arguing and call the ambulance company.

Why is bile green, anyhow? What, chemically, causes that to happen? I never learned that in school.

Anyway, tonight it's Scotch and muscle relaxants (don't try this at home, kids!) because I also threw my back out this week, and then bed. I'm hoping I don't get awakened by Playful Mongo at some ungodly hour of the morning.

Tuesday, November 11, 2014

We need our own goddamned poster.

Recently, the unit I work in won an award. It was one of those not-Press-Ganey awards; the kind of award that has to do with things that are nursing quality indicators. You know, the "you haven't had a central-line infection in two years; here's a cookie" kind, but bigger.

Much bigger.

And it was nurse-driven, nurse-implemented, and exacting. And national. So, kind of a big deal.

During the hootenanny surrounding the award, we were shown a slide of everybody (so said the CEO of the hospital) who'd had a hand in making Such A Great Thing possible.

There, front and center, was the CEO. Next to him was the director of nursing operations, a man who's been actively obstructionist and slashed staffing and resources, and who has visited our unit maaaaybe three times in as many years. Next to him was a woman I didn't recognize but who, I was told, was instrumental in something statistical.

Arranged behind those people were dozens--maybe as many as a hundred?--people, all in varying degrees of business attire.

No scrubs.

Not one nurse.

Not. One.

Especially not one from the unit, the unit I work on with some of the best nurses I've ever worked with, that won the award.

So, I'm thinking we need our own. Goddamned. Poster.


Saturday, November 01, 2014

So, finally, my patient died.

Once in a very long while you get somebody under your hands who ought to have been let go months before.

We had somebody like that the other month: multiple surgeries for a brain tumor that was not going to go away (grade IV glioblastoma), multiple rounds of chemo and radiation, and in the middle of all of that, a surgery for an abscess that led to wound-vac sponges all down one side of the poor sot's body.

The spouse didn't want to let them go. The mother didn't want to let them go. The brother didn't particularly say one way or the other.

Ever smell a person who is, quite literally, rotting from the inside out? It's not fun.

Because, see, a glioblastoma (that's the most common form of malignant brain tumor and is, thankfully, still very rare) slowly takes away your ability to think, speak, walk, control your bodily functions. Then it starts to take away your ability to breathe. And your brain's ability to control things like its temperature and blood pressure. And, eventually, it will invade the areas of your brain that register pain. At that point, you will be in pain all the time every day forever for as long as you last.


It sucked. For us, as well as for the patient.

The only reason I can think of that this person was kept alive was that they had a significant pension that would've ended upon their death.

So their spouse, the person who was supposed to keep their best interests in mind, kept them alive for two entire months in order to get money.

I very rarely get *existentially* angry at work. I get angry at the administration, or at Manglement's bad decisions. There's one house supervisor in particular that I suspect was put on this earth to make sure my lungs get a workout every three weeks or so. But I generally don't get to the point that I go in search of things to punch. Ask my coworkers: they'll tell you that I'm the sweetest-tempered, most cheerful, helpful person they work with.

Seriously. And I haven't drugged a one of 'em.

Anyway. When this person came to us (and I'm carefully not using gendered terms here, because it would probably surprise you), they were reasonably compos mentis. By "reasonably" I mean that they knew their name, they knew where they were and why, and they'd mostly follow simple commands.

Within two weeks, the leftover tumor in their brain had doubled in size. Glios do that. The things that cancer loves are space and glucose and a good blood supply, and the brain has all three. What makes glioblastoma particularly nasty is that it's a tumor of the structural cells of the brain, so it sends out little undetectable filaments all around the original site. You can never get rid of it entirely.

But you can resect, and irradiate, and chemotherapize, and that's what happened. And when the patient developed an abscess on the right side of the abdomen, it didn't heal. It kept filling up with pus and tissue kept dying, because all the things we were doing to kill their brain tumor kept the rest of their body from fixing itself.

So at the end of the day we had a patient who was not a DNR, who was not on palliative care, who could not have a feeding tube inserted into their stomach courtesy of the twenty-five centimeter wide wound in their belly that would not heal; who had been intubated and extubated and who, finally, had to be four-point restrained because the tumor had hit the pain centers in their brain.

The family didn't want continuous pain control because they felt the patient was still able to communicate. This, when the MRI showed that three-quarters of this person's brain was tumor.

All of this made me vent uncontrollably to my buddy Mark, the neurointensivist. It made me vent to Ginny The Inappropriate Chaplain, and to my coworkers, and once to the patient's spouse (in a controlled and therapeutic manner). Ethics came in, ethics bowed out, case management was crushed under the wheels of the Sustain Life At All Costs juggernaut, and we all started to have a bit of twitchy post-traumatic stress.

Finally we discharged the patient to an acute-care, long-term setting. And there they died, after multiple codes, a day ago.

.*** *** *** *** ***    *** *** *** *** ***   *** *** *** *** ***

What nobody tells you about nursing is how cases like this can haunt you. I've dreamed about that poor person at least once a week for two months, now; the news that they'd died has turned the nightmares into milder anxiety dreams.

There's something about changing and bathing and turning a person who begs to be left alone to die that scars you. I am supposed to be alleviating pain, not causing it. I have a personal rule to touch every patient in my care at least once a shift *without gloves,* no matter what they've got, in a way that doesn't cause pain. Because, frankly, a lot of people in the hospital don't get touched without at least discomfort, and that fucks a body up.

But what do you do when there's nothing you *can* do? We were barred from starting a morphine drip or giving IV pain meds. The poor patient's brain was working against them. Everything hurt. Everything was futile.

And through most of it, the patient asked, then begged, to be allowed to go home with Dad. Dad had been dead for some fifty years, but showed up at the bedside on a daily basis, trying to get our patient to go with him.

I do not often have to get angry about injustice and cruelty. I don't often cry over my patients any more.

This one, I'll do both.