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

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

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

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

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

Random 4 am musings

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Zhausted, Take Two.

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

"Why are you leaving?"

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

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

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

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

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

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

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

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

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

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

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

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

Saturday subtlety.

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

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

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

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

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

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

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

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

Which is what happened in this case.

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

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

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

Conversation over dinner

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

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

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

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

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

Product Review: Miele Neptune

So I bought a vacuum.

A five-hundred dollar vacuum.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thursday.... .... ....somethings.

last of all

It's official.

I have seen people who have had various body parts kicked in or off by various animals.

I have seen people who have been hit by drunk drivers, popped ill-advised wheelies on overpowered motorcycles, been hit by lightning, and fallen off structures of varying heights.

I have seen people who have grabbed the end of a downed power line, been run over by a truck on ice, been hit in the head with a keg of beer (full), been hit in the face with a trailer hitch at 70 mph, and who have failed utterly at trying to kill themselves.

I had never before seen somebody who's been scalped by a mixer.

Therefore, I have this to say: I believe that I have now seen it all. 

And this, come to think of it: Those plastic guards on five-foot-tall commercial mixers are there for a reason. Do not remove the guard, then lean over into the mixer to see how things are going in there, with the 300 rpm whatsis going round and round. Okay? Okay.

I wish the guy who stuck his head under the running combine to see what was making that funny noise were still around. We could double-room those two.

Hey, guys. This is kind of important.

Let's talk for a minute about donating organs and tissues, shall we? 

There are three big things that you need to know about organ donation. The first is the most serious: There Are Not Enough Organs For Everybody Who Needs One.

The second is this: Nobody Is Going To Kill You In Order To Harvest Your Organs.

And the third is this 'un: We Can Use More Than Just Organs.

Point Number One:

There simply aren't enough organs to go around. Kidneys, livers, hearts and lungs, you name it: there ain't enough. The problem is particularly acute in minority communities, as there are certain immunity factors that make successful transplantation more likely if you transplant, say, a kidney from an African-American or Asian-American into another African- or Asian-American. People die every day--thousands of them--because they've run out of time on a waiting list. You can donate even if your religion recommends that you stay in one piece for burial (Orthodox Judaism has an allowance for donation; I don't know about Jehovah's Witnesses), even if you're old, even if you're sick with certain things.

Point The Second:

When you (or somebody you love) dies of trauma or some "allowable" disease, the folks who keep your body alive and the folks who decide if you're a donor candidate are NOT the same people. Likewise, if you're wheeled into an ER after a motorcycle crash during which you weren't wearing a helmet, nobody's gonna look at you right off and say, "Hey, this is a potential organ donor; slow down on that intubation, okay?"

There are no doctors looking covetously at your liver. There are no nurses who're gonna slip you a little somethin'-somethin' to hurry you along. We're in the business of exhausting all possible resources until somebody says "stop", at which point we turn the possibility of donation over to some totally other different group that's not associated with us.

Point Numero Tres:

Even if you leave your organs in bad shape, we can still use your tendons (for people who need knee or hip surgery), bone (for trauma), skin (burns), intestines (yikes) and other bits, like corneas, to help other people. On the back of my driver's license is the notation: ALL USABLE ORGANS AND TISSUES. My family knows to compost the rest and plant a garden on top of it.

Please make arrangements to donate. Tell your family and friends. Fill out a "Live, Then Give" card--you can search online for local organ donation organizations that can hook you up.

And, if you're not in the mood to donate, or the thought of somebody using your leftovers totally squicks you out, try this: Faithful Reader Hallie has started a fundraising effort for the United Network For Organ Sharing. They're a great group--they work on national policy to make sure that organs are distributed in the most fair way possible, raise awareness, and get people set up with new bits when they need 'em. 

Hallie's dad got a new heart through their good offices and is still going strong six years later. I encourage you to learn what you can about UNOS and what they do, and donate if you have the wherewithal.

Information is here.

And thank you, from the bottom of my eventually-to-be-reused heart.

Product Reviews: Pale redhead edition

Back in the day, my Beloved Mother used to sigh resignedly when I left the house in pale base, black eyeliner, purple lipstick, and a flattop.

Beloved Mother will probably not be happy to learn that black eyeliner, black mascara, and purple lipstick have returned to my makeup box, on regular rotation, as part of a professional look.

Those of you who are well-versed in girly stuff will already have known that you can't wear the same makeup as a nearly-forty-year-old as you did when you were a teenager. I did not know that, so I had been wearing the same brown eyeliner/brown mascara/clear gloss combo for the last...oh, twenty years? as I had when I was not Going Out and trying to make Beloved Mother Sigh Deeply.

However. This summer I seem to have acquired a tan. A fairly deep tan, for a fair redhead, which means I'm approximately apricot-colored with darker freckles (it looks better than it sounds, I swear). The brown/brown/clear thing simply wasn't working. I looked tired.

So, on a whim the other morning, I yanked out the black eyeliner and mascara. Despite the fact that Flashes had chewed the end of the blending brush I use for smudging eyeliner, I perservered (and will probably end up with some obscure eye infection caused by cat saliva).  I used black eyeliner, smudged it with nearly-black/still vaguely brownish/kinda charcoal liner, and added two coats of mascara. 

Hm. Okay. I don't look like a Goth or a trollop. Hm. What's this? Purple lipstick? What's the color? "Prince's Toenail Bruise"? Sounds good. Slap some of that bitch on up, then.

And all day? People told me what pretty eyes I have. And how awake and rested I looked. Strangely enough, the solid black liner and lashes look more natural than brown. It's very odd. And the purple lipstick? Sparingly applied, it looks like I've just eaten a dozen habaneros, which, for a girl with my lippage, is saying something.

I'm going off to find that old Einsturzende Neubaten T-shirt now. And maybe consider a flattop. Because I am the epitome of femininity. 

Tessalon, Omnicef, and a heat index of 108.

According to Herr Doktor Babyface, I do indeed have a sinus infection; a bacterial superinfection after my summer cold. Which sucks, I must say, rocks. The bad news is that I'll feel rotten for a couple more days. The good news is that Herr Doktor Babyface believes me when I say I hate narcotics, and so hooked me up with some Tessalon for the cough. I'll sleep tonight, wake up in the morning (sadly), and not have to worry about itching and being dopey.

Which is good. With a heat index of 108*, I have enough to worry about. When it's this hot and humid (101*, 60%), the air conditioners at work tend to start getting overburdened and not working quite as well as they ought to. The temperature inside the building on the ground floor when I left today (early, to see HDB) was near 80. It was hotter upstairs. 

Patients don't like it when it's hot. Nurses don't like it when it's hot, but aside from sweating through scrubs and smelling worse than usual, there's not a lot about heat that's going to hurt us. People who've had large sections of their brains fingered, though, tend to have really crappy temperature-management systems internally: they get hot and cold quite easily. Add to that the usual number of people with high cervical spine injuries (who tend not to be able to regulate their own temperature either), and you're in for a fun day of ice bags and fans.

I'm thinking of moving, once my two years in the ICU is up, to somewhere with slightly less obnoxious summer weather. Spring here is such that you can go on a picnic during it, provided it doesn't happen while you're in the shower. Fall here is great, if you don't mind hay fever from hell. Winter is quite mild....but summer? Kills people. For reals.

Meanwhile, friends of mine a few hundred to a thousand miles north are talking cheerfully about camping and gardening and going for long walks in the balmy afternoon. If I went for a long walk in the balmy afternoon today, I'd be coming back in an ambulance with an IV of 3% saline. 

Y'know how people in Northern cities like Anchorage and Montreal and Toledo come out in droves in the springtime, squinting at the sun? And how all the great street festivals and so on are held in the summer? And how some people wear sweaters, even, after the sun goes down in the summer? 

Summer for us is like winter for them. We come out, squinting at the sun, in early October. Oktoberfests are huge here, partly because it's finally cool enough to dance again. We hang out all winter (with the exceptions of the two days it's really cold) and most of the spring, then go back inside in early June and stay there until the next cool front blows through on September 30th. 

Yow. I've grouched myself out. I have a sinus headache, four months of over-100* temperatures to look forward to, and I'll stop right here.

Meanwhile: does anybody have a house in, say, Portland that they'll be looking to sublet in late 2011?

Because I will be non compos mentis the next few days:

Sometimes things get really hard.

Sometimes it's really, really hard to view patients as people. Sometimes you just want to smack them instead.

When you meet somebody who is so very unpleasant in every way that being around them makes you want to take a shower with Brillo and then bleach your brain, it's hard to remember that you're there to help. It's hard to remember that your help is not contingent on their helping themselves; it's to be given, period, full stop, without conditions.

We had a patient years ago who was one of those brain-bleach folks. She was bitter, angry, mean...you name it, she'd say it to you. She couldn't strike out physically, so she was nasty with words and bodily functions. She weighed in at a little over five hundred pounds and refused to do anything at all for herself, from answering the phone to cutting up her own meat. Turning her was an adventure we had to undertake several times a day, dressed in rubber gowns, as she'd defecate and urinate on herself and others during the process. She was an absolute frigging nightmare to deal with, and ran through every nurse on the floor in a matter of a couple of weeks.

She was also a "private-pay" patient, which meant she was essentially there through the charity of the hospital. Private-pay patients are either very rich or have no money whatsoever, but we take care of 'em all without asking details. 

Most of the time, the nurses at our facility have no idea what financial arrangements our patients have made; that's handled by the folks in the carpeted areas. In this case, though, it was different, because this particular patient needed a long series of IVIG infusions. IVIG (intravenous immunoglobulin) is hideously expensive--about ten grand will buy you a liter, depending on market rates, and the average person needs several liters over several days to complete a course of treatment. 

This particular patient had already been through two other treatment options, both mindbogglingly expensive, on our dime. The question now was whether we could afford to continue treating her when the expectation of full functionality returning was slim and her commitment to her own care was nil. We all had to sit down as a group and talk about the ethical quandaries involved in treating/not treating her.

We ended up treating her, period, full stop, and rehabbing her for several months at no cost to her.

She was brought up this week by a pal of mine, as a contrast to another patient we'd had recently.

The recent patient was one of those folks you can't help but love. She was also a charity patient, but couldn't have been more different from the first woman. She was funny, and smart, and sassy, and sweet, and had a perfectly treatable tumor on her brainstem. It had affected her ability to move, but not her brain. She worked hard to regain the functionality she'd lost, insisting on feeding herself even though it took a long time and she tended to be messy. She had a small, tight-knit group of friends who came every day just to hang out. She had good family support and had managed to make every single treatment appointment she had.

She died a couple of weeks ago. The carpeted folks decided we could no longer afford to continue to treat her tumor, and she didn't have any other options. She died with her mental faculties intact as her body shut down.

These are the sorts of scenarios that make you want to just sit down and not move for about a year. The first patient got treated, at the cost of Frog only knows how many millions of dollars and how many shreds of patience, for *months*. She got that treatment because, at the time, the economy was going full-bore and the carpeted folks figured we could afford to spend money on somebody who wasn't compliant with her treatment plan or her own care. 

The second patient died because money got tight. She had a much better potential outcome than the first patient; it was only her timing that sucked.

It would be easy to throw my hands up in the air and say, "Fine. You don't wanna take a hand in getting better? Then we won't treat you. Work with the physical therapists and quit spitting at the nurses if you want your IVIG this week." It's easy to feel that People Like That somehow are less deserving than Nice People, even if what they're less deserving of is lifesaving care.

Then, though, you're faced with the question of where to draw the line. Long-time smoker and drinker? Fine: you can die of esophageal cancer, and it's all on you. Pregnancy-induced hypertension? Fine: go ahead and get eclampsia, you fat pig; you should've been skinnier before you got knocked up. Brain tumor of a strange and rare sort? Fine: obviously, you have bad kharma. It's easy to see where blaming people leads.

I've been thinking about this for a few days, now, and I haven't come up with any solid solutions to this dilemma. Should we make compliance with care a prerequisite to receiving that care in the first place? Should we force patients to sign something? Play nice? Be pleasant? At least give a damn? Can we realistically do any of that? 

And then, on the micro level (as my sociology prof used to say), you get the problem of providing care to somebody that you, personally, would rather leave out on an ice floe. I got cussed at, screamed at, and peed upon by a person whom I'd'a rather just left alone, but I had to deal with all of that because I have a commitment to taking care of people, period, full stop.

It's never easy to do this stuff for a living, but this last couple of weeks have reminded me how very hard it sometimes gets.

There ain't nothing like a Dane, a sinus infection, and Scotch.

So I'm getting the mail today (I was too tired last night, due to this sinus infection I've got brewing) and I feel something cold....and wet....on my neck....and I hear heavy breathing.

Behind me, wagging his tail, is the down-the-street Great Dane, out on a walk with his people.

There ain't nothing like a Dane, I tell ya. As far as Stealth Fear dogs go, they rank near the top, especially when they've got uncropped ears and a long tail. Turn around and find a guy like that on your porch, looking at you eye to eye, and you'll use up your adrenaline for the month.

*** *** *** *** *** 

Sinus infection. Yeah. Hate 'em. Got a couple of things to write, and a couple of deadlines to meet, and nothing is going to be happening (sorry, Hannah!) until after I get some antibiotics and some cough stuff. Scotch is good and all, but I can't keep drinking it in the quantities necessary to keep a) the cough at bay and b) some sort of functionality in my brain. The costs are too high. My liver is already on strike this month.

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

Note to My Favorite Resident: I understand that you really need to get ahold of whoever it is you need to get ahold of, and that you've given me six phone numbers that might work for that person.

Please understand, on your end, that I have spent most of three hours calling those six numbers over and over and over and over and.... and have still not gotten any sort of response. I've left messages, I've paged people, I've called repeatedly. Is that clear? Nobody is responding. If your attending managed to raise somebody at those numbers a week ago, good on him--whatever he did worked, so maybe you should call *him* and task him with reaching those folks. 

Whatever you decide, please don't yell at me.

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

And, finally, a little Sunday Night Lindy to get you in gear for the week:

Please note the young woman in the nurse cap. That, my friends, is what every day at Sunnydale General is like.

Gentlemen:

Chuck Palahniuk is gay.

Ayn Rand was a Communist.

You are not the shee-it because you are a surgeon.

Please go tie a brick to it so it's a little bigger, then come back and talk to me when you feel like you don't have to yell any more.

Thank you.