Sunday, August 23, 2009

PS: You're a moron.

Part I

Dr X: "Why hasn't the Argle-Bargle T380A test been run on my patient yet?"

Nurse Jo: "Because it's a timed test that has to be done by the lab. It can't be drawn through a central line."

Dr. X: "Why haven't you drawn it yet?"

NJ: "Because...it's...timed. As in, it shouldn't be drawn until a...specific time."

Dr. X, growing upset: "But you could draw it right now! Out of the central line!"

NJ: "No. I can't. It can't be drawn through a central line. The heparin lock we use will screw up the test results, and besides, it's a timed test. It's not due to be drawn until 1630."

Dr. X: (incoherent ranting about incompetence of nursing staff.)

NJ: (finds herself on the opposite end of the hall, unsure of how that bruise got on her forehead. Oh, wait. It was Head-Meet-Wall again.)

Part II

Dr. Y: "Why did you change my patient from calcium gluconate to a calcium citrate and magnesium supplement?"

Nurse Jo: "Because that's our protocol for people who have had gastric bypass surgery."

Dr. Y: "But this patient didn't have a gastric bypass! She had a parathyroidectomy!"

Nurse Jo: "Yes, I know. However, the patient's history shows that she had a bypass six years ago, and her blood calcium levels have been low enough to warrant IV repletion. Therefore, according to protocol, we changed her over to citrate and mag, and her calcium levels have come up."

Dr. Y: "Are you a doctor? I didn't write that order!"

NJ: "It's the standard hospital nutritional protocol for patients who have had bypass surgery. Here it is on the computer (clicks twice)."

Dr. Y: "I didn't write that order! You had no right to change that patient's medication!"

NJ: "Her calcium has been stable at 9.2 for three days, after being between 2 and 3.5 for the proceeding week. Is there a problem?"

Part III

Dr. Z: "Why didn't you replete this patient's magnesium and transfuse blood?"

Nurse Jo, looking worried: "Because I didn't see an order for it."

Dr. Z: "Her hemoglobin is ten! TEN!! Why didn't you transfuse her??"

NJ: "Um... ... ...because her hemoglobin is ten. And has been ten for the last four days. And her magnesium is 2.0 and has been for the last four days."

Dr. Z: "But I always transfuse patients with a hemoglobin less than twelve!"

NJ, taking chart in hand: "See this preprinted sheet? You filled out this preprinted sheet. It says right here that if hemoglobin is less than nine or crit is less than 25, we transfuse. It says we replete magnesium for mag levels of less than 1.7. Her crit and hemoglobin and mag have all been above those levels for four. days."

Dr. Z: "But that's not how I do it!"

NJ: Considers banging head on desk, then decides that the bruise that's already there is enough, and wonders why on EARTH the new docs in rotation aren't briefed on our protocols.

Super freak. (Composed Saturday night; posted Sunday morning.)

Oh God, oh God, oh God.

I start the CC internship in a month. A month. What was I thinking? What the hell am I doing, leaving what I'm used to? What happens if I hate it?

What happens if I can't do EKGs? I've never been good at EKGs. And all that other CV stuff; I haven't done that in years. I can't remember what Vfib looks like. Blocks...blocks...I can't remember blocks. What's the normal for mag? I can't remember. I've been off work for too long. I'm only back for a few weeks, and then I start the internship.

Holy crap. What if I hate it? What if they hate me? I'm going to have to work nights. I've never worked a night in my life. What if I can't stay awake? What if I can't sleep the day before my first night? Oh, God, oh, God. Nights. What am I going to do about feeding the dog? How long will I have to work nights? When will I start? What if I hate it?

Seven years. I've worked on the same unit for seven years. Why did I have to go and make a change now? I wonder if it's too late to back out. It probably is. What if I hate it? I'm going to feel like a complete idiot for at least a month, and pretty stupid for at least six months after that. Ventrics. I haven't dealt with a ventric in...what? Four years? Five? I've forgotten how to level them. I mean, I know this is what an internship is for, but they'll expect me to remember this stuff.

Oh, geez, and ventilators. I wonder how much ventilator stuff we'll have to do. RT is right there, but will I have to troubleshoot? What about extubation? What about intubation? What about code team? When do you use bicarb, again? Isn't bicarb, like, your last resort? Shit. And open bellies. Open. Bellies. Covered with plastic wrap. That's insane. What am I doing, changing units?

We're gonna see a lot of flu cases this year. Probably some of 'em'll be on vents. I hope I don't get the flu. What'll I do about vents? What if I have to go to Holy Kamole and work on vents there? And what about all that damn CV stuff? Geez, I hate counting out rhythms. I need to get a better stethoscope. I need a set of calipers. My feet hurt. It's the last night of my vacation, and my fucking feet hurt. I can't sleep. What about EKGs? I wonder when they'll have flu shots for us. I wonder *if* they'll have flu shots for us. Maybe I can tell 'em I'm pregnant, and get a flu shot that way. But then I'd have to produce a baby.

Which would probably be easier than starting this damn internship.

*toss*

*turn*

Friday, August 21, 2009

Eternal Questions: Friday at 4:30 a.m. edition:

1. Why is it so hard to plug in equipment with batteries that have to recharge? Is there some anti-plug-in gene that only I am missing? It's frustrating to have every. single. pump. start screaming "LOW BATT" the minute you turn your back.

2. What the heck are they using now to mop the floors? Superglue? 'Cause that's what it feels like.

3. Why does my sweet curly lamb of a resident insist on writing floor orders on preprinted critical care order sheets? It doesn't work like that, dear. For the fifth time.

4. How is it that a hospital can make such uniformly bad vegetables? Is there a special pre-over-cooked form of veggies that are only available to large institutions?

5. Why are there six boxes of gloves in this room, but none of them are my size?

6. How many family members does it take to see one person off to surgery? My record so far is 35, all in one small room. It was...humid. And crowded.

7. Do I have a sign over my head that says "Crazies: Talk to Me! I Like It!"?

8. Where do all these college students keep getting all this Adderall? And Ritalin? And Abilify?

9. Why do I have so many pockets and so little memory?

10. Why do my patients keep bringing up health care reform to me? I don't talk politics to patients, and you won't like what I have to say anyhow.

Thursday, August 20, 2009

Yeah, I love this. I'm a nerd.


"The discovery of the gastroliths associated with this plesiosaur specimen were particularly exciting because most plesiosaur gastroliths are found associated with the long-neck morphotype", Dr. Schmeisser explained.

(Long-neck morphotype shown.)

Tuesday, August 18, 2009

You gotta know when to hold 'em.

Back in the saddle again!

A conversation I had over vacation brought to mind a patient I had a couple years ago. He told me, quite seriously, that he tended to throw punches when he got a shot.

"You won't this time" I said calmly.

"You don't understand!" he insisted. "It's like, this reaction I can't control. You gotta get a couple big guys to hold me down before you give me that shot!"

I went on filling the syringe (I can't recall what, exactly, I had to give him, but it was one of those drugs that requires a glute shot and a Z-track) and said, again, "You won't this time."

(Query: Why is it always young, healthy guys in the military who tell me this? Dude, you spend your days *getting shot at by bad men with big guns*.)

He looked at me. I said, "Roll over onto your stomach."

He did. I said, "Okay, now grab your crotch with both hands."

A sidelong glance over the shoulder. "Why?"

"Because if you try to make a fist, your balls are in the way. And by the time you get your arms out from under you, I'll be across the room."

I did not need two big guys to hold him down.

More recently, I had another patient like that. Only this guy told me that he'd kick me in the gut if I tried to start an IV on him.

"Not this time you won't," I said, calmly unpacking the IV supplies.

"No, seriously!" he insisted. I sensed a trend. "You gotta get a couple..."

"Big guys to hold you down?" I asked. "Yeah, except this time, I won't."

"Why not?" he asked, chin jutting out.

"Because I'm going to stick you once with two hands. If you kick at me, I'll stick you the second time with one hand." I tied the tourniquet around his upper arm.

"What'll you be doing with the other hand?" he asked.

"It'll be wrapped around your balls, ready to squeeze." I smiled sweetly.

One stick, no kick.

Monday, August 17, 2009

Sunday, August 16, 2009

Sunday Meditation

...And if it was all to do again, would I do otherwise than I have done? No, I would do the same. A thousand times over, I would do the same. And it would still be sin.

In our various degrees, we are all sinners. To acknowledge and accept that load is good. Perhaps even to acknowledge and accept it and not entertain either shame or regret may also be required of us. If we find we must still say: Yes, I would do the same again, we are making a judgement others may condemn. But how do we know that God will condemn us? His judgements are inscrutable....In the end there is nothing to be done but to state clearly what has been done, without shame or regret, and say: Here I am, and this is what I am. Now deal with me as you see fit. That is your right. Mine is to stand by the act, and pay the price.

You do what you must do, and pay for it. So in the end all things are simple.

--Ellis Peters, Brother Cadfael's Penance

Tuesday, August 11, 2009

I wanna party with these guys.


Extreme Pool Jump - Click here for more home videos

I am bummed.

Severely, severely bummed.

Intolerably bummed.

Listening-to-Sugarland-and-sobbing-even-at-the-happy-songs bummed.

Friend Pens the Lotion Slut will not be joining me for a week of debauchery after all.

Friend Pens has the worst boss in the world. The day before she's supposed to come see me for a week of champagne, IKEA, and swimming in spring-fed pools, he swanned into town without warning. Worse, his minions passed out a pre-arranged itinerary that had entries on it that said, in burning letters that would do J.K. Rowlings proud, "LOTION SLUT'S PRESENCE REQUIRED OR SHE WILL BE FED TO THE WOMBATS."

Pens, being an intelligent woman with a good grasp of the essentials, decided that not being fed to wombats trumped champagne and strawberry trifle. I don't blame her; I believe wombats are vegetarian (or, at the very least, have kind of dull teeth), so being nommed repeatedly by a cage-ful of them would certainly suck.

*sigh*

On the upside, it's still the week during which my pal Suz the Rat Wrangler will be liberated from the crazy man she had the bad fortune to marry lo those many years ago. So the champagne and strawberry trifle will still happen; it'll just happen without the L.S.

And, as a result, I am bummed.


Monday, August 10, 2009

Stolen from Shakespeare's Sister

Yeah I know that you wanna be Canadian, please
Even if in winter things tend to freeze
We've got the world monopoly on trees
And our country's bordered by three different seas

Yeah I know that you wanna be Canadian, please
We invented the zipper, we've got expertise
We made insulin to combat disease
Yeah I know that you wanna be Canadian, please

CHORUS
Brits have got the monarchy
The US has the money
But I know that you wanna be Canadian

The French have got the wine and cheese
Koalas chill with the Aussies
But I know that you wanna be Canadian

Et si ce n'était pas assez
On a deux langues officielles:
L'anglais et le français
Ooh la la

Yeah I know that you wanna be Canadian, please
Where else do you find mounted police
Or go to the hospital and not pay fees
Yeah I know that you wanna be Canadian, please

And when freshwater is in high demand
We've got the world's largest supply on hand
So you know that we could make a pretty good friend
But it's even better if you can be...

CHORUS

So you're thinking to yourself,
"How do I live in this beautiful country?"
Well we've got some steps for you to follow...

STEP 1: Lose the gun
STEP 2: Buy a canoe
STEP 3: Live multiculturally
STEP 4: You're ready, there is no more!

We got beavers, cariboo and moose
We got buffalos, bears, and Canadian goose
And we're sorry about Celine Dion
But she did do that good song for James Cameron...

CHORUS
Brits have got the monarchy
The US has the money
But I know that you wanna be Canadian

The French have got the wine and cheese
Koalas chill with the Aussies
But I know that you wanna be Canadian

The Greek chilled out with Socrates
Can't build a wall like the Chinese
But I know that you wanna be Canadian

In Kenya they have safaris
We've missed lots of other countries
But I know that you wanna be Canadian

Sunday, August 09, 2009

Live, from the dusty plains of Central Texas, it's Head Nurse!


I had no idea my eyes slant downward like that.

Sunday Sweetness

This blog is lovely; one little girl is lucky to have the mother she does.

You undoubtedly heard about this on NPR. It's still a good read.

Something tells me my nephew might be getting a really cool Christmas present this year.

Friday, August 07, 2009

Drive-by vacation posting

ONE:
Please. I have told you and your coworkers four times this week that Maria Wenschel does not live at this number. I have had this number for (counting on fingers) uh...five? No, *six* years now. Maria Wenschel has never lived here. Neither has Joyce Ngabe or Matthew Watkins or any of those other folks who owe you money.

TWO:
Bra. Buy one. Wear it. Please. Unless you are the adorable, bone-thin, dancer-bodied hippie chick from across the street, you need one. And she has no boobs anyhow, so she's good.

THREE:
Leash. Buy one. Put it on your dog. Otherwise, my dog will get very upset when your bait canine* comes over to the fence and starts acting all tough, because Max won't know whether to bark or be calm or run away. This is sort of an existential crisis for him, because he believes in protecting the small and weak, and your particular small and weak is begging for a beat-down.

FOUR:
Call. Before you come over. Unless you are the UPS man with new shoes, in which case you can come over any time you like without calling first. Especially if the shoes are free.

FIVE:
Bad: The idea you had to come knock-knock-a-knockin' on my door this morning at four a.m. Not only am I awake then, but I am awake with an anodized pink practice bat filled with Quikcrete** in one hand and my very large dog's collar in the other. And I do not know you, so either the bat or the dog is going to move toward you fairly soon. No, you may not use my phone.***


*"Bait Canine": any dog under six pounds who has no other obvious function than to act as bait for real dogs.

**For a while I considered buying a shotgun, because the sound of a round being chambered in a sawed-off double-barrelled shotgun is the single best deterrent to violent crime ever. However, I've now discovered that the sound of a concrete-filled bat tapping against a doorframe combined with the subterranean rumble of a Good Boy (yes, he's a good boy! Yes, yes he is!) is almost as good.

***And no, I would not have normally opened the door at all, but the knocking was getting insistent and distracting me from Go Fug Yourself.


Wednesday, August 05, 2009

In Which Jo Reveals Her Blog-Crushes (aka link roundup)

Since I don't have anybody in the meatworld to crush on, here are a list of my current blog crushes:

Design/Homewrecking

Door Sixteen. In my social group, "D16" has become shorthand for "anything you obsess about and work on with perfectionistic tendencies showing, because you know it'll be gorgeous in the end". This woman probably wipes her ass with $100 bills, and has more patience than I do, but it's a crush....so it's aspirational, right? Right?

The Daily Danny. Yes, it's all about consumption, which doesn't seem very green to me, but he does find some pretty things. And, when you really need to replace your coffee mug collection/end tables/whatever, he undoubtedly has a post about whatever it is you need a new one of. (What a sentence.)

Screamprinting. You've seen those "Keep Calm And Carry On" repro posters? Well, these folks have some that say "Bloody Hell, We're Buggered Now." I'm thinking of getting one of each and gluing them together, then hanging them on the wall so I can turn them whichever way I'm feeling that day.

News You Can Use

The New York Times. The original and still the best.

Jezebel. Not only do the brave souls of Jezebel offer commentary on this week's "Big Brother" episode, they do thoughtful analysis of news stories you won't get anywhere else.

Advertising For Love. The project of a woman doing her dissertation on old personal ads. Maybe it's not "news", but it sure is interesting, and it shows us plus ca la change, plus ca la meme chose, or wevs.

Girly Shit, Like Lipstick and Shopping

Apocalypstick Now. Not only does she have the best blog name ever, she's hilarious.

Outblush. I must admit that I read this blog only to see what the authors consider to be reasonable purchases. The average price of a dress exceeds my mortgage payment.

The Beauty Brains. Science and beauty in one tidy package! Don't buy a new shampoo without checking here first.

Esteemed Colleagues

Grunt Doc. Right up there with Sid Schwab, in my opinion (who's no longer medblogging, and what a loss that is), I always find something interesting going on with The Grunter.

March of the Platypi. Still one of my favorites, lo these many years later. It was the Platypus who showed me both that it could be done and how to do it.

Your Pharmacist May Hate You. Total blog-crush material: he likes Scotch, he's grouchy, he's overworked. What more could a woman with her own tools ask for? Plus, he writes amusingly and is politically active.

Monday, August 03, 2009

WANT.

All the way down at the bottom of the page. 1940's girl's bike.

It's blue. It has a headlight. It looks cool. I wonder if it's fixupable?

I wonder if Friend E. would mind a houseguest while I go browse?

HA!!!

Friday, July 31, 2009

Vay-cay-shunz. I has them.

Today, in the spirit of doing nothing, I sat down on the couch with the Sierra Trading Post and Title Nine catalogs.

I woke up five hours later with a pair of cats on top of me.

I think I needed the sleep.

Now I have almost three full weeks stretching out in front of me, and plans on how to use it. Faithful Correspondent and Lotion Slut Pens is coming to visit in a couple of weeks, so before then, I'd like to:

1. Re-do my bedroom. I pulled the strangely-placed chair-rail down off of the awful panelled walls a couple of weeks ago and have done nothing since. Except buy paint. The bedroom gets painted, and I might even try to score a rug or two for the floor.

2. Paint the hallway, then paper it with ads from the sixteen tons of old magazines Beloved Sister sent. If anybody has any ideas on how to stick up a gazillion old, crumbly magazine ads, please leave them in the comments. I don't want to use frames and I'm not crazy about map pins, but it might come to that.

3. Glue the kitchen ceiling back into place. Don't ask.

4. Make a pilgrimage to IKEA. I've only been to IKEA once before, and practically needed a Xanax-and-cheddar casserole when I got out of there. I've learned that touring the show rooms is a bad idea; you end up with a million ideas for great things that you'll have no energy to look for in the flat-pack section. I'm going, this time, with a specific list of things to get: plastic boxes, wooden boxes, a round mirror, magazine holders, a rug, perhaps some fabric if it doesn't suck.

5. Defrost the damn refrigerator. I've been half-assing it for too long. That will involve borrowing a cooler or some freezer space from a neighbor, but that's okay; she's had my vacuum for two weeks now. She owes me.

6. Do something creative with the storage/laundry/workout room.

7. Finally, for once and for all, refinish my dresser. It's going to be white with green glass knobs from Anthropologie (don't hate me; they were on sale). It's bare wood now, and I hate it. I'll still hate it when it's done, but I'll hate it less, and the alternative that I love (a tall, narrow, six-drawer chest in natural elm) is $1,425 on sale.

In other news, eternal questions

Is every single psychiatry resident in the world weirder than a snake's suspenders, or am I seeing a nonrepresentative sample? I mean, I know Dr. Dink is strange; he's doing okay for just recently having emigrated to this planet, but I wasn't expecting the level of bizarre I get from the psych residents I'm seeing now. (They all have to do a neurosurgery and neurology round before they finish.)

These folks are *weird*. And I say that as one of the weirdest people I know. I popped off with a goofy quip to one of them the other day and was rewarded by nothing more than a subtle lip twitch and a sudden interest in the floor. Even the neurosurgeons, not the most well-adjusted bunch in the world, would've laughed.

As for what I'm doing once Pens gets here

If she hasn't seen an IKEA, I'll wait until she gets here to go. Otherwise, we'll either hit Barton Springs (pros: close, pleasant. Cons: lots of sorority girls in mid-August) or Turner Falls (pros: uncrowded in the middle of the week. Cons: I hear banjos. Paddle faster!), my pal Annama's shop that's full of gorgeous jewelry and fabrics from Lands Beyond, and a little gift shop in town that has the distinction of being the only place around you can find Anne Taintor magnets. We'll also be drinking rose on the deck and eating basil and mozzarella.

Speaking of rose

Faithful Correspondent Rockenheimer reveals that he's going to Montreal one of these fine days. I am sick, SICK with envy. Pal Joey is out of the city at the moment, or else I'd be showing up unnanounced on her doorstep, begging a place to sleep and braving her boyfriend's irritation. I love Montreal with an illogical passion; something about a city where old cathedrals are turned into apartment buildings really charms me. I love going to the Italian quarter and not being able to communicate with anybody in any of the four languages I speak badly.

Plus, it's still soft-fruit season there, while the heat here has killed everything useful or beautiful.

And, finally

I will be sitting around in the evenings, soaking my feet in the kiddie pool out back. That is what vacations are for.

Thursday, July 30, 2009

My Vacation Starts Now.

And I just gotta say:

Dude. Look at the President. Just look at that shit. That's some thinkin', ponderin', beer-drinkin', wife's-ear-nibblin' SHIT.

THAT is some SHIT, right there.

Just look at him. Just look.

Plus, his wife will drink. your. halfcaff. latte.

And kick your ass into the bargain.

It is a good, good time to be alive, and to have three whole weeks off.


Tuesday, July 28, 2009

Wednesay Whining: Has moved!

Enjoy the Wednesday Whine, now at its own dedicated site!

Monday, July 27, 2009

It's a weird job.

Fears. Everybody has them.

My pals at work and I agree: if somebody has an aneurysm blow right there on the floor, we're not coding that person. We'll simply step over them and complain about being short-staffed again. If I'm unlucky enough to be "saved" when whatever I have in my brain goes kaplooey, then there're a couple of sympathetic MDs I work with who'll be up to the plate with morphine, potassium, benzos, and insulin--and a score of sympathetic RNs lined up behind 'em with pillows in case that doesn't work.

We do not kid about this. I am deadly serious about wanting to go toward the light when my time comes, and the friends I have through work are deadly serious about it, too. We see enough people who are kept alive after something catastrophic happens, only to die of something infinitely worse, like bedsores or pneumonia or just plain boredom.

The one fear I do have, even after all this time, is a glioma. I guess it's not as bad when you're going through it, since by the time you know you have one, it's pretty much too late. Your brain just sort of...goes, and eventually you quit caring, or even knowing that you ever cared about what's happening to you. I still am scared shitless of glioma, though, to the point that I have nightmares about people I love getting them, and I'm unable to take care of them.

Jokes. Everybody makes 'em.

We joke about everything. It's a running gag on the unit that anybody who tastes my cooking will immediately get in line to marry* (or at least discreetly support) me; I am the Butter Whore. It's also expected that somebody will crack a joke in the wake of a failed code ("What's green and fuzzy..."). The jokes mostly have to do with sex or addiction or a combination of the two. If a resident asks how I'm doing as I walk on the floor of a morning, the answer is always "Drunk. What do you think?" If we don't have the correct size gloves for a particular procedure, the gag is that the nurse is hung-over... ... ...AGAIN.

And, when one resident complemented me on having the entire setup for an emergency skull-drilling set up the first time out, he phrased it as, "Gosh! It's always so easy with you, Jo." To which I replied, not being a slouch, "You're not the first man who's said that."

Probably would've gone over better had his attending not been in the room, but whatever.

It's a weird combination of mid-twenties residents and perimenopausal nurses that sets up this dynamic. It's also something you won't find in most other hospitals; from the stories other nurses tell me, any given interaction between a resident and a nurse at our facility would result in a lawsuit at any other. The only rule is No Touching, and even that is broken when a patient codes unexpectedly and you need a hug.

Complexes: we nurture them.

I work with an incredible bunch of people. Everyone is at least very, very smart; the people who are geniuses outnumber those of us who are simply brilliant by at least three to one. Yet, in all the people I've worked with over the years, I've only come across one case of Insurmountable Ego, and that wasn't a neurosurgery resident.

As a result, we foster complexes among ourselves. Am I good enough? Am I fast enough? Can I get faster? Can I get smarter? What am I missing?

If you're the nurse for a patient on whom any service is rounding, be it otolaryngology, neurosurgery, or general surg, you'd better have every single bit of trivia about that patient on the tip of your tongue. Not just the potassium levels and hematocrits from the last two days, but everything from the last week needs to be on your mind: "This patient's sodium was 119 on Thursday, but with a fluid restriction of 1 liter and a free water restriction of 300 cc's, we've gotten him to 133 as of this morning at 0500."

Outstanding work: We reward it.

The most outstanding work you do on our unit won't be compensated with a raise (in these tough economic times) or a TEAM PLAYA pin (since that went the way of all flesh); rather, you'll hear an attending say, when he's not aware you're just outside the room, "I have no worries about you when Jo is taking care of you. She's one of the best nurses I've ever worked with."

My own complexes lead me to dispute that, but it was nice to hear anyhow.

And it's also nice that the surgeons see us as people, and we them, and not just as professionals. When Kim's wedding invitation went up on the bulletin board in the locker room, we all gathered 'round to jibe her about how we were going to caravan to New Mexico in hippie vans and crash her reception. When BoBo's mom died, far too early of something we ought to have been able to fix, we all rallied 'round with casseroles, cards, and a money tree. (That last is a Southern thing.) It's because we work together well, without ego or bullshit, that we can do that.

It's marvelous beyond expression when the patient we helped heal from something awful remembers us every year on the anniversary of his discharge and sends us flowers (one bunch for every nurse on the floor, zut alors!) and a tray of deli meats and cheeses. It's equally amazing when a former patient sends us the birth announcement of the child we all doubted would ever be born.

If you're a new nurse, or an old, bitter nurse in a crappy situation, look at how the people interact when you visit a possible employer. Notice if they say hello and ask when you might start. See if they look happy. Ponder how they address each other.

In ten million lifetimes, I could not have wished for a better work environment. Even with the cliquish, crappy behavior of some of my coworkers, even with Manglement screwing up our best-laid plans, it is still the best. place. ever. to work.

Now, if I can just net me a bottle of vodka and an empty elevator shaft, with that cute new guy from Orthotics... ... ...

(*line forms to the left. No pushing, please. And the first spot is already reserved.)

I'm outnumbered.

Yes, I have no face on purpose.

Lazy Monday Link-O-Rama

The old-leather and cigars edition!

I want one of these bags. I would also like to rewrite the website so every product description isn't about how cool the owner of the company is, but I'd settle for a bag. One of the light ones, you know, like a pouch or a satchel. Except I already own a pouch from Scandia, and I love it.

This is one of the better websites for just-plain-browsing-around that I've come across.

Jezebel has a hilarious takedown of one of those dumb articles from Men's Health.

Pull up a club chair, get yourself a martini, and check out the best-named blog ever.

Or, if you don't like martinis, check out this guide to single malts.

And, finally:

Friday, July 24, 2009

Friday night musings

"The thing you must remember," (said my friend Paul the Pastor the other day) "is that David danced naked before the Ark of the Covenant."

Workplace bullies tend not to be bullies if a) you call 'em on it; or b) you just look at them with wide eyes and then laugh in their faces.

If you feel like you're about to start crying at work (see above), go work out some tricky drug dosage calculations and you'll feel better.

Cats are annoying. That is, they're annoying until they start doing something incredibly sweet without reservation. At which point they become adorable and you have to snorgle their bellies.

Always read the concentration on the Narcan vial. The two different concentrations are packaged in ampules that look exactly the same.

There is always time for freshly-picked home-grown tomatoes, blueberries, good Swiss muesli, or coffee.

The look on your dog's face when he realizes he's going on a WALK is the best thing ever.

If it's a full-body rash with blistering, five gets you ten it's a Dilantin rash, no matter what the dermatology consult says.

Bamboo cannot be killed. Don't even try. Find a way to incorporate it into your landscaping.

And, for God's sake, don't plant wisteria where it can pull down large limbs from old pecan trees. The neighbors and I have had this problem lately.

Hummingbirds occasionally perch. If you're lucky, they'll perch on the arm of the chair next to yours on the deck. Breathe quietly.

Seeing ants crawling over the walls of the hospital room is, usually, a reaction to narcotics.

If in doubt, change the Foley. If in doubt, change the peripheral IV. If in doubt, administer oxygen and fluids.

But, for the love of Mike, don't touch the Quinton.

I was driving down the street, coming back from Home Despot the other day, when I saw a navy-blue Chrysler New Yorker zipping along. Following it was an orange International Harvester truck. I was suddenly thrown back into the past, when You Could Do Anything In A Chrysler. Getting older is like that; the oddest things trigger memories.

Nothing is ever lost, only changed. That's both the first law of thermodynamics and faith.


Friday Furballs.




Why is Max lying on the floor in the hallway, rather than on his nice squooshy bed? And why does he look so sad?


Oh. That's why.

Thursday, July 23, 2009

HA!!!

Thursday tranquility: Scenes from my refrigerator door.


Slightly blurry, but that's the coffee talking. Le Pied De Cochon's business card has a place of honor on the door of the Shrine To Pork.



The Anne Taintor magnets are gifts from my Beloved Sister.

The slightly diseased-looking monkey is a gift from Dad.


Notamus, looking uncharacteristically nondestructive, on the back of the futon. No, I don't know where those stripes came from.

Wednesday, July 22, 2009

Wednesday Whining: Bing-Bang, Walla-Walla Ding Dang Edition

My back is going "Ooo, eee, ooo, ah-ah".

Somehow, I wrenched my lower back on the treadmill. The damn *treadmill*.

So. Walking is difficult, sitting is uncomfortable, treadmilling is impossible, and lifting is out of the question, at least for the next few days.

Meanwhile, though, I've done pretty well food-wise. I'm discouraged by the fact that I can't twist or lean without significant pain, but I'm not taking it out on donuts.

More later, when sitting again becomes comfy.

The lunatic is in the hall. And, sadly, the break room.

One of the things that happens when the management of a place starts to break down is that the weirdos come out of the woodwork.

It doesn't happen immediately. Sometimes it takes a while, as the nice, normal, everyday people in the place get replaced by nutjobs. Eventually, though, when things get weird enough, the weird (as H.S.T. said) turn pro. And, oh my children, it has been the Masters' Tour of Wack on the unit lately.

The ontorexics and tanorexics I can handle. The woman with sixteen fluffy little dogs (I exaggerate; it's really only something like four) is no problem. The nurse who wears what is probably the entire stock of Sephora and jumps like a startled rabbit every time you speak to her doesn't bother me a bit. The golf-obsessed? I don't turn a hair. The Cultist, though, really threw me for a loop.

He doesn't wear white robes and Nike sneakers, at least not at work. I've never caught him offering any sort of sugary drink to anyone else. And, for a while, I thought he was okay, if a bit overbearing and loud. Well, and self-righteous. And strange. Until, that is, he started talking about religion.

(Rhetorical question: What *is* it about religion and politics? I mean, I get weird too, if I start talking politics. Anyway.)

We had a run of people who had just been diagnosed with HIV the other week. Two things about the epidemic are really fucking depressing: the fact that AIDS is the leading cause of death for African women, and the fact that HIV infection is beginning to increase again in the very young and the older-than-40. We were seeing a few of all of those groups. It's a shock to be transported back to the bad old days of the late 1980's when you see a 20-year-old who's just been diagnosed with full-blown AIDS and had no idea he's positive. It's depressing to have the second immigrant woman in a week come in who contracted HIV from her husband. And it's difficult to have to talk to a guy in his 60's about how, exactly, he managed to get this infection that "only" young/gay/Black/whatever people get.

So we're talking about this over lunch (because we know how to have fun) and The Cultist pipes up that HIV is a reason he's glad *his* wife was a virgin when they got married.

Pause for contemplation on the part of the rest of the crew.

Sweet Loretta asked, carefully, if he thought that lack of virginity was the issue with the two positive women on the floor. Well, of *course* it was, silly! Because everybody knows that only nasty, dirty strumpets (and, I guess, Godless pervs) end up with nasty, dirty diseases.

Longer pause as we all digested this.

The Cultist took the longer, more aghast silence as an invitation to explain why and how this was a fact, and how it was supported by Biblical texts, and how the truth of the matter (about the nasty, dirty strumpets, I mean) had been covered up for years by a secret cabal involving the Pope, the government, and the WHO.

It was like a combination of Monday morning at the health department and "The DaVinci Code". I think the Illuminati actually got mentioned once; I wasn't paying that much attention. I was too busy checking to make sure that the world was still on its axis and gravity was still working.

I'm still not sure how we all got out of there. By some miracle, beepers started going off and people started remembering meds they had to pass; within about five minutes, only The Cultist was left, eating his sandwich and muttering about the Four Horsemen. I've never been so grateful for patients who call every ten minutes, let me tell you.

That was, of course, before I walked 'round the corner and smack into The Bully....but that's a different post.

Sunday, July 19, 2009

I got nothin'.

The blogging gods are angry with me.

There has been exactly nothing that's been crazy, out-of-line, or nutso that's happened this week at Sunnydale General. Everybody's been well-behaved, the pharmacy has gotten us meds on time, nobody's brought in livestock or tried to steal a TV. There haven't even been any Resident Follies to speak of.

I hate weeks like this. It does not bode well for the next month or so that nothing tremendous has gone wrong. Any day now I expect the power will go out, the generators will fail, the cafeteria will catch fire (okay; that wouldn't be so bad), the director of nursing will finally completely lose it and run naked and screaming down the halls, and six patients will have seizures at the exact same moment.

This week has been the hospital equivalent of that scene in a horror movie during which one character turns to another and says, "Gosh, I'm glad that's over" or "We've seen the last of them!" Next week, I'll probably have plenty of fodder. But for now, I'm going back to bed.

Wednesday, July 15, 2009

44-38-44; Or, Jo Has A HOLY SHIT Moment

Welcome to the inaugural Wednesday Whine here at Head Nurse.

I bought a swimsuit the other day. Not just any swimsuit, but the swimsuit I've dreamed of for years: A very modest tank top (black, with red seaming, but you can't have everything), shorts that come midway down my thighs (solid black), a keypocket in the shorts (closes with Velcro!); in short, the only thing I could wear that covers nearly as much as a swim burqa without looking like an idiot. (I should mention here emphatically that swim burqas are the bomb. The only reason I would look like an idiot is that I am Not Muslim. It would be like me dressing up in, oh, a kimono. Or a hula skirt. I would not be workin' it.)

I got this swimsuit in a size 16W.

I am not pleased by this.

Not at all.

Now, I'm fairly mobile. I'm short and stocky and still quite strong, despite not having seriously lifted (read: lifted at all) since Atilla moved off to the Big City. But I am Not Happy with wearing a size 16W.

I should mention here emphatically, and not at all parenthetically, that I am not fat hating. People come in different shapes and sizes, period. What is healthy for a woman who was born to be a 16W is much different from what is healthy for me, who has the bone structure and genetics to be a size six. I am not fit or healthy (look at that waist measurement: it speaks of increased risk of stroke, heart attack, diabetes) at the size I am now.

So it's going to change. I thought about starting another blog to chronicle what I'm doing fitness-wise and diet-wise, but I got stumped by the title. "Fat, Flatulent, and Forty"? "Dammit, No, I'm Not A 16W"? "Holy Shit, That's A Lot of Beer"?

I decided to just do a weekly check-in here. According to SiteMeter, I get about 10,000 hits here a month (Hi, everybody!) and I am going to need every single last one of you to keep me accountable. Weight Watchers might be easier and more personal, but I am counting on the level of impeccable snark that you guys have displayed over the last five years to get me where I need to go.

Because not everybody wants to hear a blogger whine about how haaaard it is to do 3 miles in 44 minutes on the treadmill (Dammit! I used to be able to do it in 25!), I'm segregating the Wednesday Whining posts with a tag, with title, and sticking to one day a week. Y'all can scroll on by if you don't want to read about what I did with my treadmill during the past seven days.

It's scary to do this. I'm scared it's too personal. I'm scared I'll fail. I'm scared that there's some weird metabolic thing that has nothing to do with Cheetos or sedentary living or too much Mirror Pond going on, even though I know that that's highly unlikely. I'm frightened of putting this much of my not-anonymized life out on the Intarwebs, though you've read damn near everything else I've done in the last five years.

Join me. Bitch away in the comments about the cramp in your lats or how much you hate eating frigging vegetables in the morning.

One very important note: Anybody who posts fat-hating or attack-dog bullshit will be deleted. I don't care if it's about me or toward another commenter, it's going to go. Save your keystrokes for something else; you get a predetermined number in this life. (I wouldn't be this cranky about it, but I've been reading comments about Regina Benjamin and whether she's qualified to be Surgeon General because (*gasp*) she's fat!)

Next Wednesday: First week's schedule, goals, and comprehensive bitching about shinsplints.

Tuesday, July 14, 2009

How to tell if you live in Texas, and What I Do On My Day Off, part 2:

I opened the refrigerator this morning to get milk for my coffee. Something green and scaly, with nice big claws, handed me the milk carton. I'd said "Oh, thanks" and shut the door again before I realized that whatever's in the Tupperware in there probably shouldn't have opposable thumbs. Looks like I'm going to be cleaning out the fridge today.

On the upside, whatever it is is keeping Notamus from leaping into the fridge every time I open the door. So there's that.

HOW TO TELL IF YOU LIVE IN TEXAS:

1. An oh-six-hundred opening time for the garden center sounds like a plan.

2. You grocery shop when it's dark, to avoid having your milk sour in the car during the three-block ride home.

3. Sweat is an accessory.

4. You have a refrigerator full of noncaffeinated liquids and very little else.

5. Not only do you know what "raspas" are, you have a favorite flavor, and you know that raspas are essential to surviving July.

6. Instead of lotion, you use Benadryl cream on your legs, for the mosquito bites.

7. The TV weatherman stands in front of banners that say "COOL" when the high is supposed to be only 91*F.

8. You can tell the difference between 104* and 109* when you walk outside.

9. You have a kiddie pool in the backyard for your dog. And you fill it with ice.

10. A margarita on a hot day qualifies as dinner--and nobody thinks you're a lush.

Lest any Yankees think I'm joking about any of this, let me tell you a true story about the weekend of the Fourth:

I was at my neighbor's house, on their back deck. It was a nice day, only 101* for the high. The temperature, though, doesn't drop much when the sun goes down, so we were all sitting out on the deck, with:

Two fans
A couple of galvanized tanks full of ice across which the fans were blowing
Misters going overhead
Gallons of bug spray
A baby pool full of ice water in which to soak our feet.

It struck us all that we were sitting in the midst of a whole lot of technology and ingenuity, all dedicated to keeping us cool enough after dark that we wouldn't get heatstroke.

And yet we did not go inside.

*That's* how you know you live in Texas.

Friday, July 10, 2009

What I do on my day off.

I woke up this morning, detached two cats from my chest, and swung my feet over the edge of the bed.

My feet landed on a combination of wood screws, rubber bands, the plastic pull-tabs from milk cartons, and twist-ties that the cats had brought, like inanimate sacrifices, and laid at the edge of the bed during the night. Max was unhappy; the constant close proximity of Dreadful CATS had made him nervous, so he'd slept in the living room. After putting my feet on all of that, I kind of wish I'd slept in the living room, too.

I do not know why my dog doesn't recognize the kittens he loved to nom as the cats who now inhabit the house. All I know is that they make him very nervous indeed.

I wandered into the kitchen, fixed two drawers and a shelf, and then decided to bolt the top two tiers of a stackable bookcase to the wall in the living room. Surprisingly, all of that went off without injury or inconvenience.

Then I did some laundry.

Then I made what's about the best omelette in the history of ever:

Jo's Four-Egg, Use-Yer-Leftovers Omelette

Slice:
Five mini-portabello mushrooms (Or the usual button type; I just had the mini-bellas lying around)

A thumb-sized hunk of yellow onion

And sear in a nonstick frying pan without added fat. When the 'shrooms have got brown edges to them, remove from the pan and put in:

A handful of mixed shredded cooked chicken and ham (or whatever chopped meat you have. Taco meat or shredded pork chop would be acceptable, bacon would be fantastic; I'd have to draw the line at barbecue or roast beef.)

Some cayenne pepper

A small handful of chopped up zucchini (Or some other soft-ish veggie. Artichoke hearts would be good here)

And cook until the zucchini gets soft and most of the liquid has evaporated.

Remove the food from the pan, scrape it out, and spray with oil. Beat four eggs with a little water, and dump them into the pan.

Let the eggs sit in the pan, over medium heat, until they're mostly solid. If you can't leave food alone (I can't), you can pry up the edge of the set eggs and allow some of the unset eggs to run underneath.

When the eggs are mostly solid, add a little cheese. I like Muenster for this.

Then dump in the vegetables and meat. Allow the whole shebang to sit for a little longer, call it five minutes. By this time, the eggs should be smelling done and have bubbles in them.

Using a spatula and a rubber scraper, carefully fold or roll the omelette and flip it over. If the wind is setting right and all the stars are correctly aligned, you'll be able to do this first try. If not, you'll end up with a broken omelette, but that's okay: the cheese will melt out and toast and be extra-yummy.

You can eat half of this and save the other half to make your coworkers envious the next day.

If you're really, really expert at chopping, you can talk to your Brother In Beer while slicing mushrooms. I am not expert, and so hung up on him while attempting to hold the mushrooms with my fingers and cradle the phone between my shoulder and ear. I ended up holding the mushrooms steady with my elbow and slicing them that way. It wasn't as convenient, but I didn't hang up on him again.

In other news, Friend Suzie the Rat Wrangler starts her new job today as Sub-Chief Rat Wrangler for a Large Nonprofit Research Organization. Shout it out for Suz!

Now it's time for a nap. I might paint my toenails later.

Thursday, July 09, 2009

Welcome, new residents!

He came out of the isolation room in full isolation gear, strode to the nurses' station, removed one glove, and began to return a page.

"Hey," I said, "Take off that gown and glove and wash your hands before you use the telephone."

"I don't have time for that" he said. "Besides, I took off this glove." He waved an ungloved hand at me.

"Dude. You're not Michael Jackson. Get that gown off, go wash your hands, and don't come out of an isolation room with gear on again" I said, feeling a little growly.

"They let me do this on the cardiac floor!" was his parting shot.

"You gotta be a grown-up over here!" was mine.

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

The neurosurgery residents aren't bad at all. Neither are most of the other residents. All of 'em have been on our unit before, because of the weird residency program we have. It doesn't matter what service you're with; you're going to round with psychiatry, neurology, neurosurgery, or internal med at some point, and that means you'll end up with us.

The two exceptions to that are urology, for some strange reason, and cardiology. And, given that the head of the urology department was a nurse before he was an MD, we don't have too many problems with those residents and things like respect and infection control and signing orders in a timely fashion.

Cardiology, though? Makes me want to tear my hair out.

They're nice people. Really. They're not the arrogant assholes portrayed on popular TV shows. There's not a prima donna in the bunch. They're very hardworking (almost as hardworking as the junior residents on neurosurgery), polite, knowlegeable, thoughtful folks. But they've been spoiled by the nurses on the cardiac unit, who don't care what you do as long as you keep the patient alive.

I, personally, care a whole lot what you do. I'm not going to go through every chart you've touched to make sure you didn't rack an order; I have better things to do, and besides, that's on your watch. And it doesn't make much sense to me to keep one patient in isolation alive if you're going to transfer bits of that isolated bug to other patients and the nurses' station. By the same token, I know a little about drug interactions, but it would probably be a fine idea to consult the pharmacy if you have questions. And, for God's sake, don't attack me because a patient's on a particular antibiotic for which you have a personal antipathy. (Not coincidentally, that was the same resident who didn't take off his isolation gown. Hmmm.)

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

Other than that one service, whom we thankfully don't see much of, things have gone smoothly. We have two new residents in surgery and two in neurology. The surgical residents look, as they all do, about twelve years old. One walks with his arms straight down by his side, peering short-sightedly through granny glasses, with his shoulders a little hunched. I want to feed him sandwiches and pinch his cheeks. The other has such an unfortunate surname that a nickname is superrogatory. That'll save us some time, at least.

The neurology residents may take some getting used to. The senior this time around is a brilliant woman--one of the smartest, most well-rounded people I've ever met--and a total bear to work with. Like a lot of geniuses, she's impatient with us normal folks and doesn't bother to try to hide it. The junior will be a whole lot more pleasant to work with once he gets over his shyness. Speak to him and he jumps. With the patients, though, he's great--he's careful, friendly, explains stuff in English, and never seems to be in a hurry. He's also trilingual in Spanish, Arabic, and English, which will be a huge help. He speaks a smattering of French, Farsi, German, and Russian as well. He's promised to teach me how to cuss in Farsi, which'll be my sixth obscene-word language.

So. All things considered, it's been a better week than I could've hoped for. Nobody's gotten horribly sick, my dehydrated patient with CHF didn't fill her lungs with fluid, and the number of racked orders hasn't been so large that we've had to mount a full-on offensive.

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

In non-work-related news, it's one hundred and bloody four degrees here just now. The projected high for today is 106 to 107. The only things moving are the cicaidas' vocal apparatus. Max is sacked out on the kitchen floor, just in front of the air vent. For those of you without a good idea of what 104 feels like, I offer this: I just went outside and hung up a load of wash on the line. It was scrubs and jackets. After I finished hanging up the last pair of scrub pants, I went back to the first ones I'd hung up and took them down. They were bone-dry.

The kittens, apparently unaffected by the general heat-related malaise, have destroyed a makeup box, my CD player, two shelves full of books, a hot-pan-holder, a box of drill bits, and two stuffed animals (those last are theirs to destroy) in the last three days. I'm going to have to bolt the bookshelves that my grandfather built to the walls, as Notamus is such a fatass he's going to bring them down one of these days.

Friend Elizabeth has a 1949 stove to get rid of. Does anybody want it? It lacks a thermostat for the oven, but is otherwise in good shape. It weighs about three hundred pounds and is currently in Manhattan, Kansas. Anybody in the area from Wichita to KC who might want a vintage stove and oven, please let me know. We'll work something out.

Sunday, July 05, 2009

Updated: Jo's Rules For Living.

General:

1. Pick up after yourself.
2. Don't be an asshole.
3. Say "thank you."

On Work:

1. If you have to jack with it, it's wrong.
2. Every surface should be thought of as dirty until proven otherwise.
3. Have an extra pair of scrubs.
4. Always take extra supplies into the room with you.
5. Wear shoes you won't fall out of.

On Drinking and Eating:

1. If the ingredients list has words beginning with "para" or "quasi", don't eat it.
2. Cheese always helps.
3. Good bread is worth the money.
4. It's not worth getting drunk on fine wine; you won't remember how good it is, and your head will hurt just as much as with the cheap stuff.
5. Eat butter, not margarine or Promise.

On Partying:

1. If you drink, pace yourself.
2. Don't say it drunk if you wouldn't say it sober.
3. Remember: If you start something, *somebody* is going to have to finish it. It might not be you.
4. Always have an alternate plan in case your designated driver craps out on you.
5. No, that's not a good idea.

On Relationships:

1. Pick up after yourself.
2. Don't be an asshole.
3. Say "thank you."

Tuesday, June 30, 2009

Aaaaaand as an antidote for that last post, possibly the weirdest rendition of "Working in a Coal Mine" ever. It's Swedish.

From Jezebel, strangely enough, and about Mark Sanford...

...but it still punched me in the snoot. To wit:

Lots of people do get into relationships that require way more work to hold together than it seems like is healthy for anyone. I'm as guilty of this as anyone else: I've had my ultimatum-issuing moments; my moments of pretending everything's okay for the sake of keeping the peace ; my moments of silently weeping in bed, waiting for someone to fall asleep, pretending that not talking about it can make the problems go away and that just trying harder will make us not-unhappy and that not being miserable is a step along the path back to happiness. Commitment is important, right?

And, sometimes, I suppose, it can be. But other times — many other times — the betrayal is too great and the emotions are too dark and the road ahead doesn't go back to being nicely paved, but turns into gravel, then dirt and then mud.



Random 4 am musings

One of the best things ever is waking up at 0400 and realizing you don't have to work today.

Add to that that the cats were all over me, doing their "We love you so much; here, let us lie on your belly" act, and it's been a good morning so far (all fifteen minutes of it, anyway). 

I wonder what the house's previous owners were thinking when they painted the office ceiling high-gloss beige.

It's time I defrosted the freezer. Yes, I have a non-frost-free freezer; my refrigerator is Polish. It's the only one I could find that fit the space I had for it in the kitchen. Plus, who needs 120 cubic feet of refrigerator space when it's just one person?

We need a new definition of patients eligible for rehab. If they're strong enough to get themselves into a wheelchair, get out the door of the hospital, get 300 yards down the street, and score some meth, they're not candidates for rehab and can head on back to the house.

Max is thrilled that his girlfriend is back. Sophie lives next door. She can play "So's *Your* Mama" through the fence like nobody else, and loves to wrestle when they're in the same yard. She'd been gone for a week on a camping trip, and Max was bereft. 

It's a really good feeling to wake up and know that not only do you not have to go to work, but you cleaned house yesterday and so have a free schedule today. I might, I dunno, fix some drawers in the kitchen this afternoon.

I just remembered that July 1st is coming up, and with that date, a whole new crop of residents will start rotations. It should be a fun month. 

Texts From Last Night is one of the funniest things I have ever read. I went through about 20 pages of it and was crying, I was laughing so hard. (Link not safe for work; not safe for Mom.)

If you're hitting your PCA button 122 times in an hour, and you're half-asleep while doing it, there's something not right.

I need some new light-blocking curtains for the bedroom. Hm. Time to go to Target, I guess.

One of my coworkers and I did a little song-and-dance routine while chanting the lyrics to "Short Skirt/Long Jacket" the other day. It went over big. We may have found a weekend job.

Somebody added stickers with the words "Don't" and "Believin'" to the stop sign at the end of my street. Whoever you are, I salute you.

Friend Suzie's mom apparently just killed her third rosemary plant. I have got to head over there and see what she's doing wrong. Killing rosemary is damned near impossible, even for me.

When I was told that I had to fill out a requisition for a 20-gauge coudet catheter, I simply went up three floors and swiped one from another unit. This is why the supply situation is so bad.

I wonder what I'm doing this weekend. For the first time in seven years, I am not working over the Fourth. Not quite sure how that happened, either. Something tells me the weekend will involve Prosecco and good Mexican food and a mariachi band.

Notamus just leaped from the futon to my shoulder. He is HEAVY.

And now it's time to stop musing and have some more coffee.




Monday, June 29, 2009

Zhausted, Take Two.

I'm ready for my exit interview, Mister DeMille; or, Don't Ask If You Don't Wanna Know

"Why are you leaving?"

It's a question I get asked on a daily (at least) basis. Do you really want to know?

It's because, when I asked not to be assigned to a patient who'd been sexually aggressive with me and harassed me both verbally and physically, I was told I couldn't refuse an assignment....yet Manglement did nothing to protect me or the other nurses from that winner.

It's because, when I go into the clean supply room, I can no longer count on finding the things I need to take basic care of a patient. In the name of saving money, we now don't have enough urinals. Or bedpans. Or bandages. Or catheters. Apparently, we were being entirely too profligate with our Foleys.

It's because, though I've worked on the same unit for seven years, Friends of Manglement get preference for assignments, vacation requests, and scheduling. 

It's because, in the name of saving money, Manglement has reduced our staffing to unsafe levels.

It's because, if a patient or a patient's family member has a complaint about a nurse/care aide/cleaning person, that complaint is taken seriously and the response is punitive. Conversely, if a nurse/care aide/cleaning person has a problem with a patient or "guest", even if that problem extends to threats of violence, "customer service" techniques are used to "resolve the issue", and the professional person's concerns are belittled.

It's because I'm tired of fighting every single damn day to be able to care for my patients in a safe way. It's because I'm tired of getting saddled with six or seven patients of varying acuities because the staffing office says that's how it ought to be. I'm tired of big decisions being made for the acute-care units by people who live on carpet and haven't worked a 12-hour shift at the bedside in twenty years. It's because I'm sick to my eyeteeth of the notion that "customer service" is more important than "good nursing care". It's because I'm exhausted by chasing around whatever person it is that needs to approve a request for a chest tube kit or extra IV pumps or more crackers for the patient pantry. It's because I'm tired of every single thing I do being evaluated, not on the basis of quality of care, but on customer service.

All I can say is, it must suck to be the manager of my unit. My manager's stuck between the very real needs of the nurses and staff and the insane demands of Manglement. Manglement makes it almost impossible for the manager of any of our acute units to actually do his or her job; instead, there's a bizarre combination of micro-management and total indifference that has got to be raising blood pressures on all ten floors. 

Fortunately for me (and anybody else who wants to go into or is already in critical care), the critical care pods are managed by a totally different group. The nurses get what they need, from equipment to staffing, and their worries and problems are taken seriously. I get a real sense of community and teamwork, since there's not a culture of "rat out your coworker, get a gold star" there. The managers of the CC pods are working nurses who pull shifts at the bedside every week, not just when they feel like they're getting rusty. The upper management of the CC pod, likewise, are CC nurses who hold down a job in management and one in actual bedside nursing as well.

Several years ago, Manglement instituted a number of changes on one of our acute units. Mostly they had to do with staffing and the types of patients the nurses would be caring for. Within six months, there had been a complete staff turnover on that unit, with a number of the nurses ending up, surprise surprise, in the critical care pods. 

This year Manglement did the same thing to my home unit. Nothing like learning from your mistakes, hm?

I'm the first to go. Somehow, given how many of my coworkers have taken me aside and asked me about the application process for the CCPs, I doubt I'll be the last.


Saturday, June 27, 2009

Thursday, June 25, 2009

So, yeah. It was a bad day the other day.

She'd been fine when I saw her at 0730. A little groggy, yeah, but that was because she was on tremendous amounts of Neurontin and various painkillers, a result of her having had a spontaneous epidural hematoma. (Note to Googlers: spontaneous epidural hematomas are extremely rare; two of my patients on the same day had had them. Such is life at Sunnydale General.) At any rate, she was moving all the limbs that she had been moving before, and could speak fluently, if sleepily, in response to questions.

Then, at ten past eight, her daughter called. She was concerned because Mom wasn't picking up the phone. Daughter is the sort of thorn-in-the-side, pain-in-the-ass advocate for a patient that we simultaneously dread and admire: she'd enlisted the help of a couple of family friends who were nurses, and she called regularly for updates. 

Anyway, Mom wasn't answering the phone. This wasn't unusual, as Mom tended to sleep in. Plus, as I'd said before, she was groggy that morning anyhow. But, because my Spidey-Sense started to tingle, I went into her room anyhow, to see if she needed help ordering breakfast.

I found an obtunded patient who couldn't move her right side and couldn't speak. She'd stroked out at some point in the last forty minutes.

After the usual stat CT scans, administration of Narcan and a bolus of normal saline in the vain hope that this was merely dehydration, rushing around notifying family members (thank God I didn't have to do that), and transferring her to the ICU, I sat down with the intensivist for a post-mortem of what might've happened.

Turns out she'd had an episode the day before of having one arm go dead. Her legs were already gone, thanks to that spontaneous epidural hematoma, and we couldn't feed her coumadin or heparin or any of the usual anti-clotting drugs, thanks to that spontaneous epidural hematoma. Although she'd recovered her arms in a matter of seconds the day before, the fact that she'd lost one at all (and by "lost one" I mean "lost all motion and sensation") led us to believe that she had some sort of clotting disorder besides the original one.

And, sure enough, she had a previously-undiagnosed bit of atrial fibrillation. A-fib, as we call it in the biz, is a condition in which the top chambers of the heart don't squeeze regularly. Instead, they sort of shiver. This doesn't affect how you feel, much, but it allows small clots to form in the backed-up blood that isn't cleared from the atria. When the heart muscle finally gets its shit together and manages to actually contract the atria, clots can shoot into the brain.

Which is what happened in this case.

The bitch of it is, the utter, total, black-furred bitch dog of it is, there was nothing at all we could've done. Some part of her clot cascade was impaired to the point that she had an eleven-inch long hematoma in her spine with no rational cause, so it's not like we could anticoagulate her. Doing so would've caused the hematoma to restart, and would've certainly killed her.

So, instead, she gets to live with only one (partially) working arm, no speech, and no ability to recognize her daughter.

The daughter was on the way to the hospital later that afternoon. I am not looking forward to seeing her. Even though there was nothing I could've done differently, and nothing would've changed even if I had witnessed the stroke, I still feel responsible.

Wednesday, June 24, 2009

Conversation over dinner

Me: "I can't help it. I'm feeling cranky. And grouchy. And disillusioned. And bitter. And grumpy. I no longer believe in love or the sanctity of romance. I hate everybody."

Friend Suzie, deadpan: "Take. A. Fucking. Motrin."

Product Review: Why the Germans are kicking our asses on the cleanliness front

Many, many years ago, I moved into an apartment where the previous tenant had been a middle-aged German woman. Everything was spotless. The coils on the back of the fridge were clean. The closet that housed the water heater was clean. The rug squeaked when you walked across it. The walls had been scrubbed. The tiny galley kitchen, off of which the back door opened, was so clean that I didn't waste any time wiping things down when I moved in.

Germans have a longstanding bad attitude about dirt, and now I now why.

Product Review: Miele Neptune

So I bought a vacuum.

A five-hundred dollar vacuum.

Sainted Father is slapping his thigh right now and making a noise of utter disbelief. Beloved Mother is raising one eyebrow skeptically. Beloved Sister is going "Nnnnggg" with envy. The Brother In Beer is wondering if I've ever vacuumed before in my life.

I bought a Miele Neptune after reading thousands--and I mean literally thousands; it took me weeks--of reviews online and finding very few negative ones. The negative reviews I found had to do with things like the length of the power cord and how easy it is to reduce the suction if you're clumsy and hit the suction-reduction button by mistake. Every model of Dyson I read about, by contrast, had volumes of bitching about noise, reduced suction, bits breaking off, things catching fire (!!!), and attachments not fitting correctly.

The Neptune arrived today. It is compact (about twelve by twenty inches), light (about six pounds) powerful (watch out for jewelry on the floor!), and quiet. Max, who gets nervous about noise of any sort, raised his head when I turned it on, glanced at the machine, and laid his head back on his paws and went back to sleep. The kittens had to be physically removed from the area; they were playing with the parquet head.

First I vacuumed the bare floors and wondered why the old vacuum/dust mop/Swiffer combination hadn't picked up all the dirt. The floors shine like they've been waxed, now. Then I moved on to the big jute rug in the living room, and wondered again what the old vacuum had been doing. After that I vacuumed all the walls and the ceilings and the top of the refrigerator and the bookshelves and a pleated fabric lampshade that I thought was cream-colored but, on vacuuming, turns out to be white. Then I vacuumed the top of the fridge, the bathroom floor, the utility room (aieee!), and the woodwork.

The entire time, the animals were totally unmoved. I heard a text-message alert come on my phone, and listened to NPR without having to turn up the volume. 

If I could vacuum myself without injury, I would. I think I would be clean enough to perform surgery without a preliminary scrub.

Drawbacks, if they can be called that, include the fact that if you're trying to pull the vacuum over a rug and around a corner simultaneously, it will tip over and turn itself on. Also, the cord is only about ten feet long. My house is a whopping 900 square feet, not including the utility/everything room, so that isn't a problem. The instructions that come with the machine are Germanic in the extreme, so you might want a couple of slugs of good liquor before you read them. The Miele cannot be used on animals or in wet environments. It also probably should not be used under water or in zero gravity, though it'd probably work in that last. And the suction control on the wand is easy to open by mistake, but only if you're as clumsy as I am.

Verdict: Save up. Spend five clams on a vacuum. Within fifteen minutes I knew this was the best five bills I'd ever spent on anything.

Tuesday, June 23, 2009

I had a wonderful post all written in my head....

...about how I watered the tomatoes last night and found that, although the neighborhood raccoon had tried to eat all of them, he'd missed a few.

Also about how it was the solstice, and thus how the sun had hung on the horizon for what seemed like forever on Sunday night, lighting the dinner and Rogue that my friends next door gave me.

Also about how the solstice reminds me of watching eagles hanging in midair over the mountains, with sunset not happening until nearly midnight, and the sense of infinite possibility.

Also about how yesterday was full of kittens and dogs and gardens and my basil blooming.

Instead, one of my patients went very, very bad today. It's nobody's fault, but I'll be taking a couple of days off. Because you kind of have to, after a day like today.


Saturday, June 20, 2009

What To Expect When You're Expecting A Central Line!

So. You're in the hospital, stuck with a disorder or disease that requires multiple infusions of something nasty like chemotherapy or Vancomycin or suchlike, and your doctor tells you you need a "central line". What the bejimminy blazes is a central line, and how do they work? And why the hell is this a good idea, anyhow?

Listen up: you'll thank yourself for getting one, especially if your particular condition requires not only infusions of Nasty Stuff but also frequent blood tests.

Central lines are, as the name implies, intravenous lines that go into one of the really big veins that drains into the center of the body. They come in three types: Really Temporary, Sorta Permanent, and Really Permanent.

The Really Temporary type is most common if you're having something like plasmapheresis done for CIDP or MS. Normally it's inserted at the bedside by a surgeon, and it goes into the internal jugular vein (that's the big one in your neck). Very occasionally they'll put one into the big vein in your groin, but that's kind of a pain in the ass, so it's to be avoided if at all possible.

Most likely, your IJ (internal jugular) central line will have two separate toggles on it and will be short and sort of curled on the ends. Through this, nurses and doctors can draw blood and do plasma exchanges. It saves you from getting large-bore IVs started every time you need a plasma exchange, and saves you from getting stuck multiple times for blood draws....but there's a drawback: no matter how carefully-inserted the thing is, it has to come out after a week, two weeks at the most.

The Sorta-Permanent type of CL used most often is something called a PICC line. PICC stands for Peripherally-Inserted Central Catheter. It goes into your arm and threads up the big brachial vein, to end just above your heart. PICCs are very handy indeed, as they come in one, two, and three-lumen (opening) versions and can be used for everything from injections of IV contrast (provided they're the right sort) to blood draws to chemotherapy infusions. 

PICCs can stay in for weeks to months; I've seen 'em stay in and be usable for six months or more. Generally speaking, though, you want the thing out within about 14 weeks, just to reduce the risk of infection.

The Really-Permanent type of central line is called a Mediport. (This, by the way, is a brand name. Please don't sue me. Thank you.) Mediports are cute little buttons that sit under your collarbone and attach to a line that runs, again, into the big vein above your heart. The advantage of Mediports is that they can stay in basically forever, be used for blood draws and suchlike for years, and don't have as great a risk for infection as the other types of central lines. The drawback, of course, is that you're getting something implanted under the skin of your chest, so you're gonna need anesthesia and stitches and so on. Plus, they're kind of a pain to take out. However, if you're going to need chemo for a long time, like if you have MS and need periodic infusions of Rituxan, they're a good bet.

Mediports are accessed by a stick. That's another drawback if you really hate needles, but hey: it beats getting stuck with enormous needles over and over in one or both arms, right? Right.

The drawbacks of all central lines are pretty much the same: you could get a whopping infection either at insertion or later on. To combat that, they're put in using sterile technique, and everybody's very careful about using them. 

Another possible complication is that the line either busts through the vein wall or doesn't go where it ought to, leading to punctured chest cavities, internal bleeding, or other screwy stuff. Luckily, lines are what we call "radio-opaque", which means they'll show up on X-ray. Once they're placed, we can check that they're in the right spot with an X-ray, and reposition that sucker if necessary.

A final complication, and the most common one by far, is that the central line will form what's called a fibrin sheath on the end, so you can neither draw blood nor infuse drugs through it. Fibrin, by the way, is a component of blood clots. When this happens, we have a cool drug called TPA that can dissolve the fibrin, thus making the line usable again. And no, it doesn't mean a clot will go shooting toward your head; it dissolves the blockage into such small pieces that your body doesn't even notice them. I do a LOT of central line declotting at work.

That's your Central Line Primer for the week. Consider asking for one if you're undergoing treatment for MS, MRSA, cancer, or anything that'll require frequent sticks and blood draws. Your peripheral veins will thank you. 

Thursday, June 18, 2009