Channelling Andy Rooney

Grump, grump, grump.

There's nothing like being awakened three times during the night by someone else's child, then treated to the sound and sight of repeated temper tantrums at 0630 in the morning on your day off. This is why I do not have children. This is also why I left The Boyfriend's house this morning without coffee or a shower.

Please explain to me why people can drive like bats out of Hades when it's raining and pissing and visibility is what you'd see in, say, the middle of a tar pit, yet slow down in the same construction zones on perfectly clear nights. There are two construction zones--the sort with no shoulder, where three lanes of traffic zoom between concrete barriers--between me and work. Every clear, lovely night people slow down and we crawl through at 25 miles an hour. On nights like Saturday night, when it's raining cats and dogs, they blast through the flooded areas going 80. Riddle me that.

If you tell me that you're friends with the hospital board president, it will not make me treat you any better. Especially if you're obnoxious. Let's face it: unless Mister Bigshot is in the room with you, holding your hand, you're just another patient.

My hospital hobbyist is now in isolation. Unfortunately that means little or nothing to HH's spouse, who insists upon heating up dinner in the communal microwave and removing equipment from the room. Given that these are the same people who think that empty rooms are good for taking naps or entertaining the kids, I'm not surprised...

Goodness. In my current mood, the only thing to do is scrub the shower. That'll make me feel less grouchy, and I'll end with a sparkly clean bathtub.

Never, ever, evereverever....

Drink with a fireman.

Especially a fireman who's just gotten off his 24 hours. An English fireman (that is, an Englishman who's here fighting fires) at that. Perhaps especially, never ever drink with an English fireman from Islington, a place that apparently endows its children with heart of oak and liver of stainless steel.

If you do decide to drink with a fireman, do not trade stories about work. If you do decide to trade stories about work, do it somewhere other than a quiet pub. Otherwise, people might start to look at you funny.

At least I know that my job, whatever its adventures, is not so bad. "What's the hardest thing you've done lately? Trauma?" I asked. "Oh, no" he replied. "Trauma is easy. CPR on a 400 pound corpse is hard." "How corpsey?" "Very, very corpsey."

In other news

We have four ICU overflow beds on our floor. That is, when the intensive care unit is tippy-top full, the Powers That Be send the extra neuro ICU folks to us. I worked a shift this weekend in the overflow unit, with--thank you, God--only one patient, and her with only one drip.

Having ICU overflow beds on a regular floor is a bad idea. The number and type of monitors, drips, and tubes your neuro ICU person has wired into his head or heart requires that the room be set up differently and that it be out of the way, in a place surrounded by signs warning of the Dangers of Cellphone Use. That means that the only practical place to put overflow patients on our floor is in a suite of rooms off in the boonies where nobody can hear you scream.

More importantly, we are not ICU nurses. Hand me a patient with a nicardipine drip (used to control blood pressure) and I can handle it without too much trouble...but I don't like it. I'm not in practice for it. Telemetry, while not a completely closed book, is not something I do every day. I can bumble along, true--but bumbling along is not something you want for a person who's sick enough for the ICU.

It was lucky for everyone involved that my patient was stable.

How to be an addict

If you're poor, you'll have to get your hits from the street or a series of ERs. If you're rich, you can milk a few months out of various hospitals with a series of ever-more-complex problems that require Demerol and Phenergan to treat. If you're rich and well-connected, you can find a doctor who will diagnose you with a rare disorder, one that requires diagnosis by exclusion, and you can run with the Dilaudid for years on end.

One of our pet Hospital Hobbyists came in three weeks ago and is still with us. This patient is still getting various fun narcotics to control pain that's caused by a rare disorder--one that allows a significant amount of activity in the hospital but apparently renders one inable to go home to perform the same activities. Dilaudid every two hours, nausea medications every four, and a tea-time dose of some sort of tranquilizer is helping the Hospital Hobbyist get through the day, see friends and relatives, and take a little vacation from real life.

I had another of the Hobbyists a few months ago, with the same attending physician, and got into an argument with said physician over my unwillingness to push 50 milligrams of Phenergan and 8 milligrams of Dilaudid every two hours. For those non-nurses in the audience, these are drugs at doses that would knock down a small hippopotamus for several hours. Yet the Hobbyist in question was still happy and conversant, completely sane, and relieved that the withdrawal symptoms had stopped for a bit. Not that any Hobbyist would ever admit that, of course. Nor would a Hobbyist appreciate the observation that their hospitalizations tend to come over holidays and other high-stress times in their lives.

Don't ask me why people do this. Don't ask me to speculate on how they get this way or why their physicians allow the behavior to continue. I swear that when my liver decides to cut out the middleman and hop out of my body to find a bar on its own, it won't have to go past hospital security to do it.

Finally, a political post.

This gentleman is the reason I'm a liberal.

"Comfort women." Nice. Just...well, I'll be honest with you. I understand that a blog's a blog; that people can be just as sweet or as nasty or as purposefully inflammatory as they want, and that a lot of folks are inflammatory for fun. We'll take that as read; I'm not naive enough to believe that everything written in the NetWorldBlogOSphere is meant to be taken seriously.

But "comfort women"? Uh...do the thousands of Korean women who were tagged with that name originally not mean anything to you?

Curb stomping and comfort women. Amazing. Makes me wonder if somebody like Joe Lieberman is, in this guy's eyes, a Comfort Heeb. You know, not too bright, but good with the deli meats and bagels.

Holy shit. This is the reason I'm not moving to Canada. Specifically, the likes of Ann Coulter and William Bennet are the reason I'm not moving to Canada. *Somebody* intelligent has to stay and enunciate the other side's views.

For the record, the above link came from Pinko Feminist Hellcat's blog.

Ethical noodlings, or, Friends Don't Let Friends Treat Friends. Or Family.

Geena at Code Blog has a story that every nurse can echo: the conundrum of the patient whose doctor is unwilling to let him die the way he'd like. When something like what she describes starts to go down, everyone around gets involved--the family, the nurses, the residents. Sometimes it works out. Sometimes it doesn't. Here, from my own experience, two stories that came swimming back to the top of my head after I read Geena's post. Note that these are even more heavily fictionalized than usual.

Case #1: Bill W.

Bill W. was a high-powered executive with a large national company based in our town. He was well-liked, considered by friends and coworkers to be a highly ethical, stand-up kind of man. He had a large supportive family. He was diagnosed with lung cancer at 45 and, with extensive treatment, went into remission.

His remission lasted twelve years, at which point he ended up with brain, liver, and spinal metastases. The prognosis was quite poor; you rarely end up beating back a disease as aggressive as lung cancer more than once. He ended up in my care on the medical floor. The first day he was communicative but disoriented. The second day he was responding to touch but not making any sense. The third day he stopped responding at all.

He and his family agreed that he should be no-coded (ie, a "DNR," or "do not resuscitate") and that treatment should be palliative. His doctor, on the other hand, was unwilling to let his patient die. On the third day I had Bill in my care, his doctor wrote orders for IV fluids at 125 ccs per hour (about half a cup; much more than is necessary for palliative care), every-six-hour fingersticks for blood glucose, insulin injections, and three different IV antibiotics.

The man was comatose. His kidneys had failed; he was producing about three tablespoons of urine in an hour. What his kidneys couldn't get rid of had settled in his legs, his scrotum, and his lungs. His hands and arms were swollen and bruised from repeated IV sticks and lab draws. His breathing was harsh and slow, with long periods of apnea.

The resident and I got into a very polite shouting match about his treatment. I told her that it went against my grain to go against his and his family's wishes for his death; she told me that her boss (his attending physician) felt he had to "try everything" for the man and the family he'd known since childhood.

Eventually, the family's and my viewpoint carried the day and Bill was put on an IV morphine drip. Palliative care was all we gave; we stopped the insulin injections and the antibiotics. He died the next afternoon with his family in the room with him; I bathed his body and walked it to the morgue.

Who was right? Who knows? Who can say that a person at the edge of death, unable to talk or make his wishes known, might not experience a change of heart and want others to do whatever's necessary to bring him back? Is it cruel to run IV fluids and antibiotics and stick somebody with needles when they most likely can't feel it, or at least can't translate the pain into anything meaningful? And would the person in the bed want to go through all that, if it meant that his wife and kids could sleep better at night?

Case #2: Kelly G.

Kelly was involved in a one-car accident that left her in a persistent vegetative state. The trauma of her accident had led to one of her arms being amputated below the elbow and one leg being amputated above the knee. She had a tube going into her stomach for feedings, a trach to breathe through, and a tube coming out of her belly just above her pubic bone to drain urine. She came to our floor without purposeful response to anything including pain, with only basic brainstem reflexes, and with very sluggish pupillary reflexes.

She also, because of the sort of trauma she'd had, had seizures. In order to relax her rigid muscles and prevent the seizures, she was on a number of medications, all of them sedating.

By the time I saw her the first time, she'd been like this for four years. She'd endured seven bouts of pneumonia, uncountable urinary tract infections, bedsores, and her limbs were contracted from lack of use. Her parents had bankrupted themselves to care for her. They were convinced that she would someday wake up and begin to respond to them in a meaningful way.

Shortly after her last hospitalization with us, her parents began to wean her off of all sedating medications, including the ones that were preventing her seizures. Their theory was that the medications were delaying or derailing any chance she had of getting better. Within six months she'd had six tonic-clonic ("grand mal") seizures. One had lasted three and a half minutes, a long time for a seizure. Her spasticity had gotten worse, and she'd begun to vomit tube feeding and inhale it, thus setting herself up for more bouts of pneumonia.

But her parents persisted, thinking that at some point she would, in the words of one of my more blunt colleagues, "Sit up and ask for a Pepsi."

Again, who's right? I can't imagine what her parents went through, having a bright and talented 16-year-old who came so close to dying and returned to them far from intact. Was it cruelty to keep her alive on life support in the first place? What about each successive case of pneumonia? Should one of them have gone untreated? And is it ethical to subject a person, no matter how unable to think or feel or respond, to repeated seizures in an attempt to bring them out of the shell that brain injury creates?

And the question comes up again: would the patient have wanted to go through this in order to spare her family the late-night what-ifs?

At the end of the day, I guess it's just not up to us, as caregivers, to have the definitive answers to those questions. The best you can do is to have some sense of when things are crossing the line for you, personally, and when you have to get somebody else to provide care. Sometimes it's hard like this; most of the time things are easier. Thank God.

I'll get to it, I swear.

Sorry, kids. I just don't have the energy today to deal with The Types of Nursing Student. Maybe next week.

Beekeeping, or odds and ends cleared up

GruntDoc has noticed that I don't have a description of ED docs in my guide to specialists. As I told him, I'm depraved on account of I'm deprived--our hospital, being referral-only, has no ED.

However, I'm sure that ED guys and gals are uniformly the most attractive, most talented, most charming, and most tasteful doctors of them all.

I've not written lately because my arm is acting up. I have an old case of ulnar neuropathy that doesn't take kindly to typing, though it'll handle cooking just fine. The result is that I've made a huge salad to last the week and baked some apples today.

The rash is better, thanks for asking. Not gone, but not as leprous as it was.

Head Nurse: Now With More Poop

I got a request via email for more poop and mucus stories. (You know who you are.) Therefore, I present to you the Worst Poop Story of Them All:

A young man with a high cervical injury was admitted to our floor by the PM&R doc that sees him most often. His diagnosis was fecal impaction: not unusual in spinal-cord-injury patients, as nothing below the level of the injury really works as it ought to. Even daily bowel programs don't always do the trick.

This kid was scheduled for a colostomy to reduce the need for occasional admissions for disimpaction. Problem was, he hadn't had a normal bowel movement in something like six weeks. He'd been having *daily* bowel movements, but not enough to keep him from....well, from backing up.

On assessment, the guy had a distended belly. Let me rephrase that: He looked like he was ten months gone with quadruplets. Bowel sounds were almost normal all over except in the lower-left quadrant. He complained of a lack of appetite and difficulty breathing; not surprising considering what he was dealing with. His belly was tympanic to percussion. (In English, that means it went "bomp bomp bomp" like a drum when I whacked it gently.)

His doc decided to try the gentle stuff first: a couple of doses of Sennakot over a few hours, digital stimulation, and see what happened.

Nothing.

So she went to two bottles of magnesium citrate and digital stim.

Nothing.

Enemas. Nothing. More mag citrate. Nothing. Further doses of laxative. Nothing.

Finally, I called her just before shift change and asked permission to coordinate with another nurse who worked nights and simply do our worst.

So James and I went to work in tandem, him on nights and me on days. Our poor distended patient got a couple of Triple-H enemas (high, hot, and a hell of a lot) and a gallon of Go-Lytely, given in a dose of fifty cc's every ten minutes. (In a case like this, you want to work from both ends and not dose the person too hard with Go-Lytely, lest something bust open.) In the morning, he got yet another enema and some more mag citrate, drunk slowly and carefully.

About two o'clock in the afternoon things started to happen. By four his belly was soft and nontender, its normal size, and we'd all had three changes of clothes. It ended up being easiest simply to hold him up while he sat on the regular toilet--not the bedside commode--and flush every thirty seconds or so as he sat.

Some medications dissolve through their capsule, leaving their shells--the actual tablet or capsule part that you see--intact. He had literally hundreds of those backed up in his colon. That should give you some idea of what our day was like.

If the government is ever looking for a cheap, easy way to put people into low-earth orbit without a spacecraft, I recommend magnesium citrate and a hose.

Taking care of business

A few updates:

1. My rash is slowly improving. On the offchance that this could be pellagra, the plague, or alien invasion, I'm upping my vitamins and doubling up the Clarinex. Maybe I'll see the doctor; maybe not.

2. Faithful reader Mark has suggested that I do something called an RSS feed on this blog. Watch this space for technical foul-ups and broken links as I attempt that very thing.

3. You may soonish be seeing an ad on this very blog. Please attend:

It was my original intention to make this site something that maybe one or two people would read three or four times a year, after heavy doses of antiemetics and Immodium. Unfortunately, as with so many other things in my life, I failed miserably in the attempt. So much so that some very nice but probably not-too-bright person in Cyberland wants to link a site he manages to this one.

I didn't want to go commercial (as it were) at first, but damn, I can really get behind the site in question. I like the writing, I like the premise, and the folks there seem to be doing good work. When the link goes up, you'll see what I mean. I've no idea when that might happen; the person in charge of such things is just as laissez-faire about deadlines as I am.

I really wish I felt inspired.

Sorry, folks. The guide to nursing students will have to wait. Right now I feel rather like an old car that suddenly has things going wrong with it all over.

The count so far is:

1. One left ankle that's still complaining when I try to put weight on it in a certain way

2. One right arm that's having a flare-up of ulnar neuropathy

3. One left deltoid that's developed an odd, itchy reaction to the flu shot I (miraculously) managed to get yesterday

4. Several square feet of skin that's now covered, not just with an itchy bumpy rash, but also with hives in weird spots (back of one thigh, front of one shoulder).

The plan for today, therefore, is to stick my check in the bank, swing by the early-voting place and vote, and then hit the drug store for things I avoid, like Benadryl. I wouldn't normally touch that stuff, but being goofy and sleepy and weird for twelve hours, even with the attendant hallucinations, beats looking like something that ought to be sitting in rags, bowl held out beseechingly, on the street of a medieval walled city.

Once many years ago, when I still worked in a large college bookstore, I had an interesting Benadryl reaction. Actually, all of us had interesting Benadryl reactions.

It was during the fall rush, the busiest time of year for textbook departments. Those of us who normally worked in the front office placing orders were drafted to help unpack wholesale order after wholesale order of used textbooks. Those damned things come in by the freightload and are in all sorts of shape--from soaked in perfume and god-knows-what to pristine and lovely.

Fall here is bad for allergies. Fall in a dusty warehouse with only fans to cool the place is worse. Fall in a dusty, fan-cooled warehouse with several tons of textbooks is one circle of Hell.

So we all--eight of us--had been pumping the Benadryl for several days as we cleaned books, priced 'em, and tried to get 'em into the hands of the students. If 25 milligrams of diphenhydramine works well, 50 must work better...and if you've built up such a tolerance that 50 will still let you sniffle and sneeze, go on up to 75. At which point you'll begin hallucinating.

And if you're working with seven other people who've also been snacking on antihistamines, you'll soon find that *all* of you are hallucinating. What's more, you're all hallucinating roughly the same things. For us, this meant ten- and twelve-hour days lifting literally two tons apiece while small fuzzy black things scuttled at the edge of our vision.

Lather and rinse that bad boy for ten days, no time off, and see how you're doing at the end. You lose your ability to gibber on about day 5 and become irretrievably punchy on day 8.

And *that*, my chickens, is why I'm going to hide all the sharp things, make sure there's plenty of farina in the house, and lock all the doors before I take my first antihistamine today. If I start dreaming I'm back at the bookstore, at least I won't be moving other peoples' books around.

Growl.

How many nurses does it take to change a lightbulb?
-
-
-
-
-
-
-
-
-
ONE, to call the intern!

Oh, fuck you.

In case you hadn't noticed, I'm the person that calls you to let you know when you've fucked something up. If your patient has a critically-high potassium level because you've been supplementing them out the wazoo without requesting more levels, I am the person who catches it.

I'm the person who wakes you up, sweetie, before your attending walks into the station and justifiably fries your ass.

I'm the person who holds your patient's hand while she dies, then spends thirty minutes trying to locate you because your department can't get the call schedules right. When you do finally show up, I'm the person who shows you how to fill out the paperwork you should've been familliar with months ago.

I'm the person your attending yells at when *you* fuck up. If you write an order that doesn't comply with our chemo protocol, and forget to have your attending clarify it and cosign it, I am the one who will have to endure thirty seconds of blasting in the nurses' station from your overfed, undercivilized boss.

I'm the person who, just last week, paged you a total of forty-eight times over the course of eight hours about a patient who was hemorrhaging from an incision. I had, of course, already contacted your attending and had the problem dealt with by somebody else...because you had slept through your beeper on your on-call weekend.

I do an amazing amount of scutwork, from running to get you lumbar drain kits to holding your hand when you're doing a procedure you've never done before. I'm the one who keeps that patient with the undiagnosed tremors and dyskinsesia still in my arms while you do a lumbar puncture. I catch your errors more than once a day, thus saving both your license and mine. I change your dressings for you when you don't have time and correct your orders when you don't know that a) Xanax doesn't come IV or b) the dosage of phenytoin for a loading dose. Your patients weep and vent and rage to me so that they can keep a calm face to you, and maybe you won't then think less of them.

I am, in short, a nurse.

I may need you to change a lightbulb, but you apparently need somebody else to wipe your ass.

So why do it?

For starters, it's better than being shot at.

Seriously, if I get my back up at a stupid-nurse joke, why do what I do? Why not take one of those six-week miracle courses that will turn me into a legal nurse expert, or work in case management, or become an NP?

Here are some reasons:

The time I called Mario, one of the neurology residents, with what was an idiotic question. I realized that before he called back and apologized for paging him, remarking that I'd been hired for my looks, not my brains. Mario, with a total lack of irony and his usual sweetness, said, "Jo, I've been trying to tell you that for months, but was afraid it would land me a charge of sexual harassment." (To get the full effect, you need a heavy Brazillian accent on that last bit.)

Hearing a patient or a patient's family member say that they've never been in a hospital with such caring staff or such good care.

Improving one patient's mood or symptoms, or just leaving them better/cleaner/more comfortable than I found them.

The time that the Ice Queen, a brilliant and unapproachable internal med specialist, broke down and confided her worries about her elderly and ill dog. I teared up too; we ended by drinking cups of very hot and very strong tea in the family room.

Watching a total dickhead of a resident turn into a real human being and begin to be good for his patients. Sometimes this takes a while.

Being able to translate what a patient needs into language even the most inhuman doctor will understand, and being able to translate back into English what he says for even the most overwhelmed patient.

The science of neurology and neurosurgery. The joy of learning something new and incredibly neat. The fun of trading jokes with the orthopedics staff or setting aside brownies for the constantly-hungry hem/onc fellow. Seeing the aforementioned dickhead resident melt and grin and stammer when I ask him about his newborn son.

Knowing that somebody was with that person who died. If a patient doesn't have family around, we arrange assignments so somebody can be with him or her when he or she dies. Nobody should have to die alone, without another human being's smells and sounds in the room. Once in a while, I'm that other human being. That's a privilege and an important job.

I'm better at this than I've been at anything else in my entire life. Nursing is a calling, as much as medicine is, or more so--we're belittled and underpaid in a way that doctors aren't once they leave residency. "Just a nurse" is a common refrain among patients and doctors and even some nurses. (Yes, I've said it. Once. And kicked myself silly afterward.)

We don't do this because we want to lean on other people or depend on them for answers. The majority of us have a passion for the science and a fierce pride in our work. We appreciate being given room to practice and independence to make our own decisions. If we fuck up, we admit it and fix it (well...most of us do, at least).

I get cynical. I get angry. There are days when I come home exhausted, sore, covered in puke and shit and blood and less-savory substances, and fall into bed too tired to cry. There are times when I've lost a patient or had to deliver bad news or made a stupid mistake when I berate myself endlessly.

But if you offered me any other job in the world, I wouldn't take it. If I won the lottery tomorrow, I'd keep working. And there's never a morning that I don't secretly look forward to going in to work, no matter how much I might grumble over that first cup of coffee.

Blog O' The Mornin' to Ye!

Michelle Au

Be sure to check out the "Scutmonkey" cartoons. They're among the funniest things I've ever read.

Resident Wife

Love it, love it. *AND* she uses the word "schadenfreude" (spelled correctly, of course) as part of her subtitle.

Jasper Dog

James Lileks, the guy who did The Gallery of Regrettable Food, takes pictures of his dog. Many of them. Many of them are beautiful. It's your dog-fix for the week.

Damn, my ankle hurts.

I was leaving a patient's room today and somehow torqued my left ankle in such a way that it made a little teeeeeny "pop" noise and started to hurt. This was at 0900, of course, so I hobbled around on the ankle for the rest of the day, too busy to ice it or wrap it.

It wouldn't be considered a work injury, ironically enough, because though I was in a patient's room, I wasn't actually *doing anything with the patient* when the injury happened. I guess if you sprain a wrist while holding a pillow over a patient's face, that's workmen's comp for you.

It ain't broken, it's not bleeding, and it's not much swollen. Tonight I'll ice it and elevate it and compress it and all that and see if it's better by Monday.

Dark dread and horror

Monday is the rassumfrassum EKG test I've been simultaneously dreading and not studying for. I can recognize a lethal rhythm on a strip and I know what drugs to give, but some of the trickier, non-lethal rhythms are gone out of my brain. They need to git up on in here by Monday morning so I can keep my job until the next round of testing.

A lack of med blogs?

I read somewhere that medical types are less likely to blog than English majors or law folks. A Chance To Cut Is A Chance To Cure gives the lie to that.

There are some excellent nursing student blogs in there, which surprises me. I don't remember having a lot of time to breathe in nursing school, let alone write funny and perceptive blog entries. These people may well be smarter than me, though. That's usually a safe bet.

And finally, it is officially fall.

I say that because I have my Annual Weird Rash again this year. I get this same Weird Rash every year during the fall, about the same time that other people are being socked with cases of hay fever. My personal opinion is that my body can only produce so much mucus. After attempts to break the Mucus Record, my immune system gives up and focuses on rashes. Itchy ones. Itchy, bumpy ones.

Please send nail clippers and back scratchers. And a three-inch ACE bandage, if you have one. Thanks.

"Use of alcohol on call may merit expulsion!"

(Noah Wyle sighs heavily; cut to Ford commercial.)

Probably a good thing I wasn't on call tonight, then.

Tonight I went to get a nice, peaceful burger at the local bar. It was, instead of a nice, peaceful burger, Pariahs of The Medical World Night.

There was Karen, the woman who trained me at the abortion clinic. There was Julie, who used to escort there. Lisa, who did HIV outreach for the local health department and later moved to the capital city to do the same thing, was dining with Julie.

Goodness. All that the night lacked was a couple of old patients from my Planned Parenthood days.

All went well until Julie, who worked with a woman who worked with my ex-husband, brought up the ex-hub thing. Then everybody got very quiet as I struggled to put into words what the last year has taught me:

1. My marriage sucked from day one.

2. We were both too dumb to notice.

3. Regardless, I'm glad I was married to the man, and retain many happy memories of that decade.

4. He's better off now with the woman he's with, and I'm happy for them both; nay, thrilled, that they could be this content.

5. I'd rather not talk about it any more, thanks.

Perhaps I need to move to a bigger--0r a smaller--town. One where either nobody knows me and my history, or one where *everybody* knows it, but the town's so small nobody wants to talk about it.

If I stay here, my liver is going to cut out the middleman. It's going to hop out of my body, a la Lenny's brother on the "X-files," and go looking for a bar on its own.

Christ...

This is funny...

Completely off-topic

I finished Christmas shopping today

I can't talk about what I got my sister or David, since they both read this blog. But Mom and Dad have nifty things coming: alpaca sweater, horned lizard jewelry, many fine pieces of duck-shaped things for the bathroom. We have a long-running duck joke in our family, and I've used that to best advantage.

What did you say?

David made the comment yesterday that if the funding comes through for his B & B (he wants to buy one south of here, in a touristy area known for its wine) he'll get me a MINI for Christmas. Not likely, but I can dream.

Extremely touching

One of the nurse techs at work told us how he proposed to his wife. She was flying to LA, at the other end of the state, and he had the gate attendant wipe all the flight information off one of the boards and replace it with the words, "Maria, will you marry me?" The gate attendant then announced the proposal over the airport intercom, and everybody around them applauded. Cynical me got a tear in her eye over that one.

Straw what?

I've recently developed a fascination with straw-bale construction. It's termite- and rodent-proof, earthquake- and tornado-proof, damned near fireproof, and cheap cheap cheap to build. A per-square-foot cost of $10 is about all I'll probably be able to afford, ever, and most existing houses are far too big for me. I'm looking at two bedrooms, two baths, and right at 1,000 square feet. Preferably passively-solar-heated, with in-floor hot water heating in the bathrooms (I found I loved that in Denmark) and solar panels on the roof. I don't want to go totally off-grid or sell back energy to the utility folks, but it would be nice to have a system that would make things cheaper, as well as act as a backup.

The neatest thing about straw-bale construction is, for me, the "truth window". That's a little bit of un-plastered wall you leave in the interior part of the house, covered with glass, to show the structure of the house.

They say that hemp bale construction is even better than straw in terms of insulation (straw has an R-50 value on its own), but I hear that hemp dulls chainsaw blades, is a bitch to work with, and is hard to pierce with the rebar that allows it to be load-bearing. Plus, you can't get it anywhere but Canada.

The Nurse's Guide To Specialists

Internal Medicine:

Fit, well-dressed, with a cholesterol of 130 and the oddest prescribing habits you've ever seen. If you need electrolytes repleted or your INR brought to its proper level (that's a measure of clotting time that's influenced by coumadin), the internal med specialist is your gal. Or guy. If you're a nurse, having an internal med consult means that you'll be cutting tablets into quarters and giving 7.5 milligrams of something that comes in a 25-mg dosage, but only on alternate Thursdays during the dark of the moon.

Neurosurgery:

Brilliant, with a necessary arrogance. Would you want somebody suffering pangs of self-doubt while their fingers are in your brain? Didn't think so. Usually underfed and underslept. Will eat anything that's moving slowly or standing still. Very nice people, overall, since they have to deal with people who can't talk, walk, or make a lot of sense. (Those are the nurses, not the patients.)

Neurology:

Sweet, but from Mars. Odd senses of humor. Usually strange facial hair (on the men, not the women). Sometimes they have a fascination with Bach or zebras or rowing. Older neurologists tend to be courtly in the extreme and wear bow ties.

Orthopedics:

The jocks of the medical world. They are carpenters and craftsmen--and I mean that as praise. A good orthopedist working on your hip will leave you with the equivalent of really good Art Deco woodwork: functional and beautiful, with nothing extra added. If you see a muscular young man or woman of few words striding down the hallway with a tiny box containing magnifying eyeglasses in his or her hand, that's your orthopedist.

They also have very strange senses of humor. A few months ago the C group at our facility had "Talk Like A Pirate Day." "Shiver me timbers! Swab the deck with that dressing, matey! AAARRR!"

Cardiothoracic Surgeons:

I do not work with any of those folks and so have no clue what they're like.

Plastic Surgery:

Artistic, with the emotional lability that comes with artistry. I'm personally uncomfortable with plastic surgeons, as I wonder if they're casting a covetous eye on my double chin.

Urology:

How much does that suck? Proctologists are probably the only people with a more-misunderstood specialty. Urologists, however, have the benefit of access to the scariest-looking pieces of medical equipment in the entire hospital.

General Surgeons:

If you see a resident asleep in a chair at the nurses' station, chances are it's a general surgery resident. They're horribly underslept but have a solid working knowledge of where everything ought to go in the body. If you're a general surgeon, you can take people apart and put them back together with no bits left over. I've gotten speech of a few of them that's beyond "mmmmrrrppphhhh" as I wake them up, but not many.

Endocrinology:

Your average endocrinologist has a second brain somewhere in his body, in which he stores minute bits of important information that came from some obscure study in Backobeyondistan five years ago. They will speak to you as equals, even if their conversation about a complex patient eventually sounds to you like "Grobble grobblescrink mmmmREEEE! ppphhhhbt!"

Psychiatry:

Well-dressed, with a fondness for expensive shoes and dangling pendants (men and women respectively). Pleasant but strange. Psych nurses are nice as well, but strange. You *have* to be a little odd to work psych and be good at it.

The best illustration of a typical non-psych-nurse and psych-nurse exchange I can come up with is this:

Me: (trying to reach a med on a high shelf) "Sometimes I wish I were taller, dammit!"

Psych nurse: "Oh...do you have body image issues?"

Next week: The Nurse's Guide to Nursing Students

A cool circle of Hell, with nice silverware.

Today I had lunch with my boyfriend's family.

They are really very nice people. His brother wasn't there, having had car trouble on the way, but his sister was, with her husband and their three kids. His mom was there as well--the reason for the lunch was her birthday.

Let me preface this tale by repeating that I like these people. They're intelligent, polite, funny, pleasant folks.

The trouble was not them; nor was it their children. It was the lunch itself, or maybe the way events conspired against the lunch.

Background: Boyfriend runs the kitchen at an exclusive little lunch-and-dinner place that's attached to a bed-and-breakfast. Fifty-five people is about as many as get served on a typical night; reservations are strongly recommended for dinner. We went to that restaurant for lunch. David came out wearing his chef gear, taking a break from preparing food for a wedding, and ate with us.

"Us" being a four year old, a two year old, a seven week old baby, Mom and Dad, Grandmother, and me.

I'm childfree for a reason. I have little to no interest in children. They don't bug or delight me; they just don't register. Mostly. Unfortunately, one of the things that I hate is adults bringing small children to exclusive eateries that have nothing to entertain kids.

I was one of those people I hate today. The poor kids were trying their best to amuse themselves quietly and politely, but the bread-basket is only going to last so long and forks hold only so much interest. Babies tend to get fussy and have to be fed. Adults tend to try to have conversations that don't have much to do with kids' interests. And no matter how you try, any meal that involves children is going to revolve around those children. Adult conversation is impossible while you're trying to keep one child or another from amputating bits of itself with a knife or tipping over backwards in a chair.

Add to that Hayseed and Hayseedette, our two "servers". I put "server" in quotes because it took us four tries to get teaspoons and three requests to get lemons for tea. "Serve from the left, remove from the right" apparently means (at least to Hayseedette) "Reach across the person who's eating to drop a spoon with a clank on the table in front of the person to her right." Water refills took two or three requests. Coffee got cold. It was bad enough that David sat vibrating with rage next to me, getting more and more humiliated by the minute. As executive chef, he's not responsible for training the wait staff, but still...it's his kitchen and his pidgin.

At least the food was good. Though I did manage to dip my breast into some red pepper puree (a common problem for the busty, Beloved Sister assures me). Nobody noticed. I think.

The brother-in-law faced the menu with trepidation: Unfussy Foodie greets Schwanky Menu. He ordered a beer with a quiet desperation that made me love him and want to take him down the street for a burger. Sister was busy with Baby, whom I tried to calm down at one point but signally failed to un-fuss, beings as I didn't smell like family. And through it all sat Grandmother, being calm and gracious and keeping the two year old from killing herself with cutlery.

All in all, it wasn't bad--except for Hayseed and Hayseedette. I want to train Hayseedette, since she looks like there might be enough synapses in her vacuous eighteen-year-old head to someday make a half-decent waitress. Hayseed I want to kick in the face. Had I known I'd see him today, I'd've worn heavier boots.

This day started with David and me bent over a power snake, unclogging his sewer line. I would've gladly done that all day.

Fat and a quarter tit*

Yesterday was Holy Mary Mother of Gawd Revelation Day. Out of curiosity, I measured myself and typed the numbers into the website for bra fitting I provided the other day, only to find that I'd moved from Cute Lacy Numbers to Three Hooks and Minimizer Size. I am now, judging from the numbers, fully a quarter tit.

John in Phoenix is a snookum-wookum who has complimentary things to say about this blog. In response, since he's a nursing student, I've decided to edit and publish my Ten Rules For Nursing Students, originally compiled some time during my third semester. To wit:

1. Type everything. Instructors prefer typed documents.

It's easier, of course, to jimmy handwriting so that you take up the requisite five pages, which is why instructors prefer typing. It's also nice to be able to read what somebody wrote without having to decipher hieroglyphics for hours. Contrary to popular belief, most nurses have handwriting just as bad as that of most doctors.

2. Handwrite everything. Instructors prefer to see your handwriting.

Or, as one particularly flaky instructor told me, "I like to get a *feeeeel* for what you're doing."

3. Concentrate on textbook learning; you'll learn skills in your graduate internship.

Not a bad piece of advice, especially if you have an internship like mine: heavy on tests for the first three weeks.

4. Concentrate on skills; you won't have time to learn them at your first job.

Foleys and IVs are all you really need to know. A trained monkey can do a dressing change. Really.

5. You will always have one instructor who is totally, completely, inarguably from Mars. Deal with it.

My From Mars moment came in a classroom discussion of ethics and the nursing shortage in our last semester, when one of the instructors on the team told us that the reason for the nursing shortage was that "we've aborted a third of our population since 1973." Everybody, for some reason, turned and looked right at me. I said nothing, preferring to marvel at the clear transmission she achieved even while orbiting somewhere outside the Van Allen Belt.

6. One in ten of your female classmates is looking to meet a doctor. One in ten of your male classmates might be, too. Deal with it.

Not much you can do about that one, unfortunately. The most you can hope for is that she'll leave the plum job she gets as soon as she meets a likely resident, leaving the position open for you.

Before anybody accuses me of stereotyping or downing young female nurses, may I present the following evidence? Out of 19 female classmates, one was in nursing school so her husband would "get off her back" about getting a job. She was pregnant at the beginning of our last semester. Another two were self-professed doctor-hunters. A fourth was admittedly in it for the money, and took a job at a pediatric clinic with the expectation that it would be low work/high pay (heh). A fifth was "drifting", in her own words, and didn't know if she'd actually use the degree or take up crystal healing.

Is it any wonder I was valedictorian of my class?

7. You will have no life for two to four years. Don't worry. It'll still be there when you get back.

I swear. Really. Honest. You'll be able to sleep and get haircuts and go dancing and everything.

8. Everybody thinks they flunked the NCLEX. Few people actually do. Go ahead and get blasted anyhow.

9. Yes, you do look dorky in those whites.

10. No matter how bad things are now, they will end. You will eventually be a nurse, subject to redefining hell. Of course, you'll also redefine happiness.

I can't tell you how much weight I lost the last six weeks of nursing school. The speculation on class ranking had really ramped up, and as immune as I tried to stay, I still felt the pressure to come in first. I think the under on me was something like 10 points.

But it ended. Valedictorian means shit in the world, except that older nurses will expect you to be able to recite the latest information on Disease X without pausing, like a computer.

And you know what? Being a nurse is infinitely easier than being a student. For one thing, being pushed out of the nest means not only the freedom to screw up, it means the freedom to make judgements. You're not really allowed to do that as a student. For another, you're finally done with those fucking care plans. For a third, you're able to sleep without dreaming that you've missed a test or three. Instead, you dream of beeping IV pumps.

To all those poor sots out there who have three, or two, or just one semester to go before the NCLEX, I raise a toast. Nursing is *not* the hardest job in the world. Being a nursing student is.

Oh, I forgot one thing:

11. Comfortable shoes. Comfortable shoes. Comfortable shoes. Comfortable shoes. Comfortable shoes, fer Godssake!!

***

*Carl Bennett, quoted by Oliver Sacks in An Anthropologist on Mars

Looks like it's time to call in the professionals.

Fair warning: girlyness ahead.

One thing nobody ever tells you when you enter nursing school is this: your hands and feet, after four years of schooling and practice, will be practically unrecognizable.

It's not just washing your hands every ten minutes or less or using alcohol foams on them. It's not just wearing heavy protective leather clogs all day long or running from place to place like a chicken. It's a combination of those things and lifting heavy patients and equipment, as well as not having the time or energy most days to fuss with cuticle remover or foot files.

My feet have grown a half-size since I started school. What was once a nice average 8 1/2 medium pair of feet is now a 9 wide. David said, as gently as possible the other night, "When did you decide to try to grow hooves?" I have calluses between my toes; that's how bad it is.

So I'm thinking that it may be time to enlist the services of a professional pedicurist and manicurist twice a month or so. Pal Joey took me for my first pedicure last summer. My shoes fit differently after the poor woman had finished sanding down my calluses. Not that I'm obsessed with my calluses, or that I'm afraid I'll injure my bed partner (although one callus, on my left small toe, left a scratch on his shin), I'm just sayin'.

Taking care of one's hands--which I do actually do--is a matter of self-interest in the nursing profession. A torn cuticle or a hangnail opens up an avenue for infection, no matter how careful you are with gloves. Long nails (ie, anything past the end of your finger) tear gloves and are a perfect habitat for bugs. I am therefore aggressive about keeping my nails short-short, using a good cuticle remover every other night, and slathering on lotion when I get home from work. As a result, my paws look workmanlike but not abused. It's my feet that resemble something from the Russian Ballet.

I guess I'll call my hairdresser, a patient woman who cuts my hair twice a month, tomorrow. I'll see if her partner has any openings on Wednesday. Her partner has horses and a fascination with straw-bale construction, as I do, so will be open to not putting pink nailpolish on my toes.

We'll see.

What's that blue stuff on the weather map?

Oh. It's a flood warning. Lovely.

Chuckleheads on Parade, Part Two

The chucklehead situation I wrote about the other day became so bad on Saturday that I could only sit back and stare with my mouth slightly open. Not only did the patient who got screwed as an inpatient get screwed as an outpatient, but I had another one of Doctor Chucklehead's patients who's going to be in just as bad of shape this morning. Thank God I'm not there to see the rivets pop out of the case manager's skull.

One quick tip for any medico who might be reading: If you write an order at 1700 on Sunday for rehab placement on Monday morning, it's *probably not going to happen*. Case managers have weekends, you know.

I don't want to go into details on the Previous Chucklehead Victim. Suffice to say that the level of arrogance, laziness, and outright disrespect I've seen from The Chucklehead Twins (attending and resident) is unmatched in my experience. Except maybe by the protesters who used to work outside the clinic where I worked. They walked the sidewalk with a baby every day for five years and got paid $38,000 a year by a local anti-choice group for their efforts.

Anyway. The case manager, a slender woman who drinks more coffee than I do, and I will have to figure out a way to do end-runs around Dr. Chucklehead and Friends. The normal routine of explaining, very patiently, why X and Y and Z orders won't work, or why one actually has to *write* an order for what one wants, rather than expecting it to be transmitted telepathically to one or more colleagues, is not going to be enough here. Punishment won't work. A good dope slap would probably be really satisfying, but it won't accomplish much in the long run.

In other news

It's been raining off and on for a week and a half now. This is wonderful for the crops and the grass and all the little birdies, but bad for the people who (like me) have to commute through construction areas. Remind me sometime to tell you what it's like to be slogging along in a Honda Civic when allofasudden the world goes away and you're covered with water.

My car also needs new tires. *sigh*

A Handy Site for Women

More than likely, you're wearing the wrong size bra. I know I am. Check this
out and learn how to fit a bra. As soon as I'm done here I'm getting out the tape measure.

Testing, testing

This week we have a series of tests at work to requalify us for whatever work we're doing. It's a hospital-based version of the ACLS or BLS or COC or whatever tests are national. In other words, we test three times a year for what normally only gets tested once. The biggie for me will be EKG stuff; I'm not a cardiac nurse for a reason. EKG strips have never made the slightest lick of sense to me. I passed that part of nursing school by taxing my short-term memory to the fullest and then promptly forgot everything I'd learned. Since David will be at a food show tonight and tomorrow, that'll be my time to cram QT intervals and P waves back into my noggin.

And so to bed

It's back to beddy-bye for me. The one drawback of working three days in a row (aside from the punchiness that hits on day 3) is that your body wants to get going at 3 am on day 4. I've been up long enough to get sleepy again. The cat will teach me how to nap.

It's schaDENfreude, asshole!

Confidential to Denise: I really, really do know how to spell 'schadenfreude'. It's just that I can barely type in English most of the time, let alone German.

Some nice person sent me an email asking "What's a typical day like for you?" Herewith, A Typical Day In The Life:

0420: Awaken to the dulcet tones of a BBC announcer soothingly reporting the latest casualties from the Gaza Strip.

0423: Pour first cup of coffee.

0424-0440: Mindless circumambulation with said cup of coffee gripped tightly in paws.

0440-0520: Shower, try to apply eye makeup without ending up in traction, dress, decide on lunch. Leave for work.

0610: Arrive at work. Eat yogurt while sitting in car, listening to the dulcet tones of Carl Kasell totalling up the latest casualties in Iraq.

0625: Stumble in to the breakroom with another cup of coffee, prepare for report.

0640: Report until 0700. Pee if possible.

0700: Start waking up patients. Most of them are grumpy, since they've been awakened every two to four hours for days on end. Check lab results from earlier in the morning. Inform the neurosurgery nurse liason if there's anything amiss. Send people to surgery, CT scan, and echo.

0800: Start charting. Morning assessments are done; all that remains is putting them on paper and hoping that I haven't charted Patient X's assessment on Patient Y's chart.

0803: Think longingly of eggs and bacon in the cafeteria downstairs, then remember latest scale numbers and cholesterol results.

0825: Five minutes for bran muffin.

0830: Begin passing morning medications. Deal with, at a minimum, six new orders and four new crises. Receive patient from ICU.

0915: Finish passing medications. Start calling residents, consults, specialists, the housekeeping people, the guest services staff, family members, and wound care/ostomy care/urology people for help or with information.

1006: Morning routine of physical therapy, bowel programs, and incoming phone calls begins. Take time to pee if possible. Change dressings, check ins and outs, empty drains. Retrieve six new orders from box. Discharge two patients home. Charting.

1128: Begin passing noon medications, hanging antibiotics, giving Decadron, and checking blood sugars and every-six-hour lab reports. Do noon assessments on neurology/neurosurgery patients. Call report on patient going to rehabilitation unit. Chart.

1230: Finish above. Begin to think longingly about sandwich. Retrieve six new orders from box. Send patient to rehab.

1240-1315: Various crises, lunch preparations, and phone calls.

1315: Sit down with sandwich. Take first lustful bite, be called away for lift help or because Patient Y has just had explosive diarrhea that covers the entire back wall of the bathroom.

1330: Return to lunch, if fortunate. If *extremely fortunate*, have time for another cup of coffee and a quick pee break.

1400: IV flushes, any dressings I didn't get to in the morning, afternoon rounds of tests start. Assess non-neurology patients again. Catch up with respiratory therapists for progress reports. Check box for new orders. Find new order written by chucklehead from any one of several services and call for clarifications. Hang new bags of tube feeding. Check ins and outs, empty drains, calculate total IV drips for the last seven hours. Check box for new orders. Hang potassium, magnesium, or calcium drips. Chart.

(Optional: four new crises.)

1530: Look at clock, realize there are only three-and-a-half more hours in the day. Fail to mourn this realization. Start 1600 assessments on neurology/neurosurgery patients. Get two new admits from surgery. Discharge late-home patient. Plow through group of new residents taking tour of unit. Be almost rude to hospital administrator taking group of investors through unit and thus blocking the entire damn hallway so I can't get a bed through. Field call bells from patients with problems ranging from inability to breathe to their fruit basket not containing enough grapes.

1700: Neurosurgery rounds start. Stare dully at wall, wishing I worked a ten-hour shift rather than a twelve-hour. Wonder what to have for dinner.

1745: Neuro rounds end. Reassess patients. Retrieve six new orders from box. Direct men who are impersonating Birnam Wood to various rooms for flowers/potted plant deliveries.

1800: Last push of the day. Hang evening medications, pass evening medications, check IV bags. Long for strong drink. Fill out report sheets. Do quick rounds of rooms, picking up dirty linens and trash, changing water in vases (yes, we really still do that). Check to see that evening labs have been sent. Sometimes, if very fortunate, practice French with Cajun patient or discuss politics with Political Heavyweight Patient over dinner. Chart.

1845: Report to night shift. Give up beeper. Hope I haven't forgotten anything.

1908: Punch out. Go home. Fall over.

Chuckleheads on Parade

I was not going to blog about what happened yesterday at work. As I told friend Arlene, it made me sick to my stomach to even think about. Then, as I was sitting outside with my coffee this morning, I started getting angry.

I have the feeling that what I did yesterday is about to blow up in my face.

Here's the situation: a young HIV positive patient came in for an emergency joint replacement. He has a condition that makes the bone in his large joints die off--it's a side effect of the medication he's been on. He had the surgery Thursday and should've gone for rehabilitation Saturday or Sunday, but he was still at the hospital yesterday. The Chucklehead Brigade from the orthopedic service had decided at the last minute that blood transfusions and more cultures were necessary. He almost left AMA (against medical advice, without formal discharge), but the lead doc on the team talked him out of it.

This kid didn't understand that the fluid a doctor had drawn out of his hip was going to be used for cultures. He didn't understand what the word "culture" meant. He didn't know why they'd transfused two units of blood into him and didn't understand that he'd given consent for the transfusion when he consented to surgery. The lead doc's explanation consisted of "I'm really busy and have a lot of patients in clinic right now, so I don't have time to talk to you."

In short, he didn't understand what was going on, and nobody had bothered to explain it to him.

I had this guy in my care for *four hours* yesterday. Of that four hours--and keep in mind I had three other patients as well, including a new admit--I spent probably two hours with him. That's a huge amount of time for any hospital nurse. This kid needed it, though.

He's poor. He's non-white. He's HIV-poz. His family has limited transportation. He needs to get home, but for some reason he can't conceive, the doctors aren't letting him go. At five yesterday afternoon, as I was filling out his discharge paperwork--because we'd both been told that everything was ready for him to leave--the ortho resident swanned in and said he'd have to stay for an internal medicine consult.

This is when Nurse Jo takes off her cute nurse mask and becomes Ratched.

Long story short, I made a lot of people very unhappy yesterday, including the attending doc who'd done the surgery and then blown off his patient. The patient, however, is going to go home today with pretty much everything he needs, including a long-term venous access for antibiotics. I told him I'd call today at ten to make sure he was on his way home and that if he wasn't, I'd raise hell.

This is what really pisses me off:

For several years, I worked as a paraprofessional with mostly-poor women, some of whom didn't speak English. I managed to make clear the consents that they signed even if they were Chinese-speaking immigrants, even if they were deaf, even if they were illiterate. Literally. I took the time in a busy clinic to do such cutting-edge things as answer questions in plain English. The place I worked didn't have a lot of money, didn't have readily-accessible doctors (the care was provided by nurse practitioners), didn't have a lot of clout politically in the community. And yet I managed to do my job, not only to *minimum standards*, but to what I think were pretty damn good standards.

Why can't a fully-staffed, cutting-edge hospital do the same thing? Why did I have a patient who was ignorant of almost everything that had happened to him in the last three days? Why had nobody informed the doctors that his pain control was bad? Why had nobody talked to him and his family about what was actually going on in his hip joint? Why was *I* the one who had to get angry and motivated in the last four hours of the day and make things happen for this guy?

I swear to God: If one person wants to give me trouble about what I said, did, promised, or acted on yesterday, all everloving hell is going to break loose. The political implications of some of my reactions and actions yesterday might lose me my job--seriously, as it's never a good idea to be insulting to an attending physician--but at this point, they can fucking have it. Any place that spends more effort on getting fruit baskets for some VIP than on making sure a run-of-the-mill patient understands why we're cutting on him is not a place that deserves me.

Some days I really, really wish I lived in the country and worked at some tiny hospital where I'd have the chance to do *happy* things, like helping babies be born or taking care of people who aren't getting jacked around.

*sigh*

Shit, oh dear, part two.

Note: avoid this entry if you have a problem with the requisite female blogger's musings on weight and body image.

So, today, I was wandering around the apartment, wondering what that funny stiff feeling was in my lower back. I couldn't bend backwards easily and felt, well, stiff.

I figured it was muscle pain. Then I put my hands on the small of my back and realized that it was my hips keeping me from bending over backwards.

Um.

At 117 pounds, the recommended weight for my height, I am skeletal. At 130, I'm just fine. At 150-something, where I am now, I am not as motile as I'd like to be. Not entirely sessile, mind you, but not terribly flexible.

Plus, I'm getting winded walking up the three flights of stairs to my apartment.

Plus plus, the two male nurses on the floor who are close to me in height weigh eight and eighteen pounds less than me respectively.

Time to start shutting the pie-hole and getting back on the treadmill.

*sigh*

This is a depressing prospect. For most of my life, the trouble's been to keep weight on. In times of stress I simply burned off anything I might've gained in happy times and kept a fairly even balance the rest of the time. Now it's looking like the Dreaded Mid-Thirties Metabolic Slowdown has hit. The fact that it's hard not to eat late at night when I don't get home until eight and that it's hard to get to the gym most nights doesn't help.

I thought it was bad six months ago. I was wrong. It's worse now.

*sigh*

Requisite musings on weight and body image might become as much of a routine here as Blog O' The Morning! is. Don't worry. I'll warn you before I mope.

Friday Fluff

Blog O' The Evening! (Blog of the Evening, Beautiful Blog...)

Incurable Hippie

Site of the Evening....

Regrettable Food

Girly Product Reviews, Inspired by the latest Allure Magazine Issue

Olay Complete Body Wash, Sensitive Skin Formula, is totally free of icky perfumes. It's also good for people with really, *really* dry skin, like me.

L'Oreal Lash Architect super-duper weirdo lash-curling waterproof formula will stand up to mineral baths in odd, out-of-the-way places, but the sensation of feeling your lashes curl is very odd. I'm sure there's some sort of polymer technology at work here, but I'd prefer to remain ignorant and simply throw the tube away. I have enough to deal with at 0500 four days a week without the sensation of various body parts being manipulated by colored liquid.

It also makes me look a whole lot like Carol Channing.

Dove products: buy them. All of them. Soap, lotion, scrub, whatever.

Dove Bars with almonds are the quintessential PMS food.

Toad Hollow chardonnay is good for a crowd. Not too expensive, not oddly metallic and oily, with a pronounced oaky flavor that dissipates if you let it breathe.

Things I have discovered I am expert at:

1. Picking all the Oreo pieces out of a pint of cookies & cream ice cream.

2. Bandage changing.

3. Driving irresponsibly fast in construction zones.

4. Timing french fries in the oven so that they come out exactly as crispy as you want them to.

5. Avoiding political topics in my online life, though I'm feminist and liberal enough in the meat world to glow in the dark.

This last is why you won't see any dissection of the war or the debates or the Presidential campaign or any of the stupid things Governor Hair has done recently here. If you want a feminist political blog, check out whatshesaid.

Rules for Residents

It's that time of year again. We got a new crop of residents this summer and they're just now beginning to feel confident on our floor. This means that some of them have turned into flaming assholes. Some of them are not so bad, true, but this isn't directed toward the not-so-bad ones.

Please note that the nurse or lab technician will be referred to herein as "she". Nursing and lab teching are primarily female jobs.

The resident will be referred to as "he". While our resident population is split roughly 50/50, I have yet to meet a female resident who yells, uses profanity, or attempts to humiliate nurses in front of other people. Those who try such antisocial tricks have been, invariably, male. Suck it up, boys; it's life.

Rule Number One: Policies, procedures, and standards do not exist solely for the purpose of inconveniencing you.

There must, therefore, be some other reason for them to exist. Perhaps it's patient safety. Or worker safety. Or Federal law. If those considerations pale before the issue of your precious convenience, do not blame the nurse or lab tech who explains the problem to you. Do not complain to them that the policy is unreasonable. Do not threaten them. It will do you no good and only make you enemies.

Instead, express--civilly, please--your frustration with the situation, if you must. Ask for help. Ask for advice. We will then bend over backwards to help you out.

Rule Number Two: If You Are An Asshole, You Will Get Zero Slack From The Floor Staff.

Remember the resident who tried to tell me that an oxygen supply line was misconnected and berated me for same in front of a patient? He now gets called by every nurse on every floor to double-check every damned connection on every piece of equipment to which his patients are hooked. Every time.

He also was hard enough on a charge nurse I work with to bring her nearly to tears. This woman is tough, no-nonsense, and strong. I don't know what he said, but it must've been something. I'm sure he felt good when he hung up on her. I'm sure he felt less good when his attending physician called him on his behavior in the weekly ENT meeting.

Another case: A resident yelled at two nurses in the space of a week for not calling him with lab results. These particular lab results were within normal limits and there was no order to notify him with the results, so we let them go. That's our policy.

That resident got called at odd hours every night for six months by every nurse he worked with. We double-checked everything with him. We called for approval before implementing pre-printed protocols. We called for orders for suppositories and Tylenol. The pharmacists called before implementing pharmacy protocols. The lab staff called with every single lab result on every single patient. Around the clock. For six months.

His behavior has improved.

Rule Number Three: Being A Jerk Will Not Provide Your Patients With Better Care.

If you're personally unpleasant, we will delegate every interaction with you to whomever will accept the assignment. We'll take very good care of your patients--that's our job--but you'll get one, maybe two phone calls a day with all the results and news of the day rolled into three minutes.

Rule Number Four: Being A Nice Guy Will Get You Perks.

We play favorites, openly and unashamedly. If Resident A gets a nickname and plates of food set aside for him from the staff's potluck lunches, there is probably a reason. If Resident B is treated brusquely and with thinly-veiled hostility by the entire staff, you bet there's a reason.

Resident A is also much more likely to find people to help with bedside procedures than Resident B. Resident A will have a staff of willing nurses who will walk through fire for him if something is going badly wrong. Resident B will be told to find documents himself or call the lab on his own.

Rule Number Five: There Is A Very Strong Probability That The Nurses You Work With Know More Than You Do.

"Very strong probability" in this context means "virtual certainty."

Our hospital's average nurse has been working with a specialized patient population for more than five years. She spends hours with her patients several days a week. They tell her things they wouldn't tell their own priests or mothers. She sees them when they're sleeping and knows when they're awake.

She also understands the basic surgical techniques that doctors use and their effects on the body as a whole. She has a grasp of the lab values that she encounters on a daily basis and knows when trouble is brewing.

Most importantly, your average nurse has a good gut sense of when it's about to hit the fan.

Therefore, if a nurse calls you at eleven on a Sunday morning with the news that everything with Patient X is so far going well, but that she has a niggling suspicion that something terrible is lurking just beyond the bend, you should listen.

If a nurse tells you that your new patient is a drug-seeking wacko with aggressive tendencies, don't be condescending. Remember that this nurse is, in all probability, older than you are and has not spent the last fifteen years in school. More than likely, she worked with drug-seeking wackos as a full-time job at some point. Listen to her. Take her seriously. Keep your eyes open. That way, when the patient hoards Phenergan in his bed or throws a chair through her window because she can't get morphine, you won't be surprised.

It's not rocket science, guys.

I promise that your balls will be just as big at the end of the day as they were at the beginning, even if you're pleasant and civil to everyone you see. I promise that your integrity as a surgeon will not be compromised by apologizing to someone that you've screamed at. I promise that things will be much, much easier if you treat those lesser beings who keep your patients alive and healthy with respect and honesty.

If you don't, that's your business. Please be aware, however, that most of us have been through much worse than you. We have no compunction about mopping the floor with your sorry ass if you step over the line.

TMI, TGDG

Too Much Information, Too Goddamned Girly.*

I should have a T-shirt that says, "My doctor put me on fucking Tequin and all I got was this lousy yeast infection." Not only did I pay $61.95--with insurance, thank you--for the privilege of eliminating a bacterial superinfection in my sinuses, but I get the added joy of trying to figure out which over-the-counter yeast infection remedy is comparable to bribing a Diflucan from the pharmacist at work. Not that I'd ever do that, or that he'd ever comply, you understand; this is merely an intellectual exercise.

The bacteria are gone, thank the gods, which means I'm left to deal only with the viral infection that started it all. I still have to finish the fucking Tequin, but at least I'm not running a high fever. I'm only producing amounts of snot that would make even the most hardened otolaryngologist quail. And I'm coughing like Mimi from "La Boheme," a reference that exactly none of my coworkers got today at work. Sucks to be the only one who can both sing "Mi chiamo Mimi" and get the joke.

Because I know how to have Big Fun on a Saturday night, I bought the following things at the grocery store this evening:

1. A bottle of Toad Hollow chardonnay. Not a bad little wine, even if it tastes like it's been stirred with a 2 x 4. The oak is pronounced.

2. Copies of "Scientific American" and "Allure: The Best Beauty Issue".

3. Generic miconazole cream.

4. Shoe polish (liquid) which I promptly squirted all over my kitchen table (not a big deal) and my carpet (a slightly bigger deal). However, my shoes are now shiny and scuff-free.

Allure's advertising-driven editorials tell me that Neutrogena has come up with some product that makes it possible to plane several layers of skin off your face--without redness or irritation!--while Maybelline has come up with a product that replicates the look and feel of the skin you've just removed. There's also a full-page ad for something called Brava, a breast-enhancement system.

This Brava thing deserves a paragraph of its own. Going to the website will give you no solid information on price, use, or configuration of the product, but it will provide scary hints as to all three.

Brava seems to be some sort of suction-based device that yanks on breast tissue until it expands and fills out. Why this is a good idea, or one which even the most desperate woman would consider, escapes me. Anyhow, you're supposed to strap on the Brava cups ("They're huge! They cover your whole chest!" says one review) in the privacy of your own home ("You can be as discrete [sic] as you like" says another) and then wait for the miracle to happen. In between uses, there are handy tips on reducing skin irritation (use cortisone cream) and fitting the product (strap the cups on with cut-up pantyhose). There's even an 800 number to call for help with financing.

Financing. For a pair of hollow half-globes that yank your tits out of shape until they give in. There is so much wrong with this that I don't know where to start.

Tomorrow morning, once I've got a little more energy, I'm going to attack the remaining shoe polish stain with rubbing alcohol (thanks, Beloved Sister!) and read "Scientific American." You just can't get the same effect from articles on the evolutionary benefits of siblings as you can from articles on peeling off bits of skin and self-curling mascara.

*Anybody who complains about the unusual Personal Squick Factor of this post can reference Belle, Diablo, Joe, or The Good Wife and kiss my ass. Thank you and good night.

Extra! Extra!

The Management is pleased to announce a new feature in this space, born of early-morning insomnia and the slightly hallucinogenic effects of Tessalon Perles.

Blog O' The Mornin'!

This will be an occasional feature, highlighting blogs and websites that The Editor has run across in her bleary-eyed InterWorldWideNet surfing.

Today's entries:

Sure thing, Babs

Spamusement!

Nominations are welcome.

Wow.

"Better than 'Scrubs'," he said.

Halfacanuck

"Mucus plugs sound really gross," she said.

Alexa's Escort Blog

Warning: the second link is more explicit than I'd normally put up, but it's also just cute as hell. Anybody who can talk about how much she loves Jimmy Choos at the same time she's mourning the lack of sensation that Viagra gives a 75-year-old man gets my vote.

Warning: the first link is to a blog whose author outdoes me in grumpiness. I mean that in a complimentary way. "I do not want a second pizza. I do not want 30% off." is how I often start my mornings.

Enjoy. I may have to start a Blog O' The Mornin'! feature.

Mucus, take two (now with addendum!)

I normally distrust physicians who have curly hair, dimples, and twinkly brown eyes. Especially if they have wire-rimmed glasses. Especially especially if they wear ties with little golf emblems on them.

I was therefore prepared mightily to distrust the doctor at the local Doc-In-A-Box this morning, until he opened his mouth and said, "Gee, you've had a lot of the same crud in the last year, haven't you? Looks like Tequin got rid of it last time."

Then he whacked on my sinuses and looked surprised when I jerked away (Yeeouch!), listened to my lungs, and nodded sagely when I told him I'd had a patient with pneumonia a few days ago. "Aerosolizing God knows what into the air, coughing in your face" he said.

Now I have a prescription for two weeks' worth of Tequin, a strong flouroquinolone antibiotic which my books assure me is good for everything from gonorrhea to Haemophilus influenzae and will take out methicillin-resistant strep as well.

David came over when I got back from the doctor. He took me for Chinese broccoli and soup, then brought me home. I crawled into bed and woke up a few minutes ago, hungry and disoriented.

I wonder what I'll take if Tequin doesn't get rid of this sinus infection. Leeches? Bleeding? Powdered frogs?


Addendum: I wrote my sister about the sinus infection and the way doctors test for it (by whacking your sinuses with their fingers) and she had this to say:

I remember once a doctor put her thumbs on either side of my nose just below my eyes and shoved, and I circled the ceiling shouting "wakwok" 57 times. On the 58th circuit I bumped my head on the light and fluttered down. This was at least a decade and a half ago and I still check every new doc out to be sure it isn't her.

Mucus, autonomic dysreflexia, and vaguely irritated bovines.

Mucus

I have a cold. Or a sinus infection; I can't tell which. All I know is that life is currently not happening without pseudoephedrine, a drug I normally avoid at all costs. It makes me do what I did this morning; that is, wake up at 2:20 and not be able to get back to sleep until six.

If I could just sleep standing up, that would be much better.

Autonomic Dysreflexia

Here beginneth the first lesson: autonomic dysreflexia is, according to Taber's Cyclopedic Medical Dictionary, a condition commonly seen in persons with an upper spinal cord injury that is caused by massive discharge of sympathetic reflexes from the sympathetic nervous system.

In English, what that means is this: A person with a complete or incomplete injury of the spinal colum somewhere high, usually in the neck, will occasionally have episodes of hugely high blood pressure, tremors, sweats, panic attacks, and other nasties. These are most often brought on by, believe it or not, a full bladder. A fecal impaction takes second place. Other causes might include positioning or bedsores.

I had five patients on Thursday. Four of 'em I cured by noon, which left me to deal with Patient Number Five. He's a high incomplete tetraplegic (quadriplegic) who had a partial transection of his spinal cord at about C6. Feel that bump at the back of your neck, just above your shoulders. His break happened just above that.

He's a nice guy. He's been a quad for about six years and has been married to his equally nice wife for three. (Note to the gaping masses: quadriplegics can and do have perfectly satisfying lives, including sex lives. It depends on the injury, the deficits, and the person.) He came in because he'd started having odd pains in his belly when he laid down in certain positions. His doctor figured it was his implanted muscle-relaxant pump malfunctioning.

(Note to the interested: baclofen pumps can be implanted in the abdomen and programmed to disperse small amounts of baclofen or baclofen in combination with other drugs to the spine, thus reducing muscle spasms and pain.)

At about one o'clock, this poor guy went into an almost-endless cycle of autonomic dysreflexia. His bladder wasn't full, he wasn't impacted, his positioning was fine, he had no bedsores. *Nothing* could explain what was going on...

...until I took a look at his labs with Sparky, his doc. "Sparky," said I, "I know his urinalysis shows colonization, but is it possible that that colonization could've turned into an active infection?" Sparky pondered for a minute, then decided that I might have a point there.

People who've had bladder infections will tell you that even a tablespoon of urine in an irritated bladder can drive you to distraction. I think that was what was happening with this guy, though I never got a definitive answer. The rest of the day I spent giving him huge doses of baclofen and Demerol in an attempt to break the spasms and the blood pressure problems by breaking the pain cycle.

The trouble with a high spine injury is that the body wants to work on a positive-feedback mechanism. Any mechanical engineer will tell you that that will lead to a burnout in machinery. In a human, it leads to blood pressures of 290/155.

It was not a fun afternoon. He stabilized during the night shift, though, and presumably is on his way home now.

And vaguely irritated bovines

Question: what do you call it when a person has a brain biopsy that comes back inconclusive for Creutzfeld-Jakob disease?

There is no answer for that one. If I knew of a good punchline, I'd've used it already.

Yet another patient came in with some indefinable brain problem that causes them to shake, become nonresponsive, and curl up in a ball. The biopsies we did don't show anything definite, so the diagnosis will probably be made on autopsy (as so many of them are with troubles like this).

CJD is different, by the by, from "mad cow".

Mad cow disease, or variant CJD (vCJD) hits early in life, in a person's twenties or thirties. It starts with odd neurological defects that often involve quite a bit of pain and takes several years to kill the victim. It's transmitted by--and pay attention, here--eating the neural tissue of infected animals. Chuck roast is fine, filet mignon is safe. T-bones are a little tricky, and ground beef (especially the mystery-cut ground stuff in the prefab chubs) is most dangerous, as it's extracted by a process that often mixes in bits of spinal tissue by mistake.

Creutzfeld-Jakob disease, on the other hand, is spontaneous. It has no recognized trigger, though genetic mutations might play a role. For some reason we don't understand, tiny proteins in the brain called prions suddenly start flipping over and turning into what's essentially a mirror image of their old selves. They induce other proteins to do the same, and you eventually end up with a brain full of holes like Swiss cheese.

It hits people in their 50's to 70's and takes about six to eight weeks to finish them off. As far as we can tell, it's relatively painless.

(Tangent: People often ask me if I'm worried about getting vCJD from eating beef. My answer is this: I commute 40 miles a day on a hugely busy highway and cross a busy street to get to work; I stand a much higher chance of ending up pasted to the front of a city bus than I do of getting vCJD. Go ahead and eat your steaks, people.)

CJD is quite rare. Only about one person out of a million will get the disease, which means we've got the area's biggest CJD population rotating in and out of our hospital. You know it's bad when all a nurse has to say during report is, "Well, it's typical CJD" and everybody around the table nods in understanding.

And finally, a piece of good news

Georgia of Odious Woman has been kind enough to link this blog from hers. Omigoodness!

I urge you to check out Odious Woman. Georgia is a crack writer and makes even lifting weights and running sound fun.

I saved somebody's life yesterday

Well, I helped, at least.

I sucked a mucus plug out of a patient's trache, no big deal. But it's left me unexpectedly shaky and flipped out.

Here's the deal: I had a patient of a sort I'm not used to: a radical neck dissection for laryngeal cancer, with a tracheotomy that was fresh. Frech traches are nasty, since your body produces lots of mucus to try to deal with the insult of having a hole cut in your airway, plus you have lots of swelling. Those issues combined with the fact that the trache tube can come out make a fresh post-neck-dissection patient a bit of a worry all around. I was paranoid-ly checking on her every fifteen minutes all morning.

The patient's daughter came out of the room at 0918 and said, "Jo?" in that tone of voice that means "I hope whatever's happening isn't really happening." I flew into the room to find my patient panicking and unable to breathe--no breath sounds in the chest, no air movement through the tube. So I called Dave, our charge nurse, and he brought in an ambu-bag. (Ambu-bags are those squeezy things that pump air into your lungs when you're on "E.R." on a gurney being rushed down the hallway by Noah Wyle.)

Her oxygen saturation had gotten to 25% by the time Dave and I managed to knock that plug loose, me with suction and him with the bagging. 80% is considered a critical level.

At 25%, a person goes limp. Her mouth falls open, her eyes dilate, and she doesn't respond. Her heart kind of flutters around in her chest, unable to keep beating without the stimulus of the lungs.

Then, when you finally knock that damned plug loose with the bag and the suction, her breath rushes back into her throat with a huge rattling sound and she starts to grimace. That's when you come back into your body and realize dimly that everything you've done for the last two-and-a-half minutes has been totally automatic, without thought, without conscious action. You realize that you've ordered a crash cart and that it's appeared from somewhere without your noticing, that Daughter and Son-In-Law are looking a bit tense, and that you're shaking.

Then you look at the clock and see that it's 0922. It feels like 1630.

Like I said, a mucus plug is officially no big deal. They happen a lot, so you're prepared for them: the fresh trache is near the nurses' station, right across from the cabinet where the respiratory team keeps its supplies. I didn't have to call a code (thank you, God, thank you), and my patient came back fine and dandy, if a little tired.

It affected me much more badly. When her O2 sats dropped to 25, I thought "Fuck." That was all. Just "fuck." Not "Fuck, now I'll have to code her" or "Fuck, now she's dead" or "Fuck, her pupils aren't reacting" just "Fuck." With everything else rolled into it.

Dave looked at me afterwards and said, "Good job." From him, that's high praise.

I went and got mashed potatoes and green bean casserole and buttered carrots for lunch.

Cholesterol

I am turning thirty-five in a few months. That means I'm older than Britney Spears, thank God, and still younger than Daniel Schorr.

Beloved Sister just got her cholesterol back from the lab. It's high, and her LDL and HDL suck, as she put it, dead rat. This makes me nervous, since Beloved Sis has much better lifestyle habits than I do. She doesn't work 14-hour days, doesn't drink to excess, doesn't eat Sonic. She also works out constantly and can donkey-press something like 700 pounds.

35 is the benchmark age for a lot of stuff. First mammogram if you have a first-degree relative with breast cancer, baseline cholesterol, aneurysm territory. It's osteoporosis risk and think about retirement funds, why don't you own a house and a working car time, oh you never had kids, risk of thus-and-so jumps mightily. You're more likely to get hit by a bolt of lightning than marry a terrorist, Toyota Scions are too young for you and the Mini is pushing it, why don't you get an Accord?

However, it's okay to like Garrison Keillor. You don't have to wear neon colors. Blue eyeshadow is beyond the pale, and nobody expects you to be really, really skinny and flat-chested. Long narrow skirts are acceptable. You get very strong in your thirties, and 35 is when you can show off your amazing biceps and deltoids. Coffee becomes a way of life rather than just a beverage. Drinking no longer carries with it the fear of hangovers, and nobody looks at you funny if you say you like Scotch, neat. You become much more interesting than a 20-year-old.

Still, I won't be a healthy forty-five year old unless I find out what my cholesterol levels are and start exercising again. *sigh* Time to forgo the donuts and start the cardiovascular workouts again.

Oh, and a few more things....

Fluff segregation

Yet another person has expressed disbelief that my entire winter wardrobe has been assembled from scratch in ten minutes. Note to the general public: all girls are not clotheshounds. I may show some alarming tendencies in that direction, but I rarely follow up on them.

Irregular Choice shoes might be the new followed-up-upon tendency.

I woke up this morning with Fruvous's (Moxie Fruvous) "Fly" going through my head. I don't know why. This, of course, brought back sitting on the roof of Lloyd, singing snippets of "My Baby Loves a Bunch of Authors" and hearing jhave say, resignedly, "You know the Fruvous." (Well, duh. They're the choice of bookish nerdgirls everywhere.) That was shortly after we watched the bald eagle spiral out of sight over the mountain and shortly before I had far too much wine.

The hospital cafeteria has come up with something surprisingly good for breakfast. I forget what it's called, but it seems to be a mixture of egg and maybe masa flavored with cumin and chili and topped with salsa and cheese, then baked in a water bath. It's kind of like Migas for the Masses.

Speaking of migas, I have a surfeit of good corn tortillas and some excellent jack cheese. Hmmm. Breakfast.

I opened all the windows this morning (it's only about 60 right now) and the cat is loving it. She likes to sit on the bedroom windowsill and feel very butch.

Interesting is a curse.

God and I are going to have a little come-to-Jesus meeting.

I found out Monday morning first thing that the intelligent, polite, charming 21-year-old man I took care of prior to his brain surgery had a metastatic tumor, not a primary tumor as we'd hoped.

Quick definitions: "metastatic" means "arising from somewhere else in the body." "Primary tumor" means "started wherever it is and might go somewhere else if it gets the chance."

Metastatic brain tumors are bad news. Because of the way the body works, the brain is segregated from the rest of the body by something called the blood-brain barrier. This is, in short, the thing that keeps you from getting an infection in your brain every time you get sick. It's very difficult for critters, viruses, cancer cells, and drugs to cross the blood-brain barrier (with a few exceptions that I won't go into here).

See, cancer loves the brain. The brain uses pure glucose for energy--nothing else. A PET scan, in which slightly radioactive glucose is injected into a person's body to show the areas of high cellular activity, will show the brain and various glands as bright white. That means that there's a whole lot goin' on in those areas. It'll also show cancerous tumors as bright white. That's because cancer cells are normal cells with their inhibitions removed: they reproduce and use glucose at phenomenal rates.

If a cancer cell gets into your brain, it's in heaven. No immune response to speak of, nice soft tissue that won't keep it from forming a tumor and expanding, and all the food it wants. It's a tough trip to get there, but once you're there, man, you've got it made.

So this fit, handsome, charming young man has cancer *somewhere* (we don't know where) that's gotten jiggy enough to move into his brain.

And this is patently unfair. Mean people, I've noticed, tend to live for damn near ever with very few problems. The good ones get shafted.

Still, the fact that this kid is healthy and fit and has a loving family and a wonderful girlfriend works in his favor. I am remaining resolutely optomistic and refusing to believe that he won't get better. So many of our patients *do* get better that it's hard to take when one doesn't. I am therefore avoiding pessimism.

But God has got some explaining to do, and I hope He's ready.

Other things I'm avoiding

I'm avoiding replying to an email at the moment because I haven't found quite the right casual, insouciant tone to use in it. It's one of those emails that could be the fuse to a powder keg, and I don't want things blowing up in my face. Not in a bad way, you understand, but in a complicated way.

I'm avoiding thinking about how hard it is to get used to not being constantly off-balance. For years I was off-balance on a regular basis--not in a bad way, but in a challenging, interesting way. Things have settled down and gotten peaceful lately, and it's a bit tough to get accustomed to.

I'm avoiding wondering why creditors are calling my phone number looking for other people. With my luck, my identity has been filched and some bad guy is running up tons of debt buying junker cars under my name.

And, right now, I'm avoiding cleaning house.