The Thanksgiving Party At Sunnydale General...

I'm on the left.

(Stolen from Manolo For The Big Girl, with thanks.)

In which Jo gets a bit snippy

When one blogs, one gets comments. One also gets emails.

It's amazing what people will say in emails that they won't say in comments. It's like the kid who bullies only when he's alone with another kid, not in front of witnesses. 

Apparently, folks don't like my grammar. They don't like my tone. A couple of 'em really hate the personal posts, while others don't like the posts about Manglement (or the fact that I refer to Manglement as Manglement). A few take issue with the new layout of the blog and get personally insulting in the process. There have been more than a few men (all have been men) who have gotten their socks in a twist because of my silly insistence that perhaps a) nurses ought to think of themselves as professionals and b) health care is one of those things that you shouldn't have to mortgage your life to get. Those guys are by far the worst in terms of being just plain rude. Guys, guys: you kiss your mother with that mouth?

I have this to say:

People. This is a blog.

There are approximately seventeen quintillion blogs out there. Approximately half of those are medical or nursing blogs. The other half, as near as I can tell, are divided about equally between cute animals doing cute things and beauty/celebrity/fitness topics.

The influence of this particular blog on anything going on in the world is proportional to its share of the Great Blogging Pie. In other words, with eight-and-a-half quintillion nursing and medical blogs out there, this one is just not that important.

You can relax, I swear. Nobody is gonna read HN and decide that it's time to overthrow the medical establishment, thus depriving you of whatever it is about your career that you find so important to protect. There is not a secret cabal of coruscating feminist nurses somewhere underground that uses HN as its template for revolution, its manifesto, its creed. HN is not going to raise your taxes, restructure your insurance company, take all the profits you make by inventing drugs and devices, turn nursing into some Amazonian society, or kick your puppy. Especially not that last bit.

Also, I am not undermining your attempts at formalized writing. See above: this is a blog. You ought to be concentrating on blogs that have posts that begin with letters and numbers and leet-speak, for God's sake. 

I am not making fun of you. Well, maybe a little. If you're the sort of doctor who reads a fictionalized account of my day and assumes that the doctor I'm talking about is you, rather than a composite of all the docs I deal with on a daily basis, then yes, I'm going to mock you. Relentlessly. You deserve it for being so damned self-important.

I do not talk to my patients the way that I write. Come on.

If you're so moved, either positively or negatively, by something that I write here, you're welcome to email me. The link's to the right. If you want to fawn, compliment, or give me big props, that's lovely. It gives me a nice warm feeling that lasts about a second, until everything snaps back into perspective.

If you want to send criticisms, that's lovely too. Just make sure they're rational and not personally insulting, okay? Ad hominem attacks will be promptly forwarded to the trash folder.

And if you just want to rant about how HN is destroying the foundations of nursing as a Blessed, God-Ordained Helping Role or how HN is fomenting revolution or how HN is a Feminazi mouthpiece, please, turn off the computer. Go outside. Pat your puppy.

It is just a blog. There are seventeen quintillion of them out there. Keep that in mind.

What to Expect When You're Expecting A Craniotomy!

Here beginneth, by the way, a series on what patients can expect from various fun procedures that are common at Sunnydale General.

So you're having a craniotomy. Let's gloss over, for the moment, whether it's for a tumor or an aneurysm clipping or an external-to-internal carotid bypass, shall we? Most craniotomies have the same side effects and recovery time, so we'll ignore the whole range of reasons for them and focus on the important thing: Somebody way smarter than you will have his (or her) fingers in your skull.

Actually, that's not quite accurate. Somebody way smarter than you will have a series of microscopic instruments inside your skull. The point is, though, that your skull will be opened up (a thing that's never meant to happen) and closed again. Great. What can you expect from the process? Read on:

Prior to Surgery

The day of surgery, you'll be expected to show up at the hospital early in the morning, probably with freshly-shampooed hair. You'll be hungry and thirsty, having not had anything to drink or eat that morning. Somebody will start an IV line on you and fluids, which will help with the thirst part, and give you a dose of something to make you happy. Then you'll be wheeled into the operating room.

Surgery Itself

At this point, one of two things will happen: you'll either be put out completely by the friendly anesthesiologist, or you'll be moved to the operating table, *then* be put out by the F.A. Your head will be positioned in a head-holder (tough medical terms, I know!) and anything from a small strip of hair to half your head will be shaved, depending on the surgeon.

Note: Most docs now shave only what they have to, so don't think you'll lose all your hair.

While you snooze, your head will be scrubbed with a sterilizing soap and draped with sterile drapes. Somebody else will be working on your other end, putting in a urinary catheter.

Once everything is ready, you'll have surgery. Since I have no clue what actually goes on inside the brain during surgery, and you'll be asleep for it, let's move on to the post-surgery period.

After Surgery

You'll wake up, more or less, in the ICU. You'll have wires on your chest, IV and intra-arterial lines in your arms and possibly feet, and you'll feel like hell. Your throat will be sore from the breathing tube they put down you to keep you breathing, and you'll still have that damned catheter in. You'll also probably have a doozy of a headache. This will all cease to matter as the fact that you're in the ICU dawns on you, and you have to cope with bright lights, beeping machines, and nurses coming in every few minutes to make sure your neurological exam hasn't changed. Expect them to ask you silly questions like "What day is it?" and shine bright lights into your eyes over and over. 

After a night or two in the ICU, you'll be moved to a neurosurgical acute care unit. All but one or two IVs will come out, along with the line in your wrist that monitored your arterial pressure. Expect some major bruising there, by the way.

After I introduce myself, I'll take out your catheter. You have eight hours to pee, which shouldn't be a problem. The catheter removal doesn't hurt (at least the way I do it) and you'll feel a lot better after it's gone.

You'll be able to eat regular food if you can, and I'll manage your nausea if you're feeling queasy. Don't ask for Phenergan, by the way, since you won't get it. It makes you too sleepy.

I'll be checking your neuro status every four hours, or more often if I'm a tad worried about you.

The first afternoon out of ICU, you'll probably sleep. This is normal. You might feel *great*, what with all the anesthesia still in your system, but you'll be sleepy the next day for sure. Either way, sleepy or not, you're getting up into a chair and walking a little bit, just so I can be sure everything got put back into the right place.

Okay, So Now What?

Let's take a look in the mirror, shall we?

You'll notice that, if your incision is along the front or side of your head, you have a whopping black eye and a whole lot of swelling on your face. This is totally normal and will go away completely within about ten days. You'll also see a shaved strip or patch of hair with either staples or sutures in it. That's where they went in, and those staples/sutures will come out in about ten days, just as you're looking less like you've been hit by a truck.

You might have punctures in your forehead from that head-holding widget I mentioned earlier. Those will heal and leave very small scars if there are any scars at all.

There are probably bruises on your arms from the IV and a huge bruised area on your right wrist from the intra-arterial line. Your jaw (if your incision is in the front or side) is sore, or your neck (if it's in the back) feels like you have one hell of a crick in it. We can take care of that; just ask for pain meds.

You will probably hear ticking, dripping, thunking, swishing, or popping noises inside your skull, especially if the incision is on the front or side, or around your ear. That is Totally Normal, and is a result of air in your head moving around. You are not insane. The surgeons *always* forget to mention that, and it makes people worry.

You will get very tired very easily. Keep this in mind. You'll find that mental things, like crosswords or reading, tire you faster than physical things. This is because you're basically trying to walk on a sprained ankle--in other words, you have to keep using the part of your body that's been injured or insulted, even as it heals.

Even with the tiredness, you may have trouble sleeping. This is due entirely to the fact that you're getting Decadron, a steroid, to reduce swelling inside your brain. That side effect will go away as soon as we start tapering (lowering the dose) of Decadron, so don't fret. In the meantime, ask for a sleeping pill.

You'll notice that I'm loading you up with laxatives and stool softeners. This is a major deal, since constipation goes hand-in-hand with pain medicine, and I don't want you straining. If you go more than two days without pooping, I will take Drastic Measures. 

Speaking of pooping and peeing, I'll take great interest in how much you drink and how much you pee. This is because opening the brain or spine can lead to various problems with how your body handles fluids, and I want to make sure that's not happening with you. 

After Discharge

When you go home, you'll want to take it easy for two to six weeks. Walk, eat, sleep, sit up in a chair, be calm. You'll have a followup appointment in about two weeks with your surgeon, at which time you'll chat about the surgery and he'll make sure he didn't leave any bits out. 

Make sure your diet is good. Your appetite will probably suck, so eat good food when you get hungry. Include protein and some fat. Avoid junk. Drink plenty of water.

Nap occasionally. Let your body tell you what it wants to do.

And don't worry about screwing something up. Depending on your doctor's orders, you may or may not put antibiotic ointment on your incision or take oral antibiotics. As long as you don't scrub the incision line with a toothbrush (and yes, I have had people do that), it won't get infected.

Don't perm or dye or relax your hair for about six weeks after the staples or sutures come out, though, 'cause that scar is still delicate. And don't use a hairdryer: it'll cause staples to become uncomfortably hot.

Finally, remember that you have had brain surgery. It might be six months before you get your stamina back, okay? Take it easy. In a year, this'll all be a bad memory.

Here endeth the first lesson.

11.11, 90 years ago.

In Flanders Fields the poppies grow 
Between the crosses row on row, 
That mark our place; and in the sky 
The larks, still bravely singing, fly 
Scarce heard amid the guns below.

We are the Dead. Short days ago 
We lived, felt dawn, saw sunset glow, 
Loved and were loved, and now we lie 
In Flanders fields.

Take up our quarrel with the foe: 
To you from failing hands we throw 
The torch; be yours to hold it high. 
If ye break faith with us who die 
We shall not sleep, though poppies grow 
In Flanders fields. 

And one for Canela Cruz, in Iraq now...

Ashbah

The ghosts of American soldiers
wander the streets of Balad by night,
unsure of their way home, exhausted,
the desert wind blowing trash
down the narrow alleys as a voice
sounds from the minaret, a soulful call
reminding them how alone they are,
how lost. And the Iraqi dead,
they watch in silence from rooftops
as date palms line the shore in silhouette,
leaning toward Mecca when the dawn wind blows.

What I cook on my day off, when I have a cold

It's been raining buckets all day. Just now it's raining double-buckets, which makes me glad that I have a cold and the next two days off. The cold isn't bad, really; I've been taking loads of zinc, which really does seem to help hold off the worst of the symptoms.

I also have a loaf of bread and a pot of soup. Therefore, the recipes:

Nurse Jo's When-You-Have-A-Cold, Clean-Out-The-Fridge Soup

1 small box chicken or vegetable broth

1 normal-sized can of diced tomatoes in juice

1 normal-sized can of red kidney beans, drained and rinsed

Dump all of these into a big pot. In a skillet, saute without browning

A half of a fist-sized yellow onion, diced 

A couple of cloves of garlic, minced (I use, like, six; but I'm weird)

A couple of stalks of celery, de-stringed (you do this by breaking the tops off and zipping the strings down the stalk)

Dump the skillet's contents into the pot once everything is nice and soft and fragrant. Turn the heat under the pot on to the point where it's not quite boiling. Add:

A small potato, peeled if you like and cut into cubes

Some corn (I used frozen)

A couple of handfuls of sliced-up green beans (I used frozen)

Some carrots, chopped 

Zucchini, yellow squash, peppers, more tomatoes; whatever you have in the fridge.

Simmer for about twenty minutes, or until the potatoes are almost done. Add:

A biggish bunch of parsley, tied with a string if you've got it

Some lemon zest if you've got it; if not, try thyme

A little rosemary (everybody has rosemary, right?)

A shocking amount of ground black pepper

More salt than you would think

Continue to simmer until the potatoes are nice and soft and come to bits when you poke them.

Eat with Basic White Bread:

Sometime earlier in the morning, if you want bread, you will have wanted to mix up in a nice, big bowl:

4 cups high-gluten ("Better for Bread") flour

A cup and a half, roughly, of water (room temp is fine)

A packet of instant ("Rapid Rise", "Better for Bread Machines") yeast

A tablespoon of salt

Mix that mess on up until it makes a big lump in the middle of your bowl. The dough should look shreddy and weird and kind of like it doesn't really want to stick together.

Dump that mess onto a clean counter that's been lightly floured, or onto a big cutting board, ditto. Knead it by pushing down with the heels of your hands in the middle of the mass, pushing outward, and then folding back in toward you. Do this for ten to twelve minutes. Don't skimp. Turn the dough around between foldings to make sure it's all evenly beaten up. Meditate on something pleasant while you knead. Pleasant thoughts make good bread.

At the end of 12 minutes, you will have a cohesive mass of still-fairly-dry dough. It'll be tacky, but not sticky, and you won't have to have flour under it to keep it from sticking to the counter or cutting board. 

Scrape the remnants of dough etc. out of your bowl and toss in a tablespoonful or so of good oil. Toss the dough ball into the bowl, turn it once so it's nicely coated, and cover the bowl with a damp towel. Set it all aside and forget about it for one and one-half hours. First, remove a stick of butter (not margarine not Promise spread not I Can't Believe It's Not Nuclear Waste--BUTTER) from the refrigerator.

At the end of 90 minutes, which I suggest you use for a nap, punch the dough down. Without removing it from the bowl, push into it gently but firmly with your fist, all over, until it looks sort of deflated and defeated and flaccid. It will give off a nice yeasty smell when you do this. 

Cover it back up and go do something else for another 90 minutes.

At the end of your second nap, dump the now-floofy and soft dough back out on your countertop or cutting board. Rummage around until you find a pan that measures 9 by 3 by 4 inches, or a good flat cookie sheet, or something to hold the dough while it bakes. Butter or grease the pan/sheet/flowerpot well.

Turn your oven to 350 degrees.

Return your attention to the dough. Squoosh and push and coax it into something resembling a loaf, or a round peasant loaf, or a long baguette, or a bust of Elvis. Put it into your greased pan/onto your greased cookie sheet/into your flowerpot and let it rise for, oh, 30 minutes or so, or until its top is nicely rounded over the top of the vessel it's in. You'll know it when you see it; your brain will say, "Oh! That's a loaf of bread! Dayum!"

Put bread in oven. Bake for anywhere from 45 minutes to an hour and 15 minutes. It's ready when it's a nice, even, golden brown all over (this bread will not get very dark) and when the bottom makes a good, hollow THUNK when you tap it. 

Note: If this is the first time you've made bread--and I swear you can, with this recipe--you will be entranced with the THUNK the bread makes when you thwack it with your finger. Do not sit in front of an open oven, bread in your oven-mitted paw, THUNKing the bread over and over.

Take it out of the oven and let it cool on a rack, out of the pan, for about 40 minutes. This part is REALLY FUCKING IMPORTANT, okay? If you cut into it when it's still hot, not only will it accordion on you and smoosh all down and get weird, but it will taste of uncooked dough. Bread continues to bake on the inside when the outside is done. So leave it alone. Do what I did today: take some cold medicine and have a whiskey-and-lemon and read for a bit. The butter will be soft enough to spread, and I promise the bread will still be warm when you cut into it.

If you're *really* smart, you'll start the soup when the bread is about ten minutes from being done--that is, when it's blonde instead of golden and doesn't *quite* smell like bread yet. That way, you can have your finished soup and your bread and butter and your hunk of smoked cheese from a dude that makes such things out of buffalo milk for dinner, and your dog will (as Max did tonight) sit quietly next to the table, whining and hoping you feed him some bread.

And then you can take some more zinc and feel good about your day off.

What the hell is WRONG with you people?

Quick update: My folks are apparently in Mexico and are fine. Uh...okay.

Now, then: What the hell is WRONG with you people? Are you all mad as a sack of badgers? Where the hell do you get off? Whiskey Tango Foxtrot, you guys?

I mean, really. Do not (I repeat, do not) start a fistfight with your relative in your elderly and ill other relative's hospital room. If you do, I will be forced to call the police. And the po-pos, having dealt with your lousy self already, will not be happy that they have to come break that shit up.

Again.

Also, do not piss and moan and complain until I move heaven and earth to find an interpreter that speaks the same language as your patient from Furthest Backobeyondistan, then fail to show up at the hospital, or even return your pages, after I find the one person in the very large metropolitan area that speaks East Wanganese. The East Wanganese interpreter will be very disappointed, and the family members will be disappointed, and there will be unhappy people wandering around, wanting to start fights in some language other than English.

Luckily, since I know exactly no East Wanganese, the torrent of abuse that was levelled at me because of your idiocy, Doctor, rolled off my back like so much milk off a cornflake.

And finally, and I can't believe I am having to say this yet a-bloody-gain, the hospital is not the place to host Tupperware parties, drinking bouts, drug deals, furniture sales, porn movie festivals, panhandling competitions, the 2008 TV-Stealing Olympics For The Poorly Dentitioned, or any other harebrained, jackassed idea you might have.

Whatever you think is a good idea, I can tell you right now is totally inappropriate, will probably have the aforementioned police showing up at your room, and might get your rhino-assed self kicked straight back to County General. 

I am now going to finish this Scotch and go back to bed. Your behavior had better have improved by Wednesday, or else I'll give you something to whine about.

JAMES JAMES MORRISON'S MOTHER/SEEMS TO HAVE BEEN MISLAID

Has anybody seen my parents? If so, could you please contact me and let me know they're okay? 

I'm afraid, what with the outcome of this election, that they've decided to move somewhere more right-wing without telling Beloved Sister and me.

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

Max has learned to bay.

He's made great friends with an extremely wiggly, extremely friendly half-grown Basset hound down the street (whose owners are kind enough to let her off-leash to come visit him) and has learned her tricks.

Given that she's a bass and he's more tenor-to-alto in his baying, it makes for a funny duet. You hear the lower, deeper dog noise and expect that Max would be making it, but instead it's Gretchen The Basset. Max is the one whining and whickering in a high voice and baying way up, an octave above Gretchen's bay.

Max and I sang a duet to the passing ambulances and firetrucks the other day, and Gretchen joined in from four houses down. 

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

Today I did 60 pushups, military-not-girly, and then did 60 lat pullups with 20 pounds and some shoulder rows (30 lbs) and some shrugs (20 lbs) and 60 Aaaahnuhld bicep curls with 15 libs apiece. My upper body is a thing of beauty. It's also very, very sore.

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

If you are a rehab nurse with a patient on a bowel program, please, please make sure the patient actually takes a shit now and then. Especially after they have a barium swallow. That will save me from the fun of milk-and-molasses enemas followed by slow Go-Lytely feeds followed by projectile vomiting (the patient's, not mine), followed by the realization that there are now no bowel sounds where there used to be a few, followed by Reglan IV, followed by erythromycin in an attempt to get the bowels loosened up, followed by an admission of failure, a GI service consult, and surgery.

Thank you. Really.

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

I do not think, coruscating feminist that I am, that it is sexist to ask what the fuck was up with Michelle Obama's dress the other night.

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

Have I mentioned how glad I am that we will have a vice president who doesn't believe that Adam and Eve co-existed with dinosaurs? I mean, really. Do people like Sarah Palin (young-Earth creationists, that is) use antibiotics? Or any sort of genetic testing? Or any of the boons that science has granted us? Because if they do, they should be outed as hypocrites.

It puts me in mind of a Doonesbury cartoon from a year or more ago, in which a doctor was telling his patient that he (the patient) had TB. He offered the patient the option of prayer or antibiotics, reassuring the guy that the antibiotics were "intelligently designed".

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

If anybody has any good sources for upholstery fabric, please email me at the link to the right.

Housekeeping note:

I've deleted a couple of links.

They were to blogs that were, for the most part, much more conservative politically than I am. It's not because the authors are conservatives that I deleted them; I agreed with those authors more often than you'd think, and on a wider variety of issues.

The reason I've deleted the links is this: in the aftermath of the Presidential election, the comments sections of those blogs, including comments left by the authors of the blogs, contained some of the most vicious, mean-spirited, and even out-and-out racist shit I've ever read. 

I understand that Republicans and other conservatives must be angry and disappointed as hell right now. If Obama had lost, I would probably still be in bed, planning only to nurse a hangover and learn French prior to my move to Montreal. I would be peevish about a stolen election and bitter and crying. So it's understandable that there's some serious, serious grouchiness out there in Conservative-Land.

What's not acceptable is the amount of vitriol and the thinly-veiled racism. Vitriol is understandable and even allowable in small amounts, but gallons of it poisons discourse. Racism isn't understandable or allowable, even in small doses. If you want to make jokes about getting rocks of crack at the polling station or how watermelon is going to be the new national food, you go right ahead--but I'm reserving my right not to have that sort of crap linked from here.

This isn't a pouty, I'm-not-reading-your-blog-any-more whine. It's an explanation of why, the day after the election, my links list is shorter. 

When the code doesn't work

Everybody loses patients. Everybody remembers the patients they lost--maybe not by name, or even by face, but you remember. Every patient who dies leaves a little hole in you.

The first one is the worst for most people. And it's bad enough when it's a patient who's been shifted to comfort care; it's worse when it's a failed code. When you walk into a room to find a person, who was fine half an hour or an hour before, is just plain dead, it's shocking. Codes are shocking, too, in their violence and their (usual) pointlessness.

That happened to a coworker of mine the other day. Her patient had been fine and stable and cheerful all shift long and had laid down to take a nap near the end of the shift. He was scheduled to go home the next day. When she made her last put-'em-to-bed rounds of the day, she found him not breathing, not pulsing, not responding. Just plain dead.

And we coded and coded and coded and it had the predictable result.

So what do you do when a code fails?

Well, first, you allow yourself a little freak-out. If you're lucky enough to work where I do, the other nurses on the floor will pick up the slack for ten minutes while you lock yourself in the bathroom and flip your lid. If you're not lucky that way, you'll have to do it while you fill out paperwork and call the eye harvester folks.

Then you figure out what went wrong. In most situations, absolutely nothing anybody could've done would've prevented the death. Short of overdosing a patient on medications or giving them the wrong blood or shoving a tube feed into an arterial line, dying is not something we have a whole lot of input into. Still, it's helpful to think about what led up to your patient's stopping breathing, if only because it'll reassure you that you didn't screw up.

Then you deal with your other patients. It's easy to forget, in the aftermath of a code, when you're overwhelmed with emotion and paperwork, that there are four or five or six other people that are still alive that are depending on you. 

Finally, at the end of the shift, you go home. 

Think about your patient. Raise a toast to 'em, if that's how you roll. Talk to your partner. Hug your kids or your dog or your cat. Roll into bed, with or without the general anesthetic of your choice onboard, and remember that every shift is a new one.

Everybody dies. Some of us die more easily than others, and in better situations. There is not a damned thing you, as a nurse, can do to prevent a death if it's gonna come anyhow. The best you can do is learn from the situation if it's less-than-ideal and use that knowledge to improve the lot of the next folks you take care of.

Yes, We Did.

Is there a physicist in the house?

You remember, I'm sure, the high school physics demonstration of the space/time continuum and how gravity affects both space and time. It's the one that uses a rubber sheet and balls of varying sizes and weights.

Your teacher (or the guy on the public-access cable channel who had sticky-up white hair and a bad lab coat) stretched the rubber sheet tight to illustrate space/time. Then she (or he) dropped a marble or a tennis ball or a bowling ball into the middle of it, and the sheet bent around the ball. Right? You with me so far? After that first object was dumped into the sheet, everything that came after gravitated toward the heaviest thing on the sheet, remember?

So here's my theory: a patient arriving from post-op or directly from admissions has the same effect on the space/time continuum as that bowling ball did when dropped on the rubber sheet. Every other patient you have will proceed to call, fall, bawl, or maul the lab tech, even if they've all been quiet and happy all day long. 

Here's what got me thinking about this, and I wish I were making this up: a patient arrives post-op. I settle them in and take vitals. As I'm doing this, I get paged that another patient has arrived from the admissions department. I settle that person in, return to the post-op patient to tie up some loose ends, and get paged that a doctor wants to see me. On the way to the desk, my phone rings with the news that another patient needs pain medication. As I'm talking to the doc at the desk, six people--and Lord, do I wish that were an exaggeration--come up to me within two minutes to let me know that *another* patient has a headache. Meanwhile, my final patient has fallen in the bathroom after an entire day of walking independently and having been discharged by physical therapy.

Ten minutes before the first patient arrived from the post-op unit, I had finished my rounds and made sure everybody was comfy.

I need a physicist to confirm that post-op patients and outside admissions bend the fabric of space/time, please. Anybody?

Saying Goodbye.

Today I loaded Strider into the car.

We drove east along a little state highway. Over the lake, across the creek, past the McCain/Palin billboard, up and down the hills where the oaks are just turning color. The sky is cloudless and blue today, and Strider had his nose out the window when he wasn't resting his head on my arm.

When we got to the place where I had gone to pick him up six months ago, he got very excited. He greeted his foster mom by rearing up and putting his front paws on her shoulders, then bending down to lick her face. She was thrilled at how beautifully his coat had come in, and how all the mange he'd had was gone. I was glad to see that he still remembered the person who'd held him on her lap (all 80 pounds of him, at the time!) and sung to him when he was so sick with pneumonia that he couldn't sleep.

Then his foster mom introduced him to her female Anatolian shepherd, popped them both into the back seat of her truck, and I hugged him goodbye through the window. The last thing I saw was his butt, tail wagging, as he got comfortable with the other dog in the truck.

Strider did well here for the first four months. Then, as he got out of puppyhood, he started developing a personality that just didn't jive with Max's. They were fighting every day, and Max (being slightly smaller and older) was getting the worst of it. I was having to patch him up nearly every night. Max was scared and miserable, Strider was turning into an aggressive bully, and I was at my wits' end.

So Strider-Man is now going to be on a farm in the far, far northeast corner of Texas, up beyond Dallas, near the Red River. It's border country, hilly and green with creeks on the property he can swim in and coyotes he can chase. That'll be his job: he'll be running the fenceline on fifteen acres and protecting everything on the property. He'll be good at it, and it'll be good for him to have both a job and almost-unlimited space to run. I expect him to be rippling with muscle, tougher than leather, and completely his own self by the middle of next year.

I am going to miss him a lot. He's a good boy. Very nearly the best boy ever, if Max hadn't already had that title.

Max, meanwhile, is basking in the sun, somehow aware that nobody's going to come out of the corner of the yard, knock him down, and worry his head. He's looking forward to renewing his acquaintance with the pug next door and going for long sunset walks.

Maybe someday I'll try another buddy for Max. For now, though, he has to get his mojo back and remember what it's like to be Top Pup.

Stridey-boy, Big Stupid Goofball, Snorgle-Pup, Scrimble-Nimble, Nom-Hound, I'll miss you.

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