Congratulations, new graduates! You'll be fine.

Really.

You won't kill anybody.

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

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

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

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

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

1. Do not freak the fuck out.

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

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

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

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

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

Yeah. That's what I thought.

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

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

Don't sleep with your coworkers.

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

I, and your other coworkers, thank you.

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

5. Don't work too hard.

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

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

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

Congratulations! And I look forward to working with you.

I'm really looking forward to a week off.

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

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

People, please:

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

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

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

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

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

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

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

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

I just won five bucks.

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

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

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

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

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

Of course.

Random, and updates.

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

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

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

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

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

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

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

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

And finally, let me make this perfectly clear:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Things that made me cry today.

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

But today?

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

Prison conditions in California.

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

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

And this:

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

Early Sunday morning listening:

*whew* *sigh*

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

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

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

All of which leaves me tapping my fingers a bit.

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

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

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

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

Well! That hasn't happened in a while!

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

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

Oh.

God, I hate it when that happens.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Love,

Yer pal,

Jo

Bad-ass Good Boy! of the day:

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

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

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

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

Limbo, limbo, lim-BO

Quick Animal update:

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

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

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

This is why Abilene Rob is worth knowing.

A Medical Comedy Scripted By The Marx Brothers

I, too, am tired of these motherfucking snakes on this motherfucking plane.

So today I get a call on one of the internal phones. These phones have super top-double-secret numbers that are only dialable from other phones in the hospital system. I pick up the phone. The voice on the other end asks for me by my real, long-form name, the one that I normally keep hidden in a Hawaiian records office.

It's the scheduler for the OB/GYN, reproductive endocrinology, reproductive oncology people. She wants to know if I've scheduled the ultrasound followup for the hot spot they found on my PET scan. The one on my right ovary.

(*sound effect of screeching brakes*)

Me: What? What motherfucking what?

Her: Uh....has Dr. Crane's office not called you with the PET results?

Me: No. How 'bout you tell me what the fucking motherfuck is going on here?

Her: Well, they found a hot spot on your right ovary and I'm sure it's benign most of these things are it's probably nothing but we want to check it out right away so how's tomorrow at two o'clock?

Me: (trying not to sound panicked) Fine. Whatever. Great. *click*

After I hung up the phone, I yelled to my partner that I was heading downstairs for a bit, then borrowed the boss lady's office to have a nice thorough bout of hysterics (I made the appointment for the ultrasound and follow-up first, though). Hot spot, PET scan, ovary, age 41, adenocarcinoma already, holy crap.

Boss Lady sent me home. She didn't even give me a chance to argue, just called in somebody else and shoved me out the door. So home I came, and watched Dr. Who until my brain exploded. Then I took a nap.

When I got up, I discovered two things: That Dr. Crane had left me a detailed voice message after the tone, and that he'd also sent an email. His communications had crossed with the phone call from the folks at OB/GYN, so I had missed 'em.

In both messages, he said that the "hot spot" was something that, according to the radiology people, looked consistent with a dermoid cyst. They'd seen it six months prior, on my first PET, but given that we were busy with other stuff, had elected to advise a wait-and-follow approach. The thing, whatever it is, is unchanged in size and uptake from the last scan, but it's still there. Given that dermoid cysts (those are the weird things with teeth and hair in 'em) can burst and cause peritonitis and so on, the Radiology Guys figured a diagnostic u/s would be a great idea. I agree with that, so I'll be prodded with a wand tomorrow.

I just love incidental findings.

So, yeah. My head, by the way, is fine. My neck and chest both look lovely. My belly, aside from the fact that I have Animal from the Muppet Show on my ovary, is pristine. My adrenal glands were a little overactive, but as Dr. Crane said, that's to be expected on a follow-up scan for cancer.

Teeth and hair. On my ovary.

This explains why I've had the compulsion to floss my Fallopian tubes.

Endings. Beginnings. (Dude. I know you follow me on Blogger.)

My ex-husband is selling the house we bought shortly after we were married. It's the house I grew up in; Mom and Dad sold it to us for super-cheap. He's asking about five times what we paid for it.

And you know what?

He ought to get every penny. It's totally worth it. He's prettied it up with refinished floors and fresh paint and a deck, but more than that, he's rewired the whole darned 3200 square feet and put in new windows and insulation. I heard all this from guys that I'd hired to do the same work on Casa Del Animules.

The kitchen looks great. The second-floor bathroom is a vintage dream. The room I called my study, where I first started to get online, is gorgeous.

Clint, dude, you do good work. Despite all our differences, that is one thing I will never, ever dispute: you do very good work.

So that's the end of a chapter. The house I knew is bordering on unrecognizable: for one thing, the kitchen is both more attractive and more usable than it ever was when I lived there either time. For another, did I mention that he added this huge, gorgeous deck where once was a totally worthless and dangerous set of concrete steps? Seriously, this is a great house.

Another thing ended today: I got a pretty good preliminary report from Dr. Crane. Although the finals from the PET won't be back until tomorrow at the earliest, and yes, I plan to risk a written reprimand to sneak into the computer system and find out what they are, the basic report looks good.

I seem to have a cure.

I am now a person who had cancer. Subject, of course, to any revelations contained in the report from the radiologist.

I seem to have a cure.

The theme of the Life Of Jo seems to be this: the things that suck the most are the things that leave me with the most lasting, most valuable lessons.

I hated my first husband for a long time. It wasn't until I started admitting things, like that he taught me how to be an autodidact, and taught me how to wrestle out the important points of an argument, and how to call bullshit, that I realized how valuable he was to me. Most of what I am, intellectually, I owe to Clint. We may have been a crappy match other than brain-wise, but he had a brain the equal of which I have not yet met, even in years of working with neuroscientists.

I hate that I had cancer. I'm still in the process of hating it; hating that I have two plastic palates soaking in water on the kitchen counter, hating that bedtime stories and casual conversation are both limited by whether or not I have my mouth in. Still, it's getting easier: I'm getting more intelligible without the Device in, and I can make jokes about it, like that I sound like an adult in a Charlie Brown cartoon without it.

I can't remember now what I sounded like without a palate in. Sometimes it comes back to me, mostly in dreams, but even my dreams now are like my real life: I sound funny without help.

Sometimes I dream about the old house. In one dream, all the furniture was suspended above the floor, and the walls were being replaced with cedar shakes. In another, the entire back yard had been plowed up and planted with soybeans. Mostly, though, they're peaceful: I walk through the house, touching things I remember that have been long sold or destroyed.

I can't remember now what I was like before I met Clint. Five years ago that would've been cause for frustration and anger. Now I'm just thankful that he taught me things that have lasted beyond all the shit we put each other through. Maybe, if I'm lucky, having had (can I say that yet?) cancer will be the same way.

I am full of Valium and Mexican food and this might just be the way to live.

The PET scan went fine. Final results probably won't be back until tomorrow, but Dr. Crane says the look he took seems okay, except that I have a stone in my tonsil. "I don't know why I didn't just go ahead and take those out," he said, referring to my tonsils, "I was in there anyhow."

He got a big ol' side-eye on that one.

Nurse Ames looks like a fluffy bunny that would come apart if you spoke to her harshly, but she drives like a NASCAR wannabe. Even with horrible wrecks between Littleton and Bigton, she managed to get us there on time and in one piece, and with minimal gleeful cackling.

I'm going to go hang up my scrubs now for tomorrow and then try to stay awake long enough to feed Max this evening. *sssskkknnnnkkkkzzzzzzzzzzzzzz*

Bad/Worse/Worst Volume 2: A quick update

Bad: Having a cat try to steal your roasted asparagus while you watch "Miss Congeniality".

Worse: Having that cat succeed. NOM NOM NOM says Notamus, eating asparagus.

Worst: Cat asparagus pee.

Srsly? The worst. Even multi-cat ain't up for this shizznit.

Or peenit. Wev. Ew.

>_<

Odds and Ends

Poor Max has had some broken sleep lately. Flashes (the smaller, stripey, smarter cat) has decided that he misses cuddling with a dog at night and so has started sneaking onto Max's bed when he thinks Max is asleep. If Max is asleep, Flashes cuddles until Max wakes up. At that point, Max lies there for a moment, thinking the doggy equivalent of "he's right behind me, isn't he?" and getting more and more freaked out, until he can't stand it any more and has to get up and go sleep in the kitchen. I've been finding Flashes on the very edge of Max's bed in the mornings, looking sort of lonely.

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

Bad is having a tube in your brain.

Very bad is having a tube in your brain that then gets infected.

Worst of all is having a tube in your brain that drains nothing but pus and chunks of brain tissue. Jo went *erp* O_< at that.

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

If you haven't already read Mindpop, go do so immediately.

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

The drought, while not broken, has been moderated in the worst way over the last few days. A series of thunderstorms/tornadoes/supercells dropping golfball-sized hail has formed right atop us this week. While we've gotten some much-needed rain--maybe all of Littleton won't burn to the ground!--it's been exciting. I tried to lie down for a nap today and was disturbed by the howl of the weather sirens and the BANG BANG BANG of hail on the windows.

Max was unaffected. So were the cats. Little bastards wanted to go outside and play in it.

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

The interview with the nice writer for Reader's Digest went swimmingly. Thank you for all your suggestions. I have one to add: "I'd never tell a patient that he's a moron for waiting a week for his stroke symptoms to improve before coming to the hospital." Although, you know, I'd like to. Especially when his wife bitches me out because "we're not doing anything" for the guy. Lady, there's nothing we *can* do. Aspirin, make sure he's not in a-fib, make sure there's no patent foramen ovale, rehab: that's the prescription for moronity right now.

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

Nurse Ames and I are making our semi-annual pilgrimage to Dr. Crane's tomorrow. There's one stop we have to make first, at the PET center. My single Valium is safely packed away in my purse. I've gone from unworried to completely freaked out to fatalistic and drinking too much wine. Just as I was reminding myself that nothing was likely to have popped up in six months, the Steel-Toothed Brain Ferrets chimed in with the fact that it was only six months between a clean check-up and the discovery of The Toomah.

Oh, well. If the PET's clean, I'll celebrate for years. If it's not, I'll have more material for the blog.

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

Bad is having a tube down your throat.

Worse is having a tube down your throat and an intensivist that doesn't know how to set the ventilator correctly.

Worst of all is sustaining lung damage because your intensivist set the ventilator wrong. Then you end up with us. Whether or not that is an improvement is up for debate.

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

And finally: A group of us (including the Cute Neurosurgeon and That Other Really Cute Guy and The Third Really Cute Guy, The One With The Crazy-Eyes) from work have started meeting for fun, adult events like going to the kids' exhibits at the science museum in Bigton (with flasks; that's what makes it adult) or going off to the driving range (with flasks). We're all heading out to a burlesque show this weekend; one of the girls from the CCU is making her girdle-and-pasties debut. We plan to dress.

La Belle Dame Sans Merci, a colleague who can wear a fascinator without looking ridiculous, is lending me a waist cincher. I am practicing using liquid eyeliner to make those little cat's-eyes lines and have bought a new dress. I am stepping up my game. Der Alter Jo has mentioned that she might join the fawn-walking-on-ice brigade in a new pair of FM pumps, and Stoya is going to wear something red and strapless that will make her look tigerish and exotic.

When I asked La Belle Dame what she planned to wear, she said, "Oh, just this black dress I've got. And five-inch platforms. And a fascinator. And gloves." Hence the stepping-up of the game.

Wish me luck. The evening will be a win if I can escape without a broken ankle. I haven't worn heels since I surprised Mom at her own birthday celebration a few years ago.

Last minute request for the Minions:

I have an interview tomorrow morning with a very nice person who's writing an article for Reader's Digest that's to be called "50 Things Your Nurse Won't Tell You." It's in the same vein as the ones she's written about what airline pilots and waiters won't tell you.

What would *you* not tell your patients?

Sunday night fluff:

There's a reason the saying is "Crazy as a pet raccoon."

If you need a little breather from OCD raccoonosity, click here. I fell instantly in love with this platypus and now want to know what sins I have to commit to come back as one in my next life.

Continuing the weird-animal theme, check this out:

I love him, too.

And, finally, the classic site for all Weird Animal Afficianados: Tamandua Girl's Living With Anteaters. The site chronicles her life with Pua, Cinco, and her other critters. Pua was a rescue, as was Stewie (rest in peace, little dude).

This should put to rest Stoya's question, "But what do they eat?"

Oooo. That last song's been up for too damn long.

Try this one instead.

My oldest friend Rob (not Abilene Rob, the Other Rob) posted this to his FB page and I fell in love.

Things here have been... ... ...odd. I've considered, more than once in the last couple of weeks, going back to waiting tables.

The NCCU is under-peopled, so The Big They (aka Manglement) want the nurses to certify as chemotherapy nurses as well, so that we can help out in case of too many chemo patients and not enough chemo nurses. It's an interesting proposition, but I think I might be the only one that feels that way. Two of the other nurses I work with will probably set their teeth and be done with it (though, on second thought, one of 'em is pregnant, so that's a no-go), while the third, Der Alter Jo, has said, "I don't want to be a chemo nurse."

I wouldn't mind being a chemo nurse, but what we're being signed up for isn't exactly chemo-chemo: It's bone-marrow-transplant chemo. Which sucks. Because you have to kill somebody's immune system without killing them. And that's hard, emotionally, because the folks in question are really, really sick. So, yeah, I'm with DAJ on this one.

That's the beauty of dealing with primarily neuro patients: although they might have chronic diseases like diabeetus or hypertension, they're mostly pretty healthy. Really sick people don't have strokes and live. Really sick people end up getting bleeds, or falling over from heart attacks, or ending their lives in some way that's pretty darned irreversible. Because my patients have things going on that are reversible or at least work-around-able, I end up doing a lot of education and tailoring treatment plans; things that I'm good at. I spend, in short, a lot of time looking at my patient rather than looking at the monitors above the person. Chemo nursing of the type The Muckety-Mucks want us to do is the exact opposite of that.

On the other hand, if I train for this, I'll keep my job and my health insurance. Which is worth doing. And, to be less cynical, I'll get a whole new set of skills, and learn a whole new set of things that I've forgotten since nursing school. So there's that.

There have been many Interpersonal Dramas of the Irritating Type in the hospital lately. Interpersonal Dramas are hard for those of us who don't like interacting with normal people, and who don't like drama. The hardest part, for me, has been not simply reacting like a tornado and carving a ditch through the middle of the hospital. Instead, I've been reading anthologies of old science fiction on the Kindle and hugging my knees in a corner in the dark. The tl;dr of this is that smart people can be really, really, really stupid, and I don't want to be stupid.

Um....what else? Oh, yes: follow-up PET is on the 26th. I'm not officially freaking out about it yet, though I can feel Intimations of Freak-Out beginning in the pit of my stomach. It's like, the first PET was clear, the sono I had to have for lumpy boobage was clear, so is this the third-time-charm? And other paranoid thoughts, repeated endlessly in a moaning, droning hum under the day-to-day stuff my unconscious has to deal with, until I end up in a corner with my Kindle, hugging my knees in the dark. You know the drill.

In critter news: Max had an existential crisis today. The postman, with whom he has a long-running agreement, showed up in the front yard at the same time that the ice cream truck drove along the street that runs parallel to the back fence. Max moved faster, motivated by the desire to play with the postguy and hatred for the ice cream guy, than I've seen him move in years. All of his Kangal came out and he tucked his butt up and raced from back to front to back of the yard with legs like steel springs. He didn't catch either one, but he had a hella good time trying.

The cats are insane. They're busily deconstructing the closet as I type, and shedding everywhere. Neither one of them will tolerate the Furminator for very long; it awakens a deep desire in both of them to KILL BROTHER. I'm convinced that kitty-eyes are like The Terminator's eyes, with instructions scrolling past in small print for every situation. Unfortunately, the default is usually KILL BROTHER. At least they've grown out of KILL ANKLE. I would hate to see what 24 lbs. of cat could do to my legs that hasn't been done already.

And there's a really cute guy at work. Friend Pens is being encouraging, which is silly. But he's really cute.

And that is all. Go back and listen to that song again. It'll do you good.

Unintentional creepiness of the day, brought to you by Ingrid Michaelson.

I hadn't given "Girls and Boys" a really, really good listen until I was on my way home last night.

This song? Is probably supposed to be about unrequited love and should fill me with despair and sympathy. Instead, I find it inutterably creepy. Like Creeper McStalkersons creepy. Like Crazy-Eyes creepy. Way creepier than "Every Breath You Take" creepy. Bunny-boiling creepy.

*shudder*

In other news, it's now Less! Than! A! Month! until Friend Rob graduates from nursing school, and I am just so excited that I could fdafdskaht. He needs to sell his motorcycle, so if you're somewhere out in West Texas and haven't completely burned up in the wildfires, check this out.

Um....what else? Oh, yes. The secretary is painted, though I still have to put the glass back in the doors somehow and figure out how to touch up the paint without messing things up.

Notamus has learned how to open all the step-on trashcans in the house.

There has been a horrific bug of some sort going around the hospital. I avoided (strangely) the sore-throat-cough-sinus part, but caught the gack-herk-bleh-tummy part. But now I'm better.

And finally, waiting a week for your stroke symptoms to subside before you present to the emergency room is probably not a good idea. We can't do a whole lot for you.

More later: blood! Bones! Bingo!

Oh, and by the way....

It's really weird to be missing a tooth. Even a tooth you don't think much about.

When popcorn goes to get lost in a tooth, you tend to notice if it's a tooth you've had avulsed. It ought to be there, and it's not.

You never get away from it, do you?

Edited to add:

I know this is really ungrateful, and I should be thankful for what I have, but:

On the 26th, I've got the first PET scan since surgery. What will I do if that PET shows something nasty? I *know* it's unlikely. I *know* that, statistically, my chances of having a recurrance are nil until 15 years post-first-diagnosis, but I still worry. My surgeon, who was one of the guys who differentiated PLGA from things like ACA and HGA, was surprised at how well I was doing. I have a hard time getting past that.

His pessimism scares me. The reaction of my prosthodonsist, Dr. Elf, scares me: he's always so amazed at how well I'm doing.

More than that, I am not whole. I am not whole in a very big way. I will never *be* whole, in that my Brother In Beer will still look at me when I try to talk with my prosthetic out and shake his head and say, "Sorry".

At some point, this thing in my head will stop being a party trick.

I would like to be understood without a plastic bit.

With the plastic bit, I have to choose what I say. Now, and for ever.

Maybe that's the lesson I have to learn.

It's never a boring day when three things happen:

Uno: I got the day off, totally unexpectedly. Which was wonderful, because being cancelled, with the attendant risks of being called in, always makes me super-productive. I now have three clean cabinets and a clean utility room.

Dos: Eyelashes are dyed and cuticles are dealt with. If you've seen either, you understand what a challenge this is. The fact that I did it simultaneously--dyeing eyelashes AND pushing back three months' worth of overgrown cuticles--without injury is amazing.

Three: I managed somehow to draw blood while vacuuming the living room today. Don't ask me how. Stoya responded to my text on the subject with "I don't Even. Want. To. Know" to which I replied, "Don't worry; I have no clue, either." One minute I was sucking up rug bits; the next I was bleeding.

Never a dull moment here at Casa Jo.

Fun links to follow while I'm painting my secretary!

(Ain't come to play; I come to get this job done!)

Elsita has been back for a few months, posting outfits on The Hidden Seed. Sometimes I wish I had her closet, but then I realize I'd just wear the same shorts and t-shirt every day, because I live in a place where the climate is hell.

Think Geek is my go-to for wardrobe updates. I really, really want the t-shirt that says "If You're Not Part of the Solution, You're Part of the Precipitate."

The Mary Sue is a great read for chick geeks, the people who love them, and the people who want to be chick geeks.

Are you depressed by the nosedive that Jezebel has taken? I was, until I found Persephone and The Hairpin. Persephone skews a bit more serious; The Hairpin is the sister website of The Awl, which has the motto "Be Less Stupid." When it comes to girly stuff, The Hairpin certainly makes you less stupid. There are tutorials! on eyeliner! by a producer of "This American Life"!

I really love The Ugly Green Chair. Most people can either write or take pictures. Whitney can do both, and does. Plus, she cooks.

NSFW, Not Safe For Mom! Somebody some time ago sent me a link to Sexy is for Everybody, a body-positive, inclusive, ethical porn site. Online porn isn't my cuppa (the letter-passing scene in Pride and Prejudice is hot enough for me), but if you're looking for something less skanky and weird than, say, Fleshbot, you should check this out.

And, finally, if you are a high school or college student who's having a hard time getting through whatever piece of classical literature's been assigned to you, you should check out Myths Retold. I found this through Antonia Cornwell's blog, Whoopee, which should be nominated for the Fucking Ass-Kickingest Blog Of All Time award. Warning: both blogs contain about as much profanity as this one, which makes them both NSFB (not safe for boss), although Antonia's is all "facking" and "bloody" and "fanny", which just makes me want to drink tequila with her that much more.

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

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

Those days are back.

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

1. Please do not have bitchy family members.

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

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

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

3. Don't abuse your elders.

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

Seriously.

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

4. Don't abuse me.

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

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

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

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

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

I need help remembering the title of a book.

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

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

Does this thread any beads in anybody's mind?

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

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

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

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

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

Two cats for sale, cheap.

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

Wait.

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

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

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

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

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

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

Wish list.

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

A heated towel rod.

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

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

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

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

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

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

Not having to think about my palate.

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

No more cancer.

A date. Seriously.

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

Spring: it's what's for dinner.

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

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

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

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

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

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

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

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

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

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

Gratuitous Ingrid Michaelson:

Thursday Morning Remedy:

Shamelessly stolen from Jezebel:

BABY ELEPHANTS IN A KIDDIE POOL OMG.

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

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

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

This broke my heart:

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

Answers to the Further FAQs....

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

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

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

4. Head positioning for various types of strokes:

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

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

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

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

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

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

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

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

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

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

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

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

The identity of illness.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Jo FAQ

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

Who are you?

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

Where do you work?

Not tellin'.

No, really. Dallas?

Nope.

Houston?

Nope.

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

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

Are the stories you tell true?

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

Who are all these other people you talk about?

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

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

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

What exactly do you do?

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

What do you do for fun?

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

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

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

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

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

Are you married? Boyfriend?

No and no.

Oh, so *that's* your problem.

That's not a question either.

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

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

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

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

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

Got any further disclaimers to make?

How kind of you to ask!

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

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

Any other queries? Ask 'em in the comments.

Is she outside-in or inside-out?

I've been thoughtful lately.

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

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

*heavy sigh*

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

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

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

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

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

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

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

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

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

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

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

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

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

Now, for the preceding in English:

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

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

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

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

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

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

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

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

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

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

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

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

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

March Moneygrubbin: Help a woman in need.

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

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

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

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

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

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

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