Mmmmmm....

I really, really meant to do the seven by seven that other bloggers have tagged me with tonight. I swear I did.

But I got distracted with making biriyani.

Oh, my God. I make some kick-ass biriyani. I do.

You can taste the ghee in the plain rice. The yogurt-marinated chicken is perfect and tender. The onions are burnt to just the right burnt-onion taste, and the potatoes are brown.

I think I'll go Google "Sindhil Ramamurthy" and "John Abraham" (my friend Deepa says, "And he has a name you can pronounce!!") now.

Mmmmm. Biriyani.

In fact, if you don't bite into one of those *$(*(*$#@&* dried tamarinds contained in the Bombay Biriyani mix, it's perfect. PERFECT, I tell you.

Mmmmm.

From the "Oh, Shit, I Forgot" Files...

Check this out.

I have no clue how long Janet has been blogging, or how long she's been a nurse. What I *do* know is this: if you want to model your nursing blog on somebody, model it on Janet's. She writes in a simple, straightforward style with understandable language and heart-wrenching simplicity. It's fast becoming my new favorite, along with Sid's.

You know it's time for a glass of wine when...

...a memo describing an upcoming change in hospital policy gets you so angry that you send a snarky, venting email with scarcely a word under three syllables off to your manager, ranting about how un-Einsteinian Upper Manglement is.

And then, even though you prefaced it with the disclaimer that it was venting and snarking and nothing more, your manager finds that it so perfectly describes the mood of The Lowly Worker that she forwards it.

To everybody.

Everybody, that is, except the president. Who will probably hear about it anyhow, within a matter of days.

Good thing I used nice, big words and phrases I can look back on with pride, such as "(the) headlong gallop down this precipitous slope to mediocrity" and "the breathless pursuit of the lowest common denominator."

The memory will keep me warm in the cardboard box I'm sure I'll be living in starting Monday.

Best blog.

Read this. As usual, I'm late on the boat, but I just spent an hour reading Dr. Sid. Can't wait to get back to him.

Minor Procedural Gripes.

If you are a doctor, please, *please* do not use the nurses' computers when the doctors' computers are entirely unoccupied. And if you do, please, for your own sake, don't grouse when I say "Excuse me, please" politely and make a long arm to reach for my charting. Even if you are an attending--and I'm talking to you, Doctor Wire-Rimmed Oncologist--I will slit your belly and hold your smoking entrails up before your dying eyes if you refer to me at work as a bitch. Outside of work I'll just kick your ass.

Just so's we understand each other. That memo? Got sent. Have a nice Monday, doc.

Jack And Jill V-Cut Spicy Barbecue Flavor Potato Chips should either be available free of charge in the continental United States or banned as a controlled substance. No more importing them from the Phillipines, people. If I can only get my Spicy Barbecue Flavor Chip Fix twice a year, I get grumpy.

Which reminds me: Mom, Dad, why did you have to raise me so that my comfort foods are refritos and blackberries? Why couldn't I have been a *normal* kid?

If you're a resident, please keep in mind one simple thing: I work at one hospital. You work at three, in rotation. Therefore, I know the rules at my hospital better than you do. Your attempt to bully me into breaking the rules at my hospital because you're too lazy to come out on a Saturday will result in your attending being...unhappy. The less said about the sequelae, the better.

If you're a nursing student, please, *please* do not look at me like I've just grown a third head and am about to take a bite out of you with it. I promise, I want you to succeed. I will go to a lot of trouble to make sure you get a good clinical experience. Just don't stammer and go silent when I say "Hello". I like you. I really like you.

Note to other nurses: If a patient is deaf or does not speak English, yelling will not make them suddenly un-deaf or fluent. A lot can be accomplished with smiles and nods and an interpreter.

I don't care if you drive a Prius: don't go 45 in the passing lane.

I'm off to my usual Sunday comfort-food and "Extreme Makeover: Home Edition" fest. And I hate the producers, actors, and director of "Grey's Stupid Whiny Anatomy" for making me curious about what happens between Meredith and Doctor McFacelift in the season premiere. I hate them. Hate them. And yet....I wonder.

Burke is much, much hotter, by the way. But Gregory House? Hottest of all.

He can almost kill me five times in forty-two minutes any time.

Quick note:

In case I should disappear for a while, it's not because I'm busy strangling hammer-wielding intruders or because I've fallen victim to some strange bug. The provider of Innernetwebwideness that I use has decided to stop providing a hookup, so I've had to go with a Large Corporate Provider. The LCP says my Innernetness will be accessible by 10/5, and I don't know how long the old line will stay up.

That is all. Return to your regularly scheduled more important things.

Results of a recent study show...

...that among nurses who watched a cumulative 4.5 hours of "Grey's Anatomy", 100% repeated, over and over and over during the course of the show, "I AM SO GLAD I DO NOT WORK WITH YOU PEOPLE."

Ten percent of respondents also volunteered the information that they would rather enoculate themselves bilaterally with a rusty runcible spoon than watch the Season 3 premiere.

Thank you. That is all.

So you're a nurse. Now what?

I got a request for a post about role confusion (that awful feeling that comes from being a new nurse), and it sounded like a good idea. The transition from student to preceptored nurse isn't as hard as you'd think; you still have to show up on time for various classes and lectures, you still have somebody following you around, you still feel like there's some leeway for mistakes.

Coming off a preceptorship, though, is a whole 'nother deal. All of a sudden, you're a Nurse. But you don't feel like one; instead, you feel like some shmuck that's been picked up off the street and dumped into scrubs. Things seem really, really hard--even simple things, like a focused assessment of a patient.

Here's what I learned when I was a new, nervous nurse, then:

1. You will not kill anybody.

Unless you do something spectacularly idiotic, which is very very very rare, you will not kill anyone. You have people looking out for you--this is true throughout your nursing career--and every action you're expected to take has gone through a number of people more experienced than you.

2. Remember the First Rule Of Nursing: If you have to jack with it, it's wrong.

That one little rule will save you every time. Hospital and clinic work has been streamlined and perfected over the years so that it's practically tired-new-nurse proof. Therefore, if you find yourself having to improvise or make things up to get something done, take a good look at what you're doing. The likelihood is that you're either doing the right thing wrong or the wrong thing altogether.

3. If you do screw up, report it immediately.

Nobody is going to fire you, yell at you, or make you feel like an idiot. (Chances are, you'll do that last one to yourself.) Everybody, even Super Nurse Extraordinaire, makes mistakes every day. That's why we have procedures in place to, say, double-check settings on pumps and so on. If you screw up, it's important to report it so you can have help figuring out *why* you screwed up, and how to manage the situation in the future.

4. Ask questions.

Everybody asks questions, including Super Nurse Extraordinaire. Most of us ask them constantly. We all double-check each other, help each other out with weird titrations, give second opinions on whether or not that patient is more or less gorked than the day before. Your colleagues are part of a team that includes doctors and other nurses and X-ray techs and respiratory folks. Ask 'em all questions. If anybody tries to make you feel stupid, respond politely and be effusively thankful. That'll embarrass them no end.

5. Honesty is the best policy.

If a patient asks you how long you've been a nurse, *be honest*. You're not fooling anybody. If you don't know something, *say so*, then vow to find out the answer. This, too, happens every day.

6. But don't volunteer information.

I say this not because patients are stupid or mean. I say this because if you give somebody too much information, it can be truly overwhelming. Stick to answering the questions you get asked, like "How long until I can shampoo?" or "When will my stitches come out?" Don't go into a dissertation on possible side effects that only occur in 0.1% of the population. This is a lesson I learned the hard, hard way.

7. Fake it.

Act confident and friendly, even if fear makes you want to throw up and pass out. Eventually you will feel confident and friendly. In the meantime, nobody else will have to deal with your vomit or prone body.

8. Going home in tears is not necessarily a bad sign.

You will be so overwhelmed, stressed out, and exhausted that you will occasionally sag against the wall of the elevator and weep. This is a normal part of the stress that comes with being a nurse. It becomes less frequent as you learn more. It's okay. Here, have a cookie.

9. People will occasionally do mean things or get inappropriate with you.

Wackos can smell a new nurse. I got odd suggestions, inappropriate physical contact, and outright bullying more in the first six months I was a nurse than I have in the following three-and-a-half years. Be patient. Eventually you will develop that Nurse Callus that allows you to see the loonies coming and deal with them. In the meantime, lean on your charge nurse and your colleagues to help you get out of rooms unscathed. And if you're getting consistently shitty assignments with a higher-than-normal proportion of weirdos, complain. It's not fair to saddle the newbie with all of the nutjobs.

10. You will, someday, feel like a nurse.

I remember when that happened. I had had a day during which I had made only a couple of minor mistakes, caught them before they'd done any harm, and had caught a problem before it developed into something severe. Further, I had had time to pee and eat and actually take *time* with my patients.

That didn't happen until I'd been a nurse for more than a year--maybe even more than two. I don't remember the exact date, but I do remember the feeling. It was though I had finally gotten the hang of swimming with the current.

This will happen to you, too. I can't stress that strongly enough. Nursing is a constant learning process. You feel off-balance every day of your professional life, and there's always something you don't know. Nevertheless, there will come a day when you realize that you're looking ahead of what's immediately in front of you, and when care plans finally begin to make sense. You'll build on skills you already have when it comes time to learn something new. Yeah, you'll fuck up royally the next day and go home in tears, but you'll have had that one day when you can say, honestly, 'I am a nurse.'

And then, a few years down the line, you'll be chatting with a notoriously hardassed doctor and apologize for doing something dumb, like calling her at 3 am, and she'll say, "Y'know, if it comes from a good nurse, I don't really mind it when I get called at 3 am." And she'll smile, and you'll know that Good Nurse = You.

A tribute to ED nurses....

PORTLAND, Oregon (AP) -- A nurse returning from work discovered an intruder armed with a hammer in her home and strangled him with her bare hands, police said.

Susan Kuhnhausen, 51, ran to a neighbor's house after the confrontation Wednesday night. Police found the body of Edward Dalton Haffey 59, a convicted felon with a long police record.

Police said there was no obvious sign of forced entry at the house when Kuhnhausen, an emergency room nurse at Providence Portland Medical Center, got home from work shortly after 6 p.m.

Under Oregon law people can use reasonable deadly force when defending themselves against an intruder or burglar in their homes. Kuhnhausen was treated and released for minor injuries at Providence.

Haffey, about 5-foot-9 and 180 pounds, had convictions including conspiracy to commit aggravated murder, robbery, drug charges and possession of burglary tools. Neighbors said Kuhnhausen's size -- 5-foot-7 and 260 pounds -- may have given her an advantage.

"Everyone that I've talked to says 'Hurray for Susan,' said neighbor Annie Warnock, who called 911.

"You didn't need to calm her. She's an emergency room nurse. She's used to dealing with crisis."

Hat tip: Grunt Doc

Read this.

Thou Art With Us.

The Bowels of the Hospital

In most hospitals in the US, poop is the nurses' purview.

Shit is our shingle.

Bowel movements are our raison d'etre.

It's an ugly fact of life, but it's true: if you have a patient who's undergone brain/cardiac/leg/facial surgery (anything, practically, short of surgery for an intestinal obstruction or ileus), it is your responsibility as a nurse to make sure that they're regularly moving their bowels. Pooping on schedule, as it were. Dumping a load like clockwork.

That sounds easier, to the lay person, than it actually is. See, we hand out narcotics like candy (what? They're not candy?), and narcotics slow the passage of feces (or "stuff", in the medical terminology) through the bowel. Stuff that takes a long time to pass through the lower intestine becomes dried out as more and more water is absorbed. Sometimes the lower intestine itself gets lazy, and then you have the dual problem of dry Stuff and Lazy Bowel.

In short, we deal with a lot of constipated patients a lot of the time.

Normally, protocols demand that a patient move (or "open", for our friends in the UK and Oz) their bowels no less than once every 48 hours. After certain surgeries, like an open aneurysm clipping, once every 24 is preferred, as to avoid straining and possible increase in thoracic and intracerebral pressure. I thought it might be nice and amusing and edifying to go over the ways in which we manage that. Note two things: that I'm on my second beer, or else I'd *never* be typing about poop, and that these hints and tips do not apply to spinal-cord-injury patients, who are a whole 'nother ball of wax. Or dung.

Stuff Softeners: The First Line of Defecation

Docusate sodium and docusate calcium fall into this category. They're over-the-counter medications that draw water into the bowel in small amounts, allowing Stuff to remain soft, pliable, and evacuate-able in the normal person. Note that overdosing a patient on Stuff Softeners is a bad idea, as the Stuff will become so soft that it either just sits there, or turns into diarrhea. Stuff Softeners won't work for a patient who has pre-existing problems with constipation or who's badly impacted. Don't waste your time.

Milk of Magnesia: The MOM of All Remedies

MOM is technically a saline laxative. Saline laxatives work by drawing water into the bowel, following the principle that heavily saline solutions on one side of a membrane will attract water to balance their concentration. (Am I reminding you of chemistry yet?) MOM works best, I've found, on an empty stomach, two hours before any medications, and when followed by sixteen ounces of water. It's good for the moderately-constipated patient with no huge health problems (the usual neurosurgery candidate, in other words).

Prune Juice: Grandma's Remedy or Old Wives' Tale?

I've never had a lot of success with prune juice, even warmed, unless it's with people who've been using it for years as a laxative. Apparently it contains some chemical that causes the bowel to move. The downside is that it won't work with most folks. The upside is that it's the Drink of A Warrior, according to Whorf (/geek).

Stimulants: Use At Your Peril

Bisacodyl and Bisacodyl Uniserts, also known as Dulcolax or Correctol (tablets and suppositories) are stimulant laxatives, as is senna (Sennakot). Both will send your patient into low-earth orbit if they're not terribly backed up, and will cause hemorrhoids if they are. I use the pills as a last resort and the suppositories as a next-to-last resort. The major drawback of stimulant laxatives is cramping; the secondary drawback is major, major pooping.

Magnesium Citrate: When Your Best Just Isn't Good Enough

Give a patient a glass full of ice-cold cherry flavored mag citrate and a straw, tell 'em to drink it fast, and then...stand back. You'll hear their bowel sounds from the doorway. Mag citrate is a saline laxative--the difference between it and milk of mag is volume. More volume equals more water equals more...well, you get the idea. I love mag citrate, though it should be used with extreme caution in people with electrolyte imbalances. It'll cure what ails you, for sure.

Back Door Remedies: When You Get Stuck

Enemas are often the nurse's best friend. You can have plain enemas (tap water or saline, warmed, with or without a little liquid soap added), weird enemas (SMOG or bubblegum or milk and molasses), or dreaded enemas (The Dreaded Triple-H).

Plain enemas are used most often as cleansing treatments. They help the patient get rid of whatever's up there, plus, they leave the intestine relatively clean in the process. My personal favorite is 750 ml normal saline warmed in a graduated cylinder in the microwave, with the remaining room-temperature saline added until the temperature is comfortable. (Note: it should feel slightly warm on your wrist.) I'm not crazy about soap; it seems too turn-of-the-century to me, though there is plenty of evidence that the irritant nature of castille soap helps with evacuation. Personally, a liter of warm saline in yer poop chute seems like irritant enough to me.

SMOG, bubblegum, and...molasses? You're Kidding, Right?

No, children, I am not.

SMOG stands for saline, milk of mag, and glycerine. Bubblegum enemas are saline with some liquid docusate sodium added. Both are low-volume enemas that depend on the chemical ingredients for Stuff softening and stimulation. They're prescribed, in my experience, by well-meaning residents who have no clue what they're up against. The experienced nurse goes for...

Milk And Molasses: An Unlikely But Effective Combination

250 ml of whole milk (or thereabouts), mixed with an equal amount of ordinary molasses, warmed, works a treat. The molasses draws water into the bowel while the milk greases the works, as it were. Results are fast and gratifying (for the patient). We keep a gallon jug of molasses in the clean utility room and go through it in about three weeks. This, along with the half prune juice, half mag citrate cocktail, should be in every nurse's arsenal.

The Triple-H: High, Hot, and a Hell of a Lot

We're talking tap water or saline (my preference) in quantities of a liter. Or more. The outcome should be obvious. I only use these in extremely constipated patients with attitude problems.

Disimpaction: A Manual Manual

Disimpaction is unpleasant for both nurse and patient. Probably less pleasant for the patient, but it's close. We do manual (sticking fingers where fingers normally don't go) disimpaction when a patient has a rectum and lower bowel full of hard, dried feces that they can't excrete. It *hurts*. Using lots and lots of lubricant and a gentle touch will help, but you can't get around the fact that you're ouching somebody who's already ouched out.

It should be avoided at all costs, and not just because it lacks dignity. You can easily traumatize delicate tissue while doing a manual disimpaction. And, frankly, if a patient gets *that* impacted while in the hospital, somebody isn't doing their job. Even a mineral oil enema to loosen things up and grease them along is preferable to the trauma of disimpaction. You can always do a cleansing enema afterwards.

And there, children, you have it. Probably more than you wanted to know, but at least a bit helpful for the new nurse or student. Enjoy your day, eat your salad, and for heaven's sake, don't let your patient go more than 36 hours without a tour of the porcelain empire.

Wahoo! Change of Shift is up...

...and I'll be happy if I can ever stop typing that as "Change of Shirt". *sigh*

Right here.

Odds & Ends

Firstly, because I am a huge noobnik, the link to the latest Change of Shift. I suck, I know. This is going up late.

Secondly, Mike from Scrubcap sent me a very nice email, asking if I'd link to his site. Sure, Mike! The only thing that bugs me about his caps is that he's only got two patterns for the caps that work for women with short hair. And it's not personal; I rarely wear the things myself. It's just a matter of principle.

The featured cap in that link is for the Oklahoma Sooners, which a quick Google informs me is a college football team. Boomer on, Sooners.

Thirdly, an answer to the nice email correspondent who asked me if I'd ever considered posting pictures of, say, my cat or my workplace. The answer on the cat is this: If ever she did anything interesting, I would be happy to start a Friday Cat Blogging feature. Unfortunately, she tends to lie in one position, either asleep or facing the camera with an "I'm going to rip your throat out, asshole" expression.

As for the workplace, same deal applies: If my coworkers ever did anything interesting, I'd take pictures. As it is, we're all drunk at work, lying around in attitudes of total dissipation while our patients hit the bell, so it's no go.

Fourthly, on a completely boring, girly, personal note, I got a "Well Done!" certificate from my personal trainer. I thought it was sweet, a child young enough to be my daughter giving me a fancy computer-printed certificate. The downside was that there were no gold stars on it. The upside is that she's impressed and a bit mystified by my strength and stability gains. Seems I've blown the top off the curve as far as building muscle mass goes. Wahoo me. Boomer on, Jo.

(You know, I may be snarky, but the fact that she printed up a certificate really touched me. It wasn't one-size-fits-all, as it had brains and cats on it. If she adds pictures of Robert Smith circa 1985 to the next one, I'll know we're getting along.)

Umm...what else? Oh, yes: the latest Change of Shift has an excellent post on "Communicating with the Doctor". I wish somebody had given it to me five years ago, just before I graduated. Instead, I had to figure all that stuff out myself, which led to me making a howling ass of myself on the phone more than once. All new nurses and nursing students should read that one.

Did I just mention the year 1985? Seems I did. Excuse me while I go take some Geritol. (Do kids these days even know what Geritol is/was?)

In other news, I have a product review for those of you who wear mascara. See, I had to replace all my eye makeup after that pinkeye thing, and I ended up buying some Maybelline waterproof Sky-High Curls mascara. Because it was on sale. Waterproof because I have to wear waterproof eye makeup for Beloved Sister's wedding, because I don't want to look like Robert Smith, circa 1985, by the end of the ceremony.

Anyway, it works well. Yes, it is waterproof, which means you'll have to use something oily to take it off. And yes, it does curl your lashes, in a weird process that involves you being able to feel your lashes curling. If I had done major drugs in college, that probably would've provoked a flashback. It does not clump, but it takes forever to dry, so don't sneeze after you've put it on. Overall, I give it a good rating, if you like waterproof mascara.

Ooooh. The best part of that mascara purchase? Was finding out that every-damn-thing at the local Target is on clearance. See, they're building a Super Target down the road, so the Non Super Target is moving. That means that all the cool stuff you never wanted to buy before, because $15 seemed like a lot to pay for a furry Sponge Bob pillow, is now 60% off. So I have all the cool eye makeup I could ever want (thanks, pinkeye!) and some other nifty stuff, as well. Boomer on, Target.

And finally, after swimming and dinner and champagne (ugh) at Friend Teresa's, I've decided that Borzois are my new favorite sighthound breed. She has three of them--one skinny, one fat, one shy. The shy one did the lean/nit/burrow thing that sighthounds are known for, plus she was furry enough to really cuddle. I'll always be a sucker for Greyhounds, but Borzois are now running a close second.

So You're Starting Nursing School...

Tips for student nurses of all ages, drawn from my own limited experience:

1. Put aside inviolable time to study every damn day. Even weekends, even holidays. Don't get into the habit of thinking that you'll do it later, or that you can catch up. Study every day. You'll be glad you did.

2. Put aside inviolable time to think about something other than nursing every damn day. That includes not thinking about nursing blogs, or blogging your own experience. If you don't keep some other interests alive, you'll turn into StudentNurseBot, and you'll go crazy.

3. Yes, you will have no social life. This will not bother you. There's plenty of time for a social life after you've passed the NCLEX; nurses are notoriously hard partiers.

4. Make the effort to look as nicely pressed and crisp and clean and starched as you can during clinicals. Really and truly, it makes a difference. You'll not only feel more confident, but your patients will feel better about having you in the room. And if you have a crappy day, at least you looked good.

5. A word about your patients: on the whole, patients don't mind having student nurses. Some of them love it. Think about it: they get individualized attention from someone who's detail-oriented. They want you to succeed.

6. A word about nurses: on the whole, nurses want you to succeed as well. In four years, I've only seen one group of students that I felt couldn't hack it as even marginal nurses. The other students I've seen I have wanted to help, encourage, and see do well. Yes, there is the occasional wackjob or sadist who hates students. You'll be able to pick that person out of a group in no time and avoid them.

7. Another word about nurses: on the whole, nurses do not eat their young. The ones that do (and I work with one) bite everybody, not just the new nurses. And nobody likes them. Their colleagues avoid them, the doctors try to do end-runs around 'em, and management knows their tricks. Do not let the Nurse From Hell ruin your day.

8. Look around at the class you're in. Two thirds of the people in the introductory courses will probably wash out. Support them, study with them, and lean on them anyway. The relationships you form in nursing school last for about five minutes after pinning, but they're the most important relationships you'll have during school.

9. Some of your professors hate nursing. Some of them will try to discourage you, or will show favoritism to particular students for unfathomable reasons, or will be nasty without cause. Ignore those professors. Cultivate respectful relationships with the instructors who love what they do.

10. Pay attention in A&P. Learn enough skills to pass your skills lab, but don't fret about starting a zillion IVs. Know your drug book backwards, but remember that you'll have a set formulary in your hospital--you won't have to remember everything forever. Care plans suck, but they're useful in figuring out disease processes and really do come in handy sometimes. Never use "Potential For" as a nursing diagnosis more than once in a care plan. Make sure you have good pens. Always carry an extra scrub jacket.

And get out there and kick some ass. Being a nurse is infinitely more pleasant and much, much easier than being a student. Soon you'll be done with school. While you're doing it, remember that those of us who've been there are pulling for you.

Sung to the tune of "Heartbreak Hotel"

*strumming guitar*

I woke up at one this morning
And didn't know what to do
My eyes were welded shut with
This nasty yellow goo

Oh, I've got the pinkeye, baby
Yeah, I've got the pinkeye, baby
And don't'cha know I
Wanna diiiieeeee

I went to see the doctor
And all she said was "Wow...
"You sure 'nuff got the pinkeye
"Go fill this scrip right now"

'Cause I got the pinkeye, baby,
Yeah, I got the pinkeye baby,
And I got this burning
In my eeeeyyyyeeeeessss

I went on to the drugstore
And there the folks all screamed
They'd never seen the pinkeye
Be quite this bad, it seemed

And oh, I say
I got the pinkeye, baby
Yeah, I got the pinkeye, baby
And I am so bummed that I could cry.

Downside: I have to throw away all my eye makeup. Upside: I get to buy new stuff, which means I could conceivably change my image from Competent Nurse to Crazy Punk Rocker.

Downside: I have seven days of truly disgusting eyedrops. Upside: The drops kill even C. perfringens, so I won't get gas gangrene in my eyeballs.

Why I love students and GNs, and why you should too.

This past week, I was at the fifty-seventh minute of the eleventh hour of my shift when a GN I hadn't met before approached me and introduced herself. Turns out she wasn't looking for me, but we had a nice chat anyhow.

I asked her if she was getting a thrill from signing "RN" rather than "GN" after her name, and something amazing happened. I don't think she realized it, but she stood up a little straighter, her face glowed, and she said, "Yes. I'm really proud."

Turns out Dad and Mom had both been working three jobs to put her through school. She did very, very well and passed the NCLEX first shot, and now got to sign "RN" after a name composed mostly of consonants. You bet she was proud. Her whole family is proud of her, and rightly so.

And *that* is why I love new RNs. It's not just that they keep me on my toes during preceptoring with questions I've never thought of. It's not that they're seemingly inexhaustable and willing to work hard, because everything is so fresh and interesting. It's not just that they come up with questions about procedures and policies that make me go, "Buh?" and realize that there's a better way to do things. It's that they are so damn *proud*.

They've worked very, very hard for two or three or four years, often while mastering English as a second language or relearning algebra that they'd gladly forgotten twenty years before. They've busted ass through difficult courses with instructors who were, at best, flaky and at worst, actively discouraging about nursing as a career. Some of them turned their backs on lucrative jobs doing something else in order to answer a calling they'd ignored for too long.

They have every right to be proud. And seeing a new nurse's face light up when you ask about the "RN" thing is marvelous. It reminds me why I do this.

Nursing students do everything that a GN does, but more so.

I remember coming on to the floor on the first day of clinicals my first semester. I was so frightened I thought I'd throw up, and seriously considered running away. As the semesters wore on, I got less nervous, but I got much, much more tired. I see that process now with students.

The nursing students we get are excellent. The one exception that I complained about bitterly last year was just that--an exception. The SNs ask questions about anatomy and physiology that require that you keep your chops up. They cheerfully volunteer for tasks that seasoned nurses hate, because it gives them experience. Inserting a rectal tube is a brand-new, shiny job when you're just starting out, after all.

And they're cheerful. On very little sleep. I had classes Monday through Wednesday, starting at seven in the morning and going until three in the afternoon, after which I would spend at least a couple of hours in the lab or the library. Thursday and Friday, clinicals started at 6 am and often didn't end until after 4 pm.

The students I work with have schedules at least as harrowing, and some of them drive two hours or more to our hospital, but you never hear complaints. Maybe a wan smile or two, or somebody might crash and burn for a day or so toward the end of the semester, and have to be revived with coffee and chocolate, but they show up smiling, work their butts off, learn new stuff every day, and graduate.

What with the shortage of nursing instructors and the lack of places in programs, you have to be exceedingly bright to even get into a nursing school. Where I am, two-year programs produce most of the bedside nurses, and the entrance exams are very, very tough. The programs are competative--perhaps thirty people will finish from a starting group of over a hundred and fifty. The women and men who graduate with an associate's degree should be proud of themselves.

And I'm proud to work with them, both as students and as new graduates. I hope I'm as good to them and for them as they have been for me.

Thanks, guys. I'll see you next semester.

The Conga Line

Today I slept.

It's been a long week. We've had a number of folks with undiagnosable whatevers--things that we either have to wait for the disease to progress to be able to diagnose, or for the patient to die so we can diagnose whatever hit them on autopsy--and that always is hard.

So I got up this evening, after sleeping most of the day, and cooked. I had a bottle of wine, three different kinds of cheeses, and a selection of fun vegetables, so I cooked.

And just after ten o'clock, I was suddenly the head of the conga line.

Every nurse has a conga line. It's made up of the patients who die--the ones whose names you remember, whose various afflictions you remember--the ones you might've known even before you were a nurse.

Unexpectedly, I felt Darlene's hands on my shoulders. I kept washing dishes until I knew that Velva was behind her, kicking in rhythm to whatever four-beat polka they play where she is. Curt joined in, his wool sweater as scratchy as it ever was before herpes took his sight and hearing, and made his sister take over the coffee shop. Last in line came Astin, dead of metastatic breast cancer that we caught too late. She and Darlene kicked in perfect rhythm, while Velva and Curt had a good time making up new steps to the music.

I conga'ed around the apartment, macaroni and cheese and zucchini cakes forgotten.

Some of my patients pray to Saint Therese. I pray to the people that I loved--and who hasn't fallen in love with a patient, wished they had been friends with them before--for help, and guidance, and compassion.

And sometimes we dance with them, in a silent conga, grinning, as the music only we can hear and the hands only we can feel guide us.

An Open Apology to My Filipino Colleagues

Guys, I'm sorry.

I know you do better for my patients overnight than I can during the day. Gerb, I appreciate your attempts to teach me to talk dirty in Tagalog. Michelle, thanks for the custard cakes and the joke about the sausage and bread and fish. Ester, you rock my world when you start IVs for me. Jay, you've pulled more folks back from the brink down in post-op than I can count. None of you complains about the schedule, or about the bigots you have to work with, or about the assholes that pepper your day. Along with the Indian and African immigrants and the occasional Slav or Russian, you make my hospital a fun, interesting place to work. I love you all.

But I cannot, cannot eat pork adobo.

I have tried. I like fried eggplant and little squiddy-squids for breakfast. I rock the lumpia whenever you decide to bring some extra. I'll eat anything that you put in front of me, really.

Except pork adobo.

Kill a chicken, pluck a parakeet, slay a sturgeon. Put it into adobo sauce or dry it and fry it and serve it up cold; I don't care. Just don't put pork in front of me, please, with or without that delicious white rice that I can't seem to cook myself.

I feel *so bad* for not liking what is supposed to be the summit of Filipino cuisine, at least according to my coworkers, who can debate for hours the relative merits of various recipes for it, all the while switching into and out of English at baffling speed.

I had a big bowl of the stuff yesterday for lunch. Don't get me wrong; I love the way it tastes. But after? Oh, my stars and garters, it was like trying to work out with a hangover today.

So no more delicious, soft, tender, perfectly-cooked, meltingly wonderful bits of pork in a tasty sauce for me.

I think I'll go on a four-day juice fast now.

Progress.

The chocolate cake for Thursday is made. For those interested, it's the recipe off the back of the Hershey's cocoa box, which even Chef Boy says is the best he's ever tasted. It stays moist for *days*.

The salad for the next two days is made. Artichoke hearts, cabbage, romaine lettuce, baby corn chopped up, red pepper, cucumber, tomato.

My laundry is mostly done.

The patient with the weird collection of symptoms turns out to have both a demyelinating process of some sort and a bizarre, very rare form of bone tumor. "I've...uh...never heard of that" I said to Doctor Number One. "Neither had we." he replied. Doctor Number Two points out that this is not the time for that patient to be playing the lottery. Patient says that's fine with him, just as long as the state doesn't come after him for the amount of the jackpot next week. Mayo says they're not entirely certain that the tumor is what they say it is, but what they say it is is the closest match. We may have something entirely new here.

After five sessions with Der Trainer, I've encountered a new embarrassing reaction at work. Previously, people used to ask when my baby is due. Now, they say "Oh! You had your baby!" Friend Pens, in her wisdom, told me I should reply, "Yep. And as I get stronger and more fit, I will be able to kick your couthless ass more thoroughly."

More reason to think that Just Because You're A Doctor Doesn't Mean You Know Everything: a patient, a doctor, decided to manage her own Parkinson's medication. No problem there, as most Parki patients prefer to continue the routine that's kept them functional for years. But! If you try to "wean" yourself prior to your brain stimulator being turned on, you will indeed fall over and freeze, and we'll have to pick your rigid body up off the floor. Note to all concerned: This is not as easy as it looks. Six people and a bedsheet later, we got her back to bed.

"House" is on tonight. It'll be the first chance I've had in months to watch an episode. I hope it's a good, snarky one. My record is still good: I've only missed two diagnoses in all the time I've been watching--the first was the pregnant teenager with autoimmune weirdness, and the second was the guy with the stuff that's transmitted through pigeon poop. I even got the nun with the IUD.

On a completely serious note: If you work crazy hours, can't motivate yourself to exercise, and hate your life, please consider dropping the dough to hire a trainer. Yes, it's expensive. Yes, it's embarrassing to realize how out-of-shape you really are. But damn; this is the second-best money I've ever spent on anything (the first being the clams to get away from The Ex Husband). No really noticable changes in my body yet, but my stamina is improving, and I feel wonderful.

And I'm not even tempted by the cake.

Why do you come here when you know I've got trouble enough?

I finally got to say it.

"Are you shitheads gonna do the same thing to me this time that you did last time?" he demanded.

"He told me that nobody would help him with his bath last time. And that the doctor wouldn't come see him. He told me he was in here ten days without a bath." she concurred.

"Ma'am, Sir," I replied, "let me be straight with you. You weren't given bed baths last time because when the aides came in, you would curse and throw things at them.

"Then you'd get up and shower.

"The doctor stopped coming in after you threatened to kill him and his family. You've been fired by every nurse on the floor except me.

"The aides have been instructed, for their own safety, not to enter your room.

"I am the only person here who is willing to take care of you. And if your behavior is anything like it was the last time you were here--any cursing, any throwing things, any threats--I have instructions to discharge you immediately. If you assault anyone, I'm going to call the police."

There was a brief silence.

"Where am I supposed to go if you discharge me?" he asked.

"You may go to any other hospital of your choice. We will assist in your transfer." I said.

"No place else will accept him," his wife said, "They've all got do-not-readmit on his chart."

Another brief silence.

Then I gave him twenty of immediate-release oxycodone, four of dilaudid, and a milligram of Xanax and went away. That was all he really wanted anyhow.

Damn. Mention poutine, and the world beats a path to your blog.

I'm not much in the mood for IMAGE WARZZ today, sorry, SS and Bob, because I had that dadratted physically and verbally abusive patient come back in AGAIN. If he hates us so much, why does he keep coming back?

Anyway. I see your naturalistic images and raise you...

this.

He looks like he would love some poutine.