What I cook on my day off: The Thank God It's Fall edition...

Maybe next year I'll have a So Happy It's Summer edition, too.

Today the low was 33. Wahoo! The guy on the radio mentioned that it would be a chilly day, with highs only in the low 70's. Everybody in Colorado and Minnesota is laughing right now. Everybody in Maine and North Dakota is crying.

So today I cooked a pot pie. Pot pies are easy and basic: all you need is a sauce and some biscuit dough to go over the top of whatever you put in the sauce. You can make 'em with a cream-based sauce and chicken and call it chicken pot pie, or use leftover stew meat and a thickened beef broth and call it shepherd's pie. Here are the very basic basics of the dish:

First, preheat your oven to 400 (200C or Gas Mark 6) and butter a  9" x 13" pan (largish; I don't know what the metric equivalent is).

For the sauce:

Two cups of broth--your choice of chicken, vegetable, or beef. (call it 500 ml.)

Four tablespoons of butter (half a stick)

A half-cup of flour (115 g)

About a cup and a half, give or take, of whole milk or half-and-half, if you want to make chicken or veggie pot pie with a cream base. (you metricians can figure that one out)

(If you don't want to use the milk, you'll need a little extra broth.)

Melt the butter in a largeish saucepan. Add the flour and stir it in with a whisk, then cook over medium heat for a minute or two so it'll lose the floury flavor.

Dump in the broth. Continue to cook over medium heat, Without Boiling, until the mixture thickens. Remove from the heat. Add milk products if you're using 'em. Stir well and set aside.

Now. From here on out you can play around. The pot pie I made today included white mushrooms, carrots, onions, and baby peas sauteed in the ass-end of some bacon I had lying around, plenty of black pepper, and some seared portabellini mushrooms (baby portabellas). It's vegetarian except for the addition of the pig. 

For a real vegetarian version, you could roast carrots, garlic, and parsnips or turnips along with some nice firm mushrooms, (everything cut into big chunks) and then combine it with the peas and onions and use a thyme-seasoned cream sauce.

For chicken pot pie, you can cook chunks of chicken in the broth prior to adding it to the flour and butter mixture (and remembering to skim the ook off the top of the broth, please), then add peas/carrots/onion/mushroom to the whole shebang. Chicken pot pie traditionally uses the cream-and-broth sauce.

For shepherd's pie, you can use beef broth without cream and add turnips and carrots to the mix, topping the whole kaboodle with some nice garlicky mashed potatoes.

The only important thing is that the innards of the dish be fairly highly spiced. As for topping, you can use a drop biscuit recipe or a good pie crust recipe. Please do not use those awful lardy soapy-tasting unfoldable pie crusts you can get at the store. Drop biscuits are easier. To wit:

Mix two cups of flour (460 g)

two and a half teaspoons of baking powder (12 g)

a teaspoon of salt, and (5 g)

six tablespoons of butter (3/4 of a stick)

in your food processor. Process until it gets sort of sandy.

Add enough milk or half-and-half until the mixture is wet but not batter-y. You don't want the traditional dry biscuit dough you can roll out, but you also don't want it soupy. About a cup will be fine. 

Then you drop your non-soupy biscuit dough on top of your giganto pan of nummy soupy goodness and bake it for 30 to 45 minutes or until the biscuits are a nice golden brown.

Devour.

Monday Morning Remedy

Hee hee hee hee hee heee *gasp* /wiping eyes\ Hee hee hee hee heeeee!

Jo Muses: The Love/Hate Edition

I'm reading Heat by Bill Buford right now, partly because I mistook "Buford" for "Bryson" and thought, "Wow! Bill Bryson's written a book on learning to cook?" and partly because it sounded interesting--a blow-by-blow account of learning to be a chef by doing, rather than by schooling.

One of the most interesting bits in the book describes the process of learning to use a knife as though it's an extension of your fingers rather than something you pick up and put down. ChefBoy has, of course, this talent. I have the same talent--all nurses do--but in a different way.

Think of how you learned to start an IV. (New nurses and students, listen up! This will be heartening, I promise.) At first, you had to think about every step in the process, and things like tape felt foreign--getting stuck to every conceivable surface except the one you were aiming for; flushes went on the floor, gloves seemed too thick or too loose. Then, one day, it all came together, and what's more, the IV needle itself suddenly became something you could feel *through*--you could tell when you hit the vein dead on or when you'd scooted to the side of it.

Buford describes this as analogous to the process of learning to throw a ball--learning like a child, he calls it--and that's exactly what you're doing when you learn how exactly to juggle IV bags, tubing, medications, piggyback setups, needles, flushes, and everything else as though you've grown a third hand. It's visual and physical rather than primarily about reading and memorizing, and it uses a totally different part of your brain. 

I love that explanation.

Something I hate: Being tossed--lobbed, really--gently under the bus by somebody who's made an amazing, stellar, incredible, obvious, historical, unbelievable screwup. I won't go into detail, but suffice to say: Doctor ResidentBoy, if you fuck up and expect to blame me for your fuckup, not only will my boss not believe you, but *your* boss won't believe you. I know what you did was embarrassing, but it's not nearly as embarrassing as knowing that I know what you tried to do. 

I know what you did last weekend. And I will continue to smile and be helpful and pleasant and take care of your patients the best way I know how, but if you dance too close to the cliff again, I will not haul your ass back from the precipice. Have a nice day!

The first rule of nursing, after "If you have to jack with it, it's wrong" is If You Screw Up, Admit It And Move On. People screw up, okay? Nobody's going to remember that particular screwup in a year--or if they do, they'll remember it in a hazy, amusing, gosh-wasn't-that-funny kind of way. 

That is also the first rule of medicine, right after "Do no harm."

Another thing I love: Waking up in the morning on the first really cool day of fall, with all the windows open, and dogs and cats sprawled everywhere on and off the bed, and realizing that I do not have to get out from under the covers and work out or go to work. It's totally different from checking in the mirror to see exactly how far down the tire tracks from that bus go.

Carnival of Crackpots!

Once, many years ago, I read a book called Letters to Ms. It had selections from the first ten years of the magazine's editorial letters, divided into sections like "Praise", "Criticism" and "Crackpots". In the introduction, the editor told the story of how Gloria Steinem once got a postcard accusing her of being a "Commie witch bitch lesbo...who sleeps with n$#*%*#s. Isn't that just like a Jew?" Ms. Steinem reportedly pinned the postcard up in her office to remind her of what she was doing right.

May got an interesting comment the other day about how female nurses are perverts who grope unconscious male patients. It was, of course, in all caps. No other content, either; apparently the crackpot who sent that one in had only that to say.

And I get the occasional crackpot as well. It's not enough that people post bizarre two- or three-word comments ("Obama Sucks!" "Clinton Kills Babies!" "Repent or DIE!"); sometimes they send me emails, too. The most recent one was a Photoshopped picture of Obama shining Sarah Palin's shoes. Lovely. 

Then there was the long, ambitious screed about how nurses these days look totally unprofessional in scrubs and should wear dresses and pumps instead, with white stockings. If the guy (yes, it was a guy) writing had stopped there, it wouldn't have reached Crackpot status, but he continued rambling, working in Feminazis and lesbians and the death of American society and how we were all going to burn when the Second Coming finally shows up, and how if men would only take back their rightful place in society, things would get considerably better, what with the Blacks and Jews and Wimmins knowing their place again, and all had gone wrong because nurses now wear pants.

Paragraph breaks, people. Paragraph breaks. Just because you're insane doesn't mean you should ignore the rules of composition.

And, of course, I get the occasional Crap Email From A Dude (Jezebel FTW), usually somebody who is or claims to be a third- or fourth-year medical student or a first-year resident, about how much nurses in general and I in particular suck. Mostly those are over-written, longish screeds that have a high syllable-to-content ratio. Only once has one been even vaguely threatening, and that poor sot wrote from his school address. With his actual name attached. And all the ISP information there, too. 

*sigh* What is it with kids these days? Back when *I* was writing veiled threats in email, I not only was grateful to be able to do it on a greenscale screen, but I knew enough to use a Web-based email anonymizer.

Overall, I would say that the male-to-female ratio of Crackpots is four or five to one. The men are more concerned with me being a ball-busting feminazi bitch who castrates the decent, hardworking men she runs across (actual quote!) or my refusal to fit into their stereotype of nurse-as-handmaiden and tend therefore to be more openly offensive. The few female practitioners of Crackpottery are much, much more worried about the state of my eternal soul and whether or not, with my attitude, I'll ever find a nice (presumably uncastrated; won't that be a surprise to ChefBoy) man to marry. Once in a while they send things that play music and show fluttering putti or cherubs or whatever when you open them, then cause my virus-snagger to go nuts.

There are a lot of really, really cool emails too. The vast majority of emails I get are from people who were either students or new nurses when I started blogging, or who went back to school in part (so they say) because of what I've written here. That warms the cockles of my hard, blackened, castrating feminazi heart. Or it would, if I hadn't already given it to Satan to show my allegiance (actual quote!)

I'll just keep deleting the nasties and keeping the nice ones for now. Meanwhile, I'm off to make a big ol' pan of macaroni and cheese and some tasty castrated-male soup with a side of shredded nurse caps. Yum!

Morning Drama

Max somehow rolled under my very low platform bed while he was asleep last night:

Those are his paws sticking out from under the bed.

When he woke up and decided he wanted to get up, there was much whimpering and scrabbling of paws until I went and lifted the bed off of him. Even lying down on his stomach, he's taller than the bottom of the bed, which presented some problems. Poor guy. Meanwhile, there's Strider:

I can haz chiropractor?

Buzz...*click* Buzz...*click*

Manglement has rolled out a New Plan for us.

It involves, as do so many things that Manglement thinks up, Customer Service.

See, Manglement recently discovered the Intertubes. They learned, much to their shock and awe, that people go online on the Innerweb to see what sort of ratings hospitals and doctors get. It's not just which hospital is covered by your insurance package any more, no sir; it's the Customer Service rating of said hospital that might just determine where you go.

So Manglement came up with a way for us to improve our Customer Service Performance. Wait for it: it's going to knock your non-skid socks off:

The members of The Healthcare Team are to make hourly rounds.

No, no. I'm not joking. Doesn't matter who does it: nurse's aide, nurse, physical therapist, respiratory therapist, occupational therapist, wound care specialist--you name it, they can round. And when they round, they have a script to follow. I'll give you mine, as I am the Nursing member of The Healthcare Team:

"Hello, Mr/Mrs/Ms Blankety. My name is Jo. I will be your nurse for the day/night. My goal for this shift is to provide Outstanding Patient Care. In order to provide Outstanding Patient Care, I or another member of Your Healthcare Team will be making Hourly Rounds to make sure All Your Needs Are Met. (Here I am supposed to sit by the side of the bed; on what, I'm not clear. Perhaps, given the dearth of chairs at Sunnydale General, I am supposed to carry my own from room to room.) What are your goals for today? Do you need help to the bathroom? Are you comfortable? Would you like assistance in repositioning? Thank you. I look forward to providing Outstanding Care to you today."

Note that I have Capitalized Some Words in this script. Here's where the fun begins:

Manglement of Sunnydale General has dragooned certain poor sots in middle management to go 'round to various folks' rooms during the day and night shift and read questions to them. The questions are meant to show the Level Of Satisfaction With Customer Service. The questions read something like this: "Did your nurse or another Member Of The Healthcare Team perform Hourly Rounds?" "Did your nurse Provide Outstanding Care?"

Remember that script and those questions. It becomes important later.

Being the sort of outcome-driven little person that I am, I asked during our staff meeting if Customer Service initiatives like this one had shown any impact on quality of care. In other words, *good* nurses, aides, and therapists are already making hourly or nearly-hourly rounds, asking about pain control, and taking folks to the bathroom; has mandating that shown any decrease in, say, preventable falls or bedsores or the like? What's the measurable outcome in terms of quality of care?

First answer: "That's not what this is supposed to measure. Falls and bedsores are measured by the Joint Commission's Core Measure standards."

Okay, but my question remains: Has this business of the scripted rounds shown any increase in quality of care?

Second answer: "Well, we imagine it would. After all, if you're rounding on your patient hourly, you're more likely to notice their skin color and stuff like that."

Okay, great. But still, have there been any studies to show that this scripted rounding increases quality of care?

Third answer: "No. But we know that it increases Customer Satisfaction."

Customer Satisfaction, that is, as measured by the scripted questions that middle managers have to ask the patients--questions that we, as nurses etc., have trained them to answer correctly by using key phrases in *our* scripts. That way, Upper Manglement can take the raw data collected by the middle managers and point out that Sunnydale General has incredibly high Customer Satisfaction scores, simply because we healthcare providers have trained our patients to respond, like Pavlov's dogs, to the ringing bells of "Hourly Rounds" and "Outstanding Care".

Now, I have lots of problems with the idea that a hospital patient is a customer. Not all of those problems spring from a condescending, paternalistic worldview, so save your angry emails. Many of those problems spring from this simple idea: 

If you treat a patient as a customer, you are treating them for the wrong reasons.

Let me say that again: If you treat a patient as a customer, you are treating them for the wrong reasons.

I doubt--seriously doubt, having done it for years myself--that retail clerks or waiters get up in the morning filled with glee at the thought of going to work again. As cynical and grumpy as I can be here, I really and truly do look forward to working nearly every day. 

I look forward to it because I have patients: people I care for, in multiple senses of the word. I can educate them, learn things from them, make them happier or more comfortable or help them to heal. They are not my "customers"--if they were, what would be the point of actually giving a damn? I could provide a service for pay, sure, and could take my heart and brain out of the equation.

Reducing patients to "customers" undermines the mission of medicine: to assist the person who's sick in healing. However, reducing patients to "customers" does something lovely for Manglement: it boosts their scores in patient satisfaction and means they get more money, because they can publicize those boosted scores and bring more patients in.

Don't I care about my patients' happiness? You damn well better be sure I do. But I do it without scripts and without mandates from Manglement. I do it because it is the right thing to do. Dammit.

Interesting email I got....

There's an interesting article up at Nursing Degrees about what drives nurses out of the profession. 

Here 'tis:

http://www.onlinenursingdegrees.org/nursingfacts/reasons-why-nurses-quit.htm

Housekeeping: It's a Good Thing.

Why, yes, I changed the format. I'm so glad you noticed. Do you like the little nurse up in the corner? I do. That's a candid photo a coworker took of me as I swanned from room to room this past week, dispensing oral Dilaudid and love to all my patients.

This new Blogger template is so easy to use that I've decided to stop being a rebel Luddite and actually add things like tags and updated links to the blog. So, in the next few weeks, you'll be seeing some changes:

1. New, updated links to blogs like Macho Nurse and Cooking Nurse. 

2. Tags! It's hard, when you're looking for a mac-and-cheese recipe or Rules For Residents, to have to wander back through the archives and read post after post, hoping you'll hit the right one.

3. Some form of organization for the archives. I've not looked into the capabilities of the new template thoroughly yet, so I don't know what sort of form that'll take, but I'll figure something out. I'm kind of tired of just having things listed by date.

4. More pictures of the dogs. Better grammar. More ranting. More naps.

Not all of these changes will happen at once, of course, but be watching.

As for the "Followers" pictures up top...I may have to ditch those. It scares me to have little people watching me all the time, plus I can already tell I'll get all competitive and weird and start counting followers.

Yours,

Organizing Jo

Gracious.

They're going to come for me and haul me down a tiled hallway as I scream "I didn't do nothin'! I didn't do nothin'!"

Here's a quick rundown of the last week:

Tanking patient snotty doctor dog fight food in fridge gone bad sick boyfriend. Another tanking patient dog fight dog to emergency vet emergency vet unavailable in surgery go back home put antibiotics in dog's eye take dog to vet in morning sick boyfriend cat vomit everywhere no clue why ah it's a hairball emergency babysitting. Get quote on doors holy shit expensive dog antibiotic dosing nap call from boss BLS due tomorrow holy shit no way to renew now sick child more dog fights doctoring dog holy shit I need a beer what the hell why is McCain still neck and neck with my man gosh wonder if Mom's okay Strider stop it that's the pullcord to the lawn mower holy shit put that down that's the cat Max stop bleeding on the rug cat vomits I haven't made the bed yet tanking patient snarky attending snotty me back prolly gonna get written up but who the fuck cares oh, finally, a day off.

And I go back to work tomorrow.

Product Reviews: Things that are worth the money and things that ain't edition.

So I had this shed kit, right? And I had it built last week by a couple of guys from Mr. Handyman, right? Which inspired this post.

Handy Home Products 10' x 10' Princeton Wood Gable Shed

Oh, Jesus. Where do I start? My Sainted Mother asked how the assembly went the other night, and I told her, "If I were blogging, I'd call it a cluster-fuck". Yeah, it was bad. The lumber was cut to the wrong lengths. The siding was of two different, incompatible types. The FUCKING INSTRUCTIONS WERE WRONG. Which is why I'm glad I had....

Mr. Handyman guys to build the thing.

They are expensive. Be warned. The cost of having the shed assembled was four times the original price of the shed kit, plus money for extra lumber and screws and so on. But honestly? Three grand for the assembly was totally worth it, because now I have a shed that won't fall down, won't leak, and that I didn't have to get drunk over on my own. Plus, they cleaned everything up, left me the usable dimensional lumber and extra shingles, and even raked up all the bits of wood and sawdust and threw them away. Nota Bene: It took a Master carpenter and a Journeyman carpenter TWENTY FUCKING HOURS to set up the shed kit. Don't say I didn't tell you.

In other news,

Borghese Crema Saponetta Facial Cleanser...

...is not all it's cracked up to be, sadly. I spent the $$$ on this stuff after reading nothing but positive reviews on Amazon, reading another blogger's raves about it, and talking to the Italian woman at work, who has gorgeous skin. It does nothing for me. It cleans well and takes off makeup, but it leaves this weird waxy residue on everything from your face to your sink. I'm happier with the Aveeno Clear Skin Foaming Cleanser I buy from the grocery store. However!

The Clarisonic Skin Brush rocks my world. Yeah, it's bloody expensive. I consider this retribution for the fact that I didn't really have acne as a teenager or young adult, but am getting it now. The last laugh's mine, though, as I can now afford an appliance that really digs shit out of your skin and makes it smooth and even and lovely.

Speaking of things that make other things clear and lovely, I recently tried Rain-X on my windshield. Results were mixed: it worked great at keeping the windshield clear in light rain, but didn't do so well when it came to not streaking or smearing with bugs. I used it to good effect on the back window of the Honda (Note to Honda: Please Put A Rear Wiper On The Accord. Thank You.) and it worked *great*--until I washed the car. You have to be *really* careful when you wash, and make sure to get all the Rain-X off, or else you end up with weird smeary bits that don't go away.

And, finally, a Tool Review. No, this isn't a review of the latest internal medicine resident to make me hypertensive; this is a review of the Black & Decker Rechargeable Drill With Enormously Heavy Battery Pack.

Now, Chefboy likes Mikita, as they're made for professional builders (which he was, in between cheffing gigs). Mikita, however, is too rich for my blood, so I bought one o' them nifty B&D thingies from Target.

And it has held up *beautifully*. It is heavy, so be careful to switch hands when you use it or else be prepared for sore forearms. It lasted through umpteen bazillion holes drilled and screws screwed the other day as I was reassembling the kitchen, then (without recharging, I'll have you know), did a great job on ramp-building and 2 x 4 screwing. I'm recharging it right now, but I really doubt that I need to. As far as I can tell, the charge will last through building a small house with no problem.

Tomorrow I head to Home Despot to buy shelving pegboard cabinets fried eggs sardines socks hammers nails small hooks etc for the shed. I don't intend to do a PR post on sardines. I promise.

In which Auntie Jo loses it and levels unwarranted criticism at people she doesn't know

Y'know how everybody has pet peeves? And how those pet peeves are totally incomprehensible to the rest of the world? My pet peeve (this week; it might be different later) is bad writing.

Not that I consider myself a great prose stylist, or anything, but dayum. I mostly avoid the worst breaches of English writing. Mostly. This is not something I could say about a lot of stuff I've been reading lately, both online and in print. Thus, here follows a list of the things that make Auntie Jo get out the wire hangers and start screaming about pronouns:

1. No more passive voice--EVER!

I don't recall where I saw it, but I ran across the phrase "Birth was given to the idea..." and immediately stopped reading. "Birth" is never "given" to anything. One can give birth, or one can be born, but for Frog's sake, don't use the passive voice to describe the act. Gaaah. This one sets my teeth on edge.

2. Periods are fun in moderation.

Run-on sentences can be used to nice effect, as can sentence fragments. I'm fond of fragments myself. However, if you're consistently expressing yourself outside the subject-verb framework, you might want to stop writing prose and get a gig writing bad free-verse poetry. 

3. If you're writing for a public audience, can the racist and sexist slurs.

On second thought, don't. I want fair warning that you're an asshole.

4. Paragraph breaks: We haz 'em.

This one's a tendency that a lot of bloggers have: they write and write and write and it's lovely stuff, but you can't tell where the hell you are in the essay because there are no damn paragraph breaks. 

Here's a hint: Hit enter twice and continue with a new thought. 

Yes, this is a structural complaint rather than a stylistic one. How, though, will I ever be able to follow your style--or your substance, for that matter--if I can't find my way out of one huge long unending jeebus grits where's the next paragraph column of text?

5. Adding -y does not make it an adjective. Adding -ly does not make it an adverb.

Fashion magazines do this all the time. You can't just create new words by adding sometimes-vowels to the end of 'em. (Well, you *can*, but you get my point.) I was flipping through a girly mag that somebody'd left behind in the breakroom and stopped dead when I hit the descriptor "Studio Fifty-Four-y." Good thing I carry ammonia capsules with me, as that unbridled use of the adjective-mode gave me the vapors.

6. Tame Cute.

Our local birdcage liner is bad, bad, bad about this. An otherwise serious wire story about, say, Pakistan will be headlined with a pun. An otherwise serious local story about high-school dropouts will contain clever double-entendres and wordplay. Yes, we know you're smart; you wouldn't be writing for a newspaper otherwise. That's enough.

7. There are different writing styles. One of them is appropriate for your use. Find it.

You don't have to be formal on a blog. You *can* be--there's no law against it--if you're doing a thoughtful, well-reasoned essay. Likewise, you can occasionally (VERY OCCASIONALLY) toss a little fillip into a piece of serious writing. The trick is to know, not only your audience, but the purpose your writing is filling. 

8. Spelling correctly is fun!

That's what the great gods of the computer world made spellcheck for.

9. Profanity, used in excess, can be really fucking annoying.

I kid you not: I read a blog post t'other day that was so full of f-bombs and s-bombs and q-bombs and the like that I couldn't follow the writer's train of thought. Stylistic trademarks aside, calm the hell down and try to write clearly, okay? (This is my big bugaboo, made worse by the fact that My Sainted Mother reads this blog and probably has to scrub her eyeballs afterward.)

10. And finally, please, for the love of all that's holy, have a point.

Even if it's just venting about other people's writing.

(Bonus peeve: Did I mention that plural words are NOT formed by the addition of apostrophe-S?)

This is fun.

Very Good Taste posted a list of 100 things every omnivore should eat. You're supposed to go through it and mark what you've eaten, to see where you stand when compared with the ideal.

Here 'tis....

1. Venison*
2. Nettle tea*
3. Huevos rancheros*
4. Steak tartare*
5. Crocodile (I've eaten alligator. Does that count?)*
6. Black pudding*
7. Cheese fondue*
8. Carp*
9. Borscht*
10. Baba ghanoush*
11. Calamari*
12. Pho*
13. PB&J sandwich*
14. Aloo gobi*
15. Hot dog from a street cart*
16. Epoisses
17. Black truffle*
18. Fruit wine made from something other than grapes*
19. Steamed pork buns*
20. Pistachio ice cream*
21. Heirloom tomatoes*
22. Fresh wild berries*
23. Foie gras*
24. Rice and beans*
25. Brawn, or head cheese
26. Raw Scotch Bonnet pepper (only once, and to my great distress)*
27. Dulce de leche*
28. Oysters*
29. Baklava*
30. Bagna cauda*
31. Wasabi peas*
32. Clam chowder in a sourdough bowl*
33. Salted lassi
34. Sauerkraut*
35. Root beer float*
36. Cognac with a fat cigar (I've had the cognac, but not the cigar. So, close but...)
37. Clotted cream tea*
38. Vodka jelly/Jell-O*
39. Gumbo*
40. Oxtail*
41. Curried goat
42. Whole insects*
43. Phaal
44. Goat’s milk*
45. Malt whisky from a bottle worth £60/$120 or more*
46. Fugu
47. Chicken tikka masala*
48. Eel (I think I remember eating eel once, but I'm not sure, so I'm not starring it)
49. Krispy Kreme original glazed doughnut*
50. Sea urchin (bleah)*
51. Prickly pear*
52. Umeboshi (bleah)*
53. Abalone*
54. Paneer*
55. McDonald’s Big Mac Meal*
56. Spaetzle*
57. Dirty gin martini*
58. Beer above 8% ABV (duh)*
59. Poutine (Oh Poutine, my favorite food!)*
60. Carob chips (bleah)*
61. S’mores*
62. Sweetbreads (nyeah, okay)*
63. Kaolin
64. Currywurst
65. Durian
66. Frogs’ legs (In Louisiana, with gumbo)*
67. Beignets, churros, elephant ears or funnel cake (State Fair, duh)*
68. Haggis
69. Fried plantain*
70. Chitterlings, or andouillette* 
71. Gazpacho*
72. Caviar and blini*
73. Louche absinthe
74. Gjetost, or brunost*
75. Roadkill (you have got to be fucking kidding me)
76. Baijiu
77. Hostess Fruit Pie*
78. Snail*
79. Lapsang souchong (my favorite tea)*
80. Bellini*
81. Tom yum*
82. Eggs Benedict*
83. Pocky*
84. Tasting menu at a three-Michelin-star restaurant.
85. Kobe beef
86. Hare*
87. Goulash*
88. Flowers*
89. Horse
90. Criollo chocolate
91. Spam*
92. Soft shell crab*
93. Rose harissa*
94. Catfish*
95. Mole poblano*
96. Bagel and lox*
97. Lobster Thermidor
98. Polenta*
99. Jamaican Blue Mountain coffee*
100. Snake (State Fair, duh)*

Not too bad, eh? I have to credit having coworkers from all over the world and some travel for the number of asterisks on the list.

How experienced a nurse are you? Take this simple quiz and find out!

A patient arrives on your unit with the following list of allergies:

Hydrocodone, codeine, morphine, Demerol, Zofran, Reglan, beef, iodine, tomatoes, Provera, Lupron Depot, acetaminophen, ASA, wheat products, soy, synthetic estrogens, Benadryl, corticosteroids, epinephrine, ketorolac, Ultram, metoprolol, oral potassium, oxygen, Lipitor, fenfluramine, PCN and analogues, mycins, Trazodone, Haldol, allopurinol, Lithium, and Lasix.

Your response is:

A. "Gosh, this person has a lot of medical issues. I'd better get to researching the possible side effects of the other drugs I might give them!"

B. "Gosh, this person must be obese, bipolar, and have hypertension and diabetes. Drag-O."

C. "Hmm. The only two drugs NOT on that list are Dilaudid and Phenergan. Also, oxygen? What, he breathes methane at home? This person is a nutcase."

If your answer was A:

You are obviously a new nurse, concerned with providing good care while protecting your patient from harm. Good for you! Concentrate on that.

If your answer was B:

You are a proficient nurse. You've learned the basics and can recognize common drug interactions and side effects. Keep working! You're doing great.

If your answer was C:

You are an expert nurse. Those of you who answered C will not need me to explain why.

Ah, the shock of role transition.

Somebody, I don't remember who now, with a glass of wine in me, asked what I would say to the newbies who are having the SHOCK of ROLE TRANSITION as they go from being a student to being a new grad/new nurse/newbie.

Honestly? All I remember from the first months of nursing practice is this: I prayed every day that I wouldn't kill somebody, and I felt horribly alone.

Both those feelings, it turns out, were bogus. Like, "Boh-oh-oh-oh-oh-oh-GUS!!" the way Tom and Ray say it on "Car Talk". Bogus, like we never imagined it could be in the 80's. Bogus, like carob is to chocolate, or Cool Whip is to whipped cream.

Being a newbie is *hard*. It's almost as hard as nursing school in that the amount of information you have to absorb is huge; it's just more focused. Being a newbie is scary, in that you don't really know what you're doing yet. Being a newbie is frustrating, in that you know some things you're being asked to do are wrong and stupid, but you don't know how to communicate that to more experienced nurses and doctors yet.

The thing to remember is this: If you're a newbie in a precepted program, you have somebody following you every step of the way, making sure you don't screw up. Nobody is going to let you kill a patient. And even if you come close, we're not going to let the worst happen. *Everybody*, from pharmacists to physical therapists to the other nurses, is looking over your shoulder--not to catch you in mistakes, but to make sure you feel confident enough to make decisions on your own and yet stop you if they're the wrong ones.

As for not knowing what you're doing, the honest truth is that a lot of times I don't know what I'm doing either, and I've been doing this for six years. As in, this specific thing, and nothing else. And I *still* run into stuff that flummoxes or stumps me. There are always people around that know more than you, and who won't make fun of you if you ask very basic questions. The trick to being comfortable as a nurse is not in learning everything; it's in getting rid of your ego so you can admit comfortably what you don't know.

And, finally, frustration. I have a story to tell about this particular problem:

Years ago, when I was still being precepted, I had a patient admitted with fulminant meningitis. It could've killed her; it's considered a huge huge huge fucking run around with your hair afire emergency. 

The very moment she was admitted was the moment that our computerized drug distribution system went down. Pharmacy was totally unable to fill any orders, since they didn't have access to anybody's allergies or tolerances or drug levels or *anything*. So, because I was a newbie, my patient with fulminant meningitis went for six hours without her first dose of antibiotics. I gave myself an ulcer in the meantime, trying to do things by the book.

I will never stop being grateful to her doctor. Rather than call me out on the floor and ream me a new one, as he had every right to do, he took me aside and explained what the problem was, and asked me why the patient hadn't gotten her meds. I explained as best I could, suddenly not 31 any longer but 10, stuttering and tearful and ashamed, and he was firm but kind. No harm had come to the patient, but he was unhappy with the level of care. He offered to go to bat for me and get the drugs from pharmacy himself--not in an "I'll go down there and kick their asses" sort of way, but in a "maybe they don't understand how serious this is" way. 

The thing I learned from that awful experience was this: No matter how set the procedures and protocols are, you can always do an end run around them. Sometimes it means finding a sympathetic doctor or pharmacist to write you an order or float you the first dose of meds. Sometimes it means going down to the kitchen to talk to the folks there about what, exactly, "halal" means. If it can be done, you can find a way to do it. The best thing to do is to set up a reputation for being pleasant, creative, and a little stupid right at the start, so when you start doing imaginative things to get your patient good care, people shrug and say, "What the hell, it's only Jo."

The upshot of all this lecturing is this: Good nurses remember, if not the details, at least the general outlines of being a newbie. They will help you out. Glom onto them like death, and do not let them go. I have a mentor at work, and you should too. Don't fret about feeling like an idiot; other people do every day, too, and you'll develop a callus against that sort of self-consciousness. And don't forget: At some point, someday, you'll find that you're finally swimming with the current rather than struggling to stay afloat, and you'll feel like a Nurse. Finally. And you'll grin like an idiot, and go on to make a stupid mistake, and realize that that's what the profession is all about. 

Neat-o site and a question:

In reverse order.

First, for those of you who work in hospitals/clinics/whatever that require uniforms or particular scrub colors: Does your facility provide any sort of scrub allowance for employees? (Nursing students, sorry, but I just want the working RNs/aides/PTs/OTs/secretaries etc. to answer this one.) Do you have particular scrub shops where you can get an extra discount? How about folks coming to the facility itself to sell scrubs? Tell me all about it.

Now, for those of you *looking* for scrubs, here's a site which has--hurrah!--coupon codes! One of the very pleasant founders emailed me the other day and asked that I put it up. 

Find Nurse Uniforms

Why this theme in particular? Because Sunnydale General has decided to go to a choice of scrub colors, all of which are hideous, beginning in November. Two of the choices are so very unflattering that I'm thinking of going with straight old-fashioned whites. Not the the degree that I'll wear a skirt and blouse, mind you, but whites. This uniformity craze seems to be a trend--I've heard lots about it from other RN friends of mine lately.

*sigh* The last time I wore whites was in nursing school. We'll see if they've come up with non-see-through pants since then.

I'm good enough, I'm smart enough, and dammit, people like me!

So...new nursing students. How y'all feeling right now? Classes start in, what, three weeks? Two?

Got your shoes ready? Got your pens and pencils? Paper? Xanax? Good.

Following is a list of tips drawn from what I remember of my own school experience, back when the earth was still cooling:

1. You are smart enough to get through this. 

You got in, right? That's no small task in a field where there are anywhere from 30 to 200 applicants for every slot in nursing school. Rest assured that if you were smart enough to get in, you will be smart enough to finish--and finish *well*--provided you remember one thing:

2. This may be the hardest work you've ever put in in your life.

I've heard from doctors who became nurses and nurses who became doctors that nursing school is harder than med school by a country mile. This is not because doctors don't learn as much, but simply because nursing school is compressed into about half the time. Even if you're getting a BSN, the nursing-clinical-focused coursework will only take up about the last three semesters of your schooling. If you're going through a bridge or two-year program, you'll have to hit the ground at a dead run. Therefore...

3. Do a little every day. Do a lot when you can.

I cannot stress enough how important time management is for nursing students (and nurses!). Set up good habits early on and they will see you through the last semester when you can't eat, can't sleep, and can't remember who that person is that you promised to love and cherish until death. Do Not Put Off Studying. Also, Don't Study Too Far Ahead. Set yourself a goal of, say, three chapters of thus-and-so every night--one review of the last class period's material, one of today's material, and a quick run-through of next week's--and stick to it. Do this every damn night. No exceptions. It's only for a couple of years; you can go dancing later. That said,

4. Schedule something non-nursing related every week, even if it's only a movie. 

Otherwise you'll turn into a Nursing School Automaton like I did. You'll lose weight, sanity, sleep, and perspective. That last is most important, because...

5. No matter what they tell you, this is not the be-all and end-all.

You get brainwashed into thinking, in nursing school, that this is the most noble, valuable, challenging (morally, ethically, intellectually) thing you could do; that it's the pinnacle of everything everybody everywhere has ever done.

I call bullshit.

Nursing school is a weird cross between professional training and entering a convent. You get your own language, clothing, and ceremonies, true...but there is a world out there outside of nursing. Try not to get so buried that you lose the ability to laugh at yourself, your professors, and the utter silliness of most care plans.

6. You will meet asshole instructors.

Unfortunately, (and here I put on my flame-proof Big Girl Panties), there are nursing instructors out there who either got totally disgusted with the profession and are bitter, or who couldn't make it as floor nurses for one reason or another, and are bitter. With luck, you'll only run into one during your schooling--but you *will* run into one. Keep your head down, do your work, and try to avoid antagonizing that person. He or she can't help what she or he is.

7. You will meet crazies.

Both in school and out of it, you will meet people who are absolutely mad as pants. If that person is a classmate, try to be polite but distant: You do not need any emotional drama while you're going through school. (Also, avoid gossiping and joining one faction over another. It's lonelier, but you'll be glad you stayed aloof when the crap hits the creamer.) If that person who's crazy as a pet raccoon happens to be a floor nurse or a patient to whom you're assigned, see tips from #6 for conflict avoidance.

8. If you meet a nurse whom you'd like as a mentor, say so right then. 

I get requests from nursing students for my email address after I've worked with 'em a couple of days. I always give 'em the address. Having a shoulder to lean on, a more experienced person to bounce things off of, or a mentor can make a hell of a difference in your sanity. And please be aware, beloved students, of this caveat: If I tell you you shouldn't work with me after you've worked with me for three sessions, it's not because I don't like you. It's because, this early in your training, you need to see a variety of work styles, time-saving tricks, and management skills. Don't get into a rut too soon.

9. Along with "Don't get into a rut too soon", don't make up your mind what you want to do too soon. 

I was *sure* I would be the world's most ass-kickingest women's health NP when I finished school. I interviewed at Sunnydale General on a total lark and ended up taking the job, also as a total lark. It was one of the best decisions I've ever made--probably not as smart as leaving my husband, but certainly in the top five. Go on at least one wacked-out job interview that you'd never consider actually accepting, be it to Medecins Sans Frontieres or to County General Hellhole. See where that takes you. You might find that you were really cut out to be a neuro nurse rather than an oncology nurse, or that working in the jungles brings you great joy. And, keep in mind that if you hate the whole process and are miserable,

10. You can always leave. Leaving nursing does not mean you're a failure.

Nursing is not for everybody. Every student finds him/herself dreading clinicals and tests, yes, but there's a general consensus that the end result will be worth the trouble. If you find yourself contemplating a career in nursing with nothing more than misery and despair, for God's sake get out now and find something else to do. It will not necessarily make you as much money or give you as much prestige (stop snickering), but money and prestige are empty cups when you cry every morning as you slap on mascara. 

If you *do* get partway through your training and decide to quit, everybody you're leaving behind will look at you with pitying incomprehension. You won't be able to speak the same language as they do any more. You might not keep in touch with all your old buddies. Don't let it get to you. The important thing is that you do what makes you look forward to getting up in the morning.

Handmaidens, Helpmeets, and the Problem of Nursing

There's a lot of discussion about the OMGWTF Nursing Shortage and of how to get younger, more diverse folks into nursing. What I've seen lately proposed as solutions make sense, but they don't get to the root of the problem: Nurses are seen as handmaidens and helpmeets to doctors rather than as scientific professionals in their own right, who often practice with a surprising degree of autonomy.

Two illustrations of that, from the educational angle: I have a colleague who never fails to mention that she finished pre-med school at the top of her class, passed the MCAT, and was accepted to medical school, but took to nursing as a sort of Med-Lite second-best when she decided she wanted to have kids and a husband. Further back, when I was starting nursing school, every single dadratted classmate I had, practically, said with starry eyes that she "wanted to *help* people!" as a reason for getting into the business.

Now, helping people is a fine undertaking. I do a lot of it myself every day, though I think of it in terms of educating my patients or working with other disciplines in the hospital to help those patients heal. And going from med school to nursing is a fine thing, too, (though I disagree with the reasons here), as it gives you a different perspective on the science of nursing.

But nursing is way, way more than helping people and being a sort of handmaiden to a big, strong, masculine-smelling doctor. By not emphasizing the technical, intellectual, skilled aspects of nursing practice, we're losing a lot of possible nurses to PA school or computer science courses. "They Dare To Care" is a touching ad campaign, but it doesn't showcase what we do every day as practitioners of a science that is equal to but different from medicine.

I'm not going to list out here what I do every day that could be considered intellectually challenging and deserving of respect; I've done that over and over in previous posts. Instead, let's look at the Helpful Handmaiden misconception and see how it impacts nursing as a whole:

First, public perception of nursing focuses too much on the "caring", touchy-feely aspect of the work. This discourages people like me, who are a little crusty and a little crotchety, from entering the profession, for fear of encountering a bunch of fuzzy-headed huggers with little or no spine. It took working with nurses for me to realize how wrong that stereotype was.

Second, take that public perception again, and narrow it down: Nurse equals handmaiden, which equals subordinate role, which means that any man in nursing must be happy with a subordinate role, which means any man in nursing must be gay. And a bottom, to boot. With that stereotype, you may now kiss still more of your potential nurses goodbye, as they go into manly sciences like software development and electrical engineering.

Third, let's take the Helpful Handmaiden Model onto the college campus: If nurses are primarily caregivers and assistants, then there's not much to teach students, is there? Therefore, we can pay a pittance to our nursing instructors and not lose out. 

Let's be blunt, here: Being a nursing instructor, especially in a small department like the one at the school where I got my degree, must suck. College instructors don't have cushy jobs as it is--growing up in a family of academics taught me that--but being told you're responsible for lesson plans and teaching three courses a semester, *plus* two clinical groups, *plus* being required to sit on various committees and boards, is particularly challenging in terms of time and creativity. 

To add insult to injury, the school where I went required at least a master's degree in nursing to teach lower-level classes. A PhD in nursing was preferred for upper-level classes. That's a lot of education...and I, as a brand-new, fresh-out-of-the-gate nurse with no experience, made double what the instructor of my first nursing courses made. After six years, I'm making more than the best-qualified instructor at that school, for considerably less effort.

In short, if you want decent nursing instructors and enough of them, you have to treat nursing with the respect it deserves. Helpful Handmaidens don't get no respect, but careful, observant scientists do.

Fourthly and finally, let's take that Helpful Handmaiden into the hospital and see what that stereotype does to us as a profession. 

If nurses are primarily interested in Helping People, and if they're assistants to Big Manly Doctors, it means that they therefore are selfless martyrs. Selfless martyrs don't mind being saddled with too many patients, being told to work mandatory overtime, and being shorted vital equipment, supplies, and support staff. Selfless martyrs, after all, welcome the opportunity to make do and mend and do everything themselves.

Now let's imagine what would happen if we had the concept of nurses as scientists and advance troops on the line of patient care: We'd get staffing. And supplies. And a say in how hospital policy is developed. And support staff, so we don't have to clean rooms and take out trash. And lower patient ratios, so we could actually, you know, *monitor* and *educate* patients and provide better care. We'd get better-qualified professors in nursing departments who could actually afford to make a living. The phenomenon I encountered, that of an instructor so burned out on nursing practice that he or she couldn't stand to be in the hospital any more (and communicated that dissatisfaction to the students) wouldn't be as common. And, finally, we'd get a more interesting, diverse, experienced crowd going to school. 

How do we get to the point where the handmaiden stereotype is dead? Activism, education, being loud and pushy (frankly) with hospital administrators, and--most importantly in my view--never downplaying what we do. 

I am not "just" a nurse. When people say, "You seem awfully tough for a nurse", I respond, "Nurses are tough." When somebody asks me why I didn't go to medical school, I tell them that I prefer nursing both because of the range of knowledge I have to master and the flexibility it gives me with my patients. When a patient tells me I'm "too smart" to be a nurse, I ask them seriously if they want a moron coordinating their care. And every time I meet a nurse-to-be, I hand out my email address and tell 'em to contact me if they want help, advice, or just to blow off steam. 

It'll take a while to change the stereotype. It'll take a lot of work, too, but it's the only way to reverse the trend of younger nurses getting burned out and leaving the field as older nurses hang on out of guilt. Helpful Handmaidens are handy to have around the house, but they don't get stuff done. Pushy Smart Tough Professionals do.

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