And, of course, as a child of the 1980's. . . .

"She led off alone on the intro to 'When U Were Mine,' her guitar thin and high and lonely. Then the rest of the band swelled up under that, with Willy on his electric demon fiddle. Carla and Dan had come up with a bizarre percussive patch for one of the synthesizers, and hung it on the end of the fiddle's phrases. The effect was that of a succession of violins being bitten neatly in half.

Eddi found that the single-minded frenzy of the first set had passed. She still had the crackling energy, but she had a clear head to use it with as well. She tried to make every note glow; she felt the rest of the band respond to that and stretch like a racehorse seeking that one winning length. . . ."

Emma Bull, War For The Oaks

Do not be this person.

This week I wanted to die, in a sustained and sincere manner, rather than return to work after my first shift back from vacation.

Why?

Because I had a patient. Who weighed six hundred pounds. That's a BMI of 79.9 if you're counting, and not something that you want to aspire to. However, the trouble was not the patient. The trouble was one of her family members, the one Person You Should Never, Ever. Be.

This Person was, she claimed, a cousin-level relative of my patient and, she claimed, a neuro ICU nurse. The fact that she was a neuro ICU nurse at a hospital in the most far-flung district of the most distant, inbred county of Back Of Beyond that Texas can provide didn't matter; she was, by God, an ICU nurse who dealt with brains and That was It.

She questioned why we were doing her relative's transesophageal echo under general anesthetic with intubation rather than at the bedside. They do them all the time at the bedside in her ICU, after all. I was forced to point out that with an airway that doesn't even register on the Mallampati scale (graded from 1 to 4, with 4 being the most difficult to maintain), a BMI of nearly 80, and the need for continuous BiPAP while awake, her cousin was not the best candidate for living through bedside sedation.

Then she accosted our doctors, asking why we hadn't either given TPA or done a clot retrieval on her cousin. Her cousin presented to her small-town ED ten hours after her symptoms began, thus making her ineligible for clotbusters. And she'd had a watershed stroke, which means that there are a lot of itty-bitty clots along one pathway that one large artery follows, so nothing to retrieve.

In short, the Family Member You Should Never Be knew just enough to be dangerous. We had it out when I found her increasing the rate on the IV pump. My patient had congestive heart failure, and CHF patients can't take a lot of IV fluid, even if their kidneys are working well, which this woman's weren't.

We all fell suddenly and irrevocably in love with Dr. Hernandez, who took the brunt of her questioning. When her voice reached near-hysteria levels as she demanded, "Why didn't you do MORE?? You haven't done ANYTHING!" he responded, "Why didn't *you* do more before your cousin reached six hundred pounds?"

Because, People, this is the thing: nobody weighs five or six hundred pounds without somebody helping them out. At that point, it's difficult, if not impossible, for your average five-foot-four woman to get her own food. Extreme obesity is like heroin addiction, but with family support and enabling. It's harder to treat than heroin addiction, but just as deadly. And the families of these folks have often been the go-to people for high-calorie food in quantities that would blow your mind.

So yeah, that happened.

It was kind of a long week.

What I did on my vacation.

The benefit of selling your soul and most of your waking hours to a corporation like Giganto Research and Healthcare, Inc. is that you, eventually, accrue almost enough vacation time to feel like a human being for part of the year.

I just took two and a half weeks of vacation time. Getting it was surprisingly easy; all I had to do was widen my eyes slightly and mutter about evisceration, and my various bosses gave in and signed off.

So: I had two and a half weeks off. What did I do?

I got a new bed. King-sized, which means Mongo and the cats and I can all sleep comfortably at the same time, and so can The Boyfiend, when he's here. It's amazing how much difference those few inches make. Yes, it's a pain in the ass to change the sheets, and yes, I'll have to go to the laundromat to wash the comforter, but believe me: TOTALLY WORTH IT.

I got the mattress and box springs from Wink on the basis of reviews and their 101-day test period. The mattress is a hybrid--that means it has both memory foam (which I hate) and springs (which can be problematic in terms of motion transfer), combined in some highly-technological way.

My previous mattress was a Sealy Posturpedic metal-frame deal with a pillowtop. The only way in which that mattress was better than this one was in the sag when you sit on the edge. This mattress has some sort of plastic framing that allows you to use it with an adjustable foundation, but it sags a bit if you sit *right* on the edge.

Other than that, this mattress is TITS. I lie down, I turn over twice, I know nothing until the morning. They've somehow managed to combine springs so that it doesn't feel like memory foam and memory foam so the whole thing doesn't shake when Mongo turns over. Yes, it cost hinty-bazillion dollars, but every half-cent of those dollars was worth it.

I cleared two or three years' worth of weeds and dead shit and mulch and crappy low-end weedblocking cloth out of my front beds, then dug in several hundred pounds of composted manure, then re-weed-blocked it, planted things, and laid down mulch.

That alone took me two of those weeks. I have two beds, one 9 x 13 and one 9 x 11, and they hadn't had any attention in a couple of years. (Don't ask me what happened; I don't remember. All I know is I got a nastygram from the city about my weeds and kind of gave up after that.)

Now I have several dwarf yaupon hollies, something grey with purple flowers and the common Latin name "vomica," and a selection of other perennials growing in those beds. There are more plants coming, things like lavender and pentstemon and salvia and honeysuckle. I even planted a rose bush to balance the rose bush I planted when I moved in here. It's all very nice.

And I hung three dozen miniature mirrored disco balls in cascades on either side of my porch.

And I planted herbs in pots and then put tiny, brilliantly-colored plastic dinosaurs in the pots. (Did I mention that I spray-painted the pots' rims different colors? Well, I did, and it looks like Pinterest barfed on my porch.) Oh, and today I built a brick pad with antique bricks I dug out of the back yard so I'd have a dry, stable place to put the trash cans.

Gardening Fever has me by the throat now, so of course I have to build a TARDIS for the yard (a YARDIS) and hang mirrors off the trees and get a bird bath at some point.

Monday I go back to work. Apparently we have a new intern; she has a degree in English lit, which is good.

And I have two weeks off in July, which I will be spending in Seattle, which is better.

Half laughing, half gritting my teeth.

Years ago, I wrote briefly about the experience of being a synesthete and how I discovered synesthesia. I had kinda always figured that everybody saw the number eight as a nice, round, juicy blueberry color and that Katy Perry tasted like burned cheese and was burnt-orange. It took an NPR story and a conversation with my sister to prove me wrong.

And I had thought about it exactly zero times since. The way you experience the world is the way you experience the world; it's not something you consciously analyze unless something is brought to your attention. Thankfully, my synesthesia (and that of my sister) is not crippling; it's just an interesting party trick. It's utterly consistent and so completely a part of the way I move through the universe that I don't even notice it any more.

Until today. Today, when my pill case showed up from Amazon.

See, my NP got on my ass the last time I saw her (Tuesday) about not being consistent with vitamin D and fish oil and all that stuff. I really need to take certain things every day, I know, but for some reason my hand just floats over the big bottle of fish oil capsules every evening. So she yelled at me a little, and I went home and ordered a seven-day pill organizer. The box for each day has four little compartments, and each box is a different color.

THE BOXES ARE THE WRONG COLORS.

And, dudes and dudettes, this is a problem. Tuesday is lavender when it should be acid green. Sunday is a soft magenta, which does not appear in this set of boxes. Monday is *not* supposed to be purple.

It's bad enough that I got all confused while I was sorting vitamins out. There are some things I'm only supposed to take three times a week, and those went into the wrong boxes. I put all the boxes back together in the holder in the wrong order. It was a physical effort to make the colors match the labels on the boxes.

I am a partial synesthete. I will soon be a partial synesthete with a label-maker, as I relabel all the boxes so that they match, or at least come close to, the days of the week.

Things For Which I Will Never Apologize, Part One:

1. Not answering phone calls from work or checking work email while I'm on vacation. Leave me voicemail if it's really important and I'll call you back.

This policy stems from the time the house supervisor called me and asked me to come in one morning for an "incentive shift." I replied that sorry, I couldn't come in, and got subjected to a lecture about how not-a-team-player I was and how my coworkers were going to suffer. I said, "Yeah, yeah, but I'm in CANADA" and that was that.

2. Being paranoid about the weather this time of year.

Bad enough we get hailstorms and flooding that wipes out entire towns, but add in the "Oop, another tornado" element and yes, I will stay glued to the NOAA webpage.

3. Thinking that "Burlesque" and "Spice World" are the pinnacle of Western movie-making.

Those two movies are the closest thing we have to Bollywood, unless you count the "Step Up" series, which I have never seen.

4. The things I keep in the fridge, like stinky cheese and kimchi.

I live alone.

5. Liking my animals much much much more than I like most people.

*They* don't complain about my stinky cheese, and an incentive shift for Mongo means lots of fuzzy, snorting hugs.

Mongo has a bone!

I was wandering around HEB today (I hate shopping without an appetite; it leads to a weird larder) and saw GARGANTUAN BONES for sale. There were weeny, teacup-Schnauzer sized bones (about twelve inches) and GOLIATH BONES (that was the name), so I bought a GOLIATH BONE.

Mongo took it from me with mingled excitement and trepidation. He chewed it for about ten minutes on the back deck, then walked around the back yard, stepping very carefully, with his head on one side as he carried it off-center in his mouth. He made sure Rocky next door and Gracie two yards over saw it, and plumed his tale out when the boxer mixes on the other side of Rocky began to bark.

He couldn't figure out where to hide it. There are two trees in the back yard: one is property of a cat, the other is a peach tree that, as yet, is not big enough to hide anything under. So he tried by the shed. Then he tried next to the deck. Then he tried by the bushes on the northwest side of the yard. Nothing worked.

So he brought his GOLIATH BONE indoors and, after a drink and a little toes-up on the living room rug, proceeded to look for a place to hide it inside. So far it's been in the bathroom, behind the toilet (no go; Humans peeing apparently are not conducive to a hiding place), in the office where I type (but he can't get to the couch at the moment, dammit), and in the linen closet. The linen closet is okay for now.

The previous three dogs I've been owned by were all either northern breeds or working breeds, or combinations of the two. That meant that Elsie would happily crunch the trochanter off a cow's femur, or Max would cheerfully, between tail-wags, chomp the bone in half at the middle, or Strider would simply make the damn thing disappear in under an hour. It was a short-lived, if dramatic, way to entertain a dog: buy them a bone much larger than anything in the human body, then wonder what would happen if I died in my sleep.

What Mongo lacks in barely-civilized, wolflike instinct he makes up for in entertainment value. I felt kind of bad for him as he pranced around the yard like a Tennessee walking horse, trying to keep The Bone from falling out of his mouth, but also amused by the fact that he grabbed it by the meatiest part rather than in the middle. And he's barely gotten two bumps chewed off since noon; this bodes well for the possibilities of an open casket funeral should I kick off during the night tonight.

Speaking of open caskets, I have started a BSN program (yes, my dears; I'm finally giving in to corporate pressure to have letters after my name) online. Tests are done with a webcam provided by the school; I have to be in sight of a proctor and with my entire workspace visible by same during the testing process.

So, I was wondering: is this the appropriate time to pull out the strapless ballgown, elbow-length gloves, and tiara I've been storing for a special occasion? I mean, my Psychology Through the Lifespan test is important; should I dress for the occasion? Would it be worth it to make the proctors crack a smile? Surely they could use a little levity in their jobs.

Mongo is yelping at one of the cats, who had the temerity to investigate His Bone. Gotta go.

There is a bloody bite block on my wall, just above my desk.

It's in a biohazard bag, don't worry. It's pinned to my wall, just above my desk, so that I can see it every single morning and remember why the hell I got into this crazy business in the first place.

We do a significant number of what are called transesophageal echocardiograms on our unit. Unlike transthoracic echoes, which take place when a tech holds an echo wand against your chest, a TEE takes place under moderate sedation, with a cardiologist feeding a long, skinny tube with an echo camera on the end of it down your throat.

You can't do this without sedation. Try, and you'll end up with a retching, fighting patient and a poor-quality image. It's just flat impossible to ask an alert human to stand for having a two-foot length of something the thickness of my index finger inserted down his or her throat and manipulated. So we sedate. We're a critical-care unit; we're all trained to administer sedation and recover patients who've been sedated.

Then, one day, Doctor deSade showed up. Dr. deS. was a new guy for us, from a different branch of cardiology, and nobody had worked with him before. The initial signs weren't promising: normally TEEs are done early in the morning, both because we want our patients to have time to get over their sedation and because they've not had anything to eat or drink since midnight. This dude promised to show up at around eleven, which is pushing it, but then didn't show up until past two o'clock.

Kitty and I each had a patient undergoing a TEE that day, so we gathered our sedation meds, our throat-numbing sprays, and our sedation-med-antidotes. The first patient was mine.

Dr. deSade put the bite block (a firm foam widget with a hole in the middle that keeps a person from biting on whatever's placed in her mouth) in, after spraying the patient's throat with benzocaine, and began to feed the probe down. "Do you want any sedation?" I asked.

"Give her one and twenty-five," he replied.

(Now: "one and twenty-five" refers to the milligrams of Versed and the micrograms of Fentanyl that the patient is getting. We normally sedate at two and twenty-five, going up from there in two milligram and twenty-five microgram steps. It's not unusual for a patient to soak up five of Versed and a hundred of Fentanyl. Both are short-acting and easy to reverse, so we prefer to front-load the patient, as it were, giving them more sedation at the beginning, and letting it wear off gradually toward the end of the procedure. So one and twenty-five was weird.)

She fought. She gagged. She cried. I had to hold her hands down as the procedure continued, and I got very nervous about her blood pressure--up into the 260's systolic, which is a dangerous place for a post-brain-bleed patient to be. Eventually, Dr. deS. agreed to let me give her another milligram of Versed, but no more. Absolutely no more.

So, at the end of the case, after I'd pulled the bloody bite block out of her mouth--and you really have to work to bite hard enough to draw blood with a block in--I stuck the block into my glove and then into my pocket. And I took Dr. deSade aside, where nobody could hear us.

"Listen," I said, "I understand you have a personal protocol for your TEEs, but we also have to make sure that our patients don't have to deal with a lot of discomfort. This woman's blood pressure was far, far too high for safety. You might consider administering more sedative before beginning, so as to lower the risk of complications in this patient population."

I had been formulating that speech for the entire twenty minutes of the TEE. What Dr. deSade did flipped me right the fuck out: he started shouting.

He continued shouting all the way up to the nurses' station, where he leveled a finger at me and shouted, "I want to write this nurse up for unprofessional behavior and for questioning my orders!"

And that, my chickens, was when the line I'd rehearsed every day in front of the mirror for more than a decade came unbidden to my lips: "Just make sure you spell my name right."

I think I hissed it.

Poor Kitty had to do a TEE after Dr. deS had had his tantrum, and guess what? Her patient did the same thing. Moreover, the guy had had another TEE a few months before and unfavorably compared Dr. deSade's to his previous one, within the doctor's hearing.

And I got written up.

But Dr. deSade got written up twice, independently, by both Kit and me, for being a fucking jackass when it came to sedation.

My patient cried when I told her how sorry I was. She was expressively aphasic, but could understand everything that was happening. I have never felt so bad as I did that afternoon--I wasn't able to protect her from somebody with an ego problem and an attitude.

Both the TEEs came back, read by a different cardiologist, as having poor image quality due to patient agitation. The write-up Dr. deS filed wasn't acted on; the ones Kitty and I filed were. Dr. deSade is no longer welcome anywhere near our patients.

Sometimes doing the right thing is why you get into a business as irritating and emotionally draining as nursing. And sometimes, to remind yourself of all of that, you keep a biohazard above your desk.

My week, in pretty moving pictures.

Doctor Sunshine, who has a reputation for badmouthing everyone and everything around him, strode out of a room and announced to the residents with him, "You'll find that this unit is weak. The nurses aren't as competent as the ones in surgical critical-care."

Four nurses, two mid-levels, two residents, and a student later complained to their respective superiors about what Sunshine had said. The particular irony in this situation was that the incompetent nurses in our weak unit had been warning Sunshine that a particular patient had been decompensating for hours. He hadn't listened. Boy was he surprised when that patient went to the pulmonary ICU!

Sunshine then got pulled into a Very Big Meeting with his boss. Said boss is a good guy, supports the nurses he works with, and has a very calm way of dealing with petulant twats like Sunshine. 

Sunshine just didn't have a very good day. Poor baby.

He accosted Marcie in the hall today and asked her who had "turned him in." Marcie was kind enough to hold her tongue and not tell him that there were at least four independent complaints.

All I have to say is:

God, I love nursing students. And new nurses. And newbies, in general.

The best shifts I have come when I get to precept nursing students or new nurses. It doesn't happen very often, probably because I have a bad, bad reputation with Manglement when it comes to new RNs. I say things like "Don't let that doctor talk down to you!" and then call the doc in question out when he's been an asshole. That does not make me popular with people whose job it is to make sure the fruit plate in the doctors' lounge is fresh and full of papaya.

Still. . . .when I get to precept a new nurse, or a student, it's such a freakin' high. People who don't know a lot, or anything, about a discipline ask the best questions. I'll be talking to a newbie about the diagnosis for Mister X, and say something like "and, of course, he's very disinhibited because he had this right-sided stroke" and the newbie will be all "Wait, what?" and then I'll have to explain it in plain English. Which is exciting, because of the whole translation aspect, and also because I have to dig deep into this brain that's been doing this for a long time and come up with answers to the questions that'll certainly follow.

So, Newbies of every stripe, pay attention:

1. Really and truly, no question is a dumb question. 

No, seriously. If you ask me a question that is extremely basic, I will not get mad at you. Often the most basic points of a problem are obscured by language or the cool stuff that isn't so basic. Ask away.

2. If you meet an instructor who says "Nurses eat their young" or "All nurses are codependent," look at them only through slitted eyes.

Most nursing instructors these days are, thank God, decent nurses. Still, you'll occasionally run into one who couldn't hack basic nursing, either because of a lack of brains or a lack of spine. Those are the ones who will tell you horror stories about nurses. Ignore them. Most of us--especially the younger ones--are without bullshit and without an agenda. We want you to succeed, we want to see you on the floor with us, and we're ready and willing to help you out.

3. Likewise, be aware of the Cunt Nurse.

The very first day I was on my own after orientation, back in the Jurassic period, I was present for a conversation between two Old Nurses. They were talking about a neurosurgery resident, a woman, who was both extremely bright and more than usually attractive. The gist of their discussion was that she must've slept with the chair of the department to have gotten as far as she did.

I remember sitting quietly, sorting my charts out, and thinking "Jesus, that nurse is a fucking cunt." I was right. She *is* a fucking cunt, and I still work with her, and I've not seen anything in the past fifteen years to convince me differently. (The other nurse she was talking with was a manager, and was fired shortly thereafter.)

The point here is that if somebody badmouths a colleague without reason, or fakes a kidney stone to get out of precepting you, or generally makes you think "that person is a cunt," you are probably right. And cunts never change. Avoid them.

4. Please have the basics down.

And by that, I mean the absolute basics. Know how to tell the upper back from the lower back. Know where the brain is (hint: it's on top). Be aware of how to take a pulse. (Note that I don't require anybody to be able to take a manual blood pressure; it's surprisingly tricky and needs lots of practice.) Know how many legs your average human should have, and whether or not your patient has a uterus. I don't require more than that, honestly. Unless you cop an attitude, and then I will make you sweat.

5. As for making you sweat, we won't do it in a mean way.

Unless you cop an attitude. As I did when I was a new nurse, and boy, did I ever have to answer for it. We may ask you tricky questions and wait, as you shift from foot to foot and glance at your fellow newbies for help, until we give you the answer or you come up with something that we'd never thought of before. We won't pimp you the way doctors do, don't worry.

Mostly, honestly, we ask you questions not because we want to know if you have the textbook answer, but because we want to see you work out a plausible answer on your own. Hell, I'll take a flamingly wrong answer that's well-conceived over a boring, flat textbook answer, simply because the wrong one was more interesting and gave more scope for teaching.

Don't be scared. Unless you're an asshole. Then, be scared.

Today I went to a funeral.

I walked in to the church and looked for people I knew. The first person I spotted was Mike, Jenna's husband, so I walked straight up to him and hugged him.

I have never seen anyone look as empty as he did.

Then Jenna's mother found me, and her brothers, and her various other relatives, and I got hugged and kissed to the point that I no longer cared about leaving makeup marks on their nice clothes.

I sat down about six rows from the back, in a pew that didn't have anybody in it. I stayed there until the music started and the family came down the aisle. Jenna's mom grabbed me and said, "Jo, you're family. Come sit with us." I started to ask "Are you sure?" but she had my hand so tight that I decided to shut the hell up and go with it.

So I ended up in what was nominally a family pew, right behind the family, with Lauren and Casey, the PAs who took care of Jenna when she was really sick.

I'm glad they were there. I didn't cry because they were there.

Everybody there but me, I think, was a believer. They read poetry and psalms and proverbs, and talked about the value of a capable and thoughtful wife. They talked about the love of a good friend, and how they were sure she would be waiting for them in Heaven when they died. They called her a pearl of great price and said her value was beyond that of rubies.

Here is the Jenna I know, the one who I was both nurse to and friends with:

She was jealous of the shirt that I have that says "My cancer is rarer than your cancer. Neener neener."

She was always more than ready to talk about something other than her illness. Mostly, that something was how ready she was to get back to work (teaching) or her kids or her husband, but it also turned to how weird life could be.

She was totally unshockable. I sent her texts with pictures of the guys across the street doing half-naked yoga on their roof, or the pile of clothes somebody left in my front yard, or the latest whacko project that one of the neighbors had conceived, and her response was always "I miss Littleton. It's such a great place!" Sometimes that was followed by "Did that dude ever come get his clothes?"

Jenna was never, that I saw, really angry about what had happened to her. I'm sure she got angry at times, or got rebellious against what she saw as God's plan for her, but she never did so with me. That's not to imply that she simply accepted things as they were: she most emphatically did not. As Lauren said, the most incredible thing to watch was how she went from being scared and anxious to being strong and confident. She didn't so much fight as she just lived, in defiance of everything.

Mike and Jenna visited me at work one day and I asked to see her head. She was really, really cute without hair. Like, more attractive than anybody has a right to be.

At her funeral, there was a slideshow: Jenna with Mike. Jenna with college friends. Jenna, as a toddler, dressed up in a bee costume, her grandmother by her side. Jenna holding a fishing pole, frowning at somebody off-camera as she stood knee-deep in a river. Jenna sitting atop some promontory somewhere, with all the sky behind her, having hiked all that way. Jenna pregnant by the ocean.

Jenna and her baby son, both of them bald as cueballs, grinning the same grin.

Here is the secret of being a nurse: your memory becomes a library of people who are no longer here. Sometimes that makes you feel like there's been too much grief. Sometimes it makes you angry at a God that you're not even sure exists, because if He or She did, then why would we need children's hospitals or funerals where toddlers are in the front row? Mostly, though, it just makes you thankful.

I didn't make a huge difference, or do anything heroic, or actually do anything special. All I did was break my personal rule and become friends with a patient. This time, that person died. This time, I was stupid and opened myself up to that horrible feeling of not having done enough, the feeling of having failed a person who is much better and kinder than I will ever be.

And next time, I will do the same damn thing all over again.

I got lucky this time. I met Jenna, and I am proud to have been her friend. She was good people.

And I will never, ever, ever forget her.

Things of which I will never tire, part three thousand and forty-six:

1. The look on an attending's face when the nursing staff in the NCCU actually knows something. We read our patients' charts before the shift begins, we review lab results, we read EKGs and check out the results on CT scans and EEGs. Yet, for some reason, the attendings will never get over that first, pure shock of a simple nurse knowing something he (usually "he") doesn't about a patient.

(Nota bene: this is not all attendings, just a couple. Dr. Vizzini and Dr. Manbags come to mind.)

2. Pure thankfulness from a resident when we solve a problem or save them from a hideous fate. Dude/ette, that's what we're here for. You got problems? Yo, we'll solve them. Check out our scans while the 'puter revolves 'em.

3. The patients who say they don't want to take metoprolol/metformin/insulin/hydralazide for their problems, because they "don't want to mess up (their) bodies with medicine." These patients fall, generally, into two camps:

     a. The patient, male or female, with an A1c of 10, a resting systolic BP of 210, and a creatinine of
         4; or,

     b. The patient, female, with acrylic nails, bleached hair, Botox, breast implants, and liposuction,
          who has had her mercury amalgam fillings removed because they leak "toxins" into her
          bloodstream.

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

Yes, I've been a long time gone. For that, I do truly apologize.

Back in December, the fine folks at Mind Over Media, the people who'd been my liason with Scrubs online magazine, informed me that my services as an essayist would no longer be necessary. (Nothing wrong on my part; Scrubs decided to go in a more fashion-related, nurse-o-nality {dear sweet baby Jesus} driven direction).

I realized quite suddenly about three weeks ago that I'd been blogging, or writing weekly essays for some company or other, for more than twenty years. It started in the early 1990's with a website called ParentsPlace and went from there. I also suddenly realized, about three weeks ago, that I hadn't written shit for HN, and it actually felt pretty good. So I continued on, not writing anything, until I had had enough "I've got to blog this" moments at work and in my personal life to make it worthwhile to put fingers to keyboard again.

It's a little strange, having dissected both my personal and professional lives for--hang on to your asses--twelve years!! to suddenly stop, but I think it was good. I quit looking at life through the lens of bloggable versus boring, and had a break from trying to stage things in writing in my head. Maybe the quality of my stories will improve? Perhaps that's too much to hope, but it's been an instructive, and very pleasant, break.

Thanks to all of you who wrote, wondering if I had been abducted by aliens, the Zeta cartel, an underground supplier of international supermodels, or PETA. I am fine, and I appreciate your concern.

That said, I have to make lunch for tomorrow. We have a brand-new attending, just hired on, whom we have to break in. My job will be getting him used to reports that contain Queen lyrics.

"Take a right by the porta-potty, then a left after the second backhoe."

If you were to come to Casa Del Doghair, those would be the directions you'd get.

Every five years or so, Littleton's infrastructure guys decide it's time to replace the gas lines/sanitary sewers (that's how they refer to them: "sanitary sewers." I would hope there's no other kind)/water lines/electrical distribution system/various bits of asphalt in my neighborhood. This month, it's the sewer lines.

Do you have any idea how big sewer lines can be? I did not until this week. Apparently, replacing several thousand linear feet of sewer lines requires backhoes, something The Boyfiend calls a backtracker (on reflection, I think he made that up), a crane, and a whole shitload, pun intended, of disturbingly large plastic-and-metal tubes. These things are large enough to get lost in. And right now, five of them are piled up on what used to be my side yard.

So be careful if you come visit. Don't climb on the equipment. And for God's sake, don't cut that left after the second backhoe too close, or you'll end up ten feet underground in a big hole, with a bunch of men in orange vests staring down at you.

In non-sanitary-sewer-related news, nursing, both as a job and a concept, is eating my lunch. Mostly as a job. The concept of nursing is fine and dandy and I'm still all up in its metaphorical grill, but the practice? is leaving some tread marks across my back.

Part of it is the new residents we've got at the moment. We trade out residents more frequently than just once a year, so every four months or so, it's like July all over again. Not all of 'em leave, of course, but we get enough new post-grad-twos and threes to make things exciting. Here's an example:

SCENE: Interior, day, conference room. Six doctors are milling about, drinking coffee and PSLs and munching on PowerBars.

DOCTOR ONE: Okay, you guys. We have a full house today, so we've got to move somebody out of the unit. Who've we got that can go to the floor?

DOCTOR TWO: Um. . . .let's see. We have three TIAs that are stable and almost done with their workups. We have that patient with the left MCA stroke who's waiting on rehab placement, and the lady with the cerebellar stroke who needs a cardiology consult. Oh, and then we have that one guy with rhabdo, in status, with an insulin drip, who we're working up for DIC. He's four hundred pounds and in four-point restraints, too.

DOCTOR THREE: Sounds to me like we ought to move out the rhabdo.

DOCTOR ONE: Great idea. You write the orders and I'll let bed control know. Oh, and listen: be sure you write an order for strict ins and outs and put in the notes to nursing that they have to d/c that Foley immediately, okay? 

I'm spending Thanksgiving with the weirder half of The Boyfiend's family, in a prepper compound, with feral-hog hunting as part of the weekend's entertainment. At this point, I am looking forward to it.

And maybe, before I go back to work, I'll end up at the bottom of a deep hole under a backhoe with a bunch of men in orange vests staring down at me.

Whaaa. . . .what? Wait, what?

The family member insists that I called her a bitch during report.

Okay. (Nods head.) A reasonable assumption.

Except I didn't. I see no point in prejudicing another nurse against a patient's family member, or using profanity during report. As opposed to the rest of the workday, when I'll happily use profanity whenever.

But this particular family member? The one who threatened to sue because the room wasn't big enough? The one who tried to get her aunt arrested for simply visiting the patient? I wouldn't call her a bitch, even in an undertone, because that would get me in trouble. I still have some self-preservation instincts left, even after more than a dozen years. Besides all that, she was worried, but not necessarily a bitch. I took the reports of her calling out security and all the other crazy behavior with a grain of salt; a lot can happen when you're stressed.

My boss, who is a thoughtful, reasonable woman, heard the news with a mild snurk and let it go on past. My explanation to her was "I got no defense; I can't help you on this one," and she took it as read and filed the complaint in the round-file.

But still. Why on earth would you say that about somebody who's wiping your father's butt, not to put too fine a point on it? Why would you try to turn all the other nurses against one nurse with an alleged (admitted) foul mouth? Are you truly that mentally ill, that you need to have an adversary in every single interaction you have with the outside world?

If people ask me what my least favorite aspect of my job is, I tell them this: it's folks who have a habit of conflict making up conflict where it doesn't exist. It bothers me, not on a personal level--because my conscience is clear--but on an existential level. What makes some people nuts? I don't get it.

I seriously don't get it.

But I'm not going to call you a bitch just 'cause I don't understand you.

Today, Raji came to me. Raji's about as Indian as Indian can be.

Perfect vase-shaped figure, long black braid, gorgeous gold earrings, and a bindi. Raji is recognizably Indian. And she came to me with the revelation that my confused patient had called her "Senorita."

I explained that he'd probably seen the long black hair and the honey-colored skin and thought that she was Hispanic. She laughed and laughed and laughed.

Later, when I'd had a minor disagreement with an attending (more on that in the days to come), she exclaimed, when I mentioned his recognizably-Indian name, "Oh! I thought he was Hispanic!"

"Hello, Senorita!" I responded. "How are we supposed to have world peace when y'all can't recognize each other from across the room?"

This is what passes for humor on my unit on a hard day.

"Why don't we ask the patient?"

Marcie and I had One Of Those Days a couple of weeks ago. Dr. Vizzini had to go do something neurological halfway through the day, so The Golden Boy took over for him in the afternoon. He gathered his residents like ducklings and re-rounded on all of the patients in the unit.

Marcie had a guy getting ready to go home. He'd had a very minor stroke in a very minor place, and was essentially without any aftereffects. He also had Stage IV cancer of the something-or-other--I don't remember what; I was busy myself--and was on so many anticoagulants it was ridiculous. (Cancer can make a person more prone to blood clots.) The fact that he'd stroked while on an injectable anticoagulant and a couple of oral ones was weird, but not unheard of.

So Mister Man was getting ready to blow that popsicle stand when The Golden Boy decided that he needed umpteen more blood tests, a couple of fairly-invasive scans, another MRI, and some other tests run. To see, you understand, what exactly could be causing him to clot. The answer to which conundrum was "metastatic cancer, DUH," but TGB wanted an exact answer. Like, down to the molecular derangement level.

And Marcie, being the sensible person she is, argued. She pointed out that we had at least a general idea of what the problem was (metastatic cancer, DUH), the patient had a limited amount of time to be futzing around with, and nothing we did at this point was going to make a damn bit of difference. There was, after all, no change we could make to his already-maxed-out medications to lower his risk of stroking again. More tests would mean at least two more days in the hospital, more discomfort, possible complications, and added cost.

Golden Boy argued back that it was incumbent upon him as a doctor to get to the bottom of the problem, and that doing less than that wasn't ethical. He had a couple of other arguments, but by that time, both my hair and my pants were on fire and I wasn't really listening.

Marcie and TGB argued politely back and forth for a few minutes, and then Marcie said something that you never, ever, ever hear somebody in a hospital say:

"Why don't we ask this guy what he wants to do?"

The Golden Boy was taken aback, but he did it. Our patient decided to head home and follow up with his oncologist as an outpatient. And just like that, problem solved.

It's interesting that a doctor would be shocked by another member of the care team wanting a patient's input into what happens to the patient. I mean, we do it all the time for big decisions like end-of-life care, but not as often when we're doing normal everyday stuff. Why not, I wonder? I mean, it's not like being in the hospital automatically robs you of the ability to make good decisions about your own health. It's more like being in the hospital sends you back in time to a more paternalistic day, when Doctor Knew Best (except for when you have a medical directive, and sometimes even then).

It's so simple, really. Ask the patient what they want to do. Just ask.

People who love my hair and people who do not.

I just ran the clippers through my hair. It's my every-two-week routine: pass a pair of clippers with a #3 guard over my head, then fade out the sides and back with a #2. Then, carefully, measure out an ounce each of color and developer and apply it to the stubble on my head and let it rest for twenty-five minutes. When I remember, I dye my eyebrows as well. My eyebrows have gone white, as has the hair at my temples and the nape of my neck, and it's nice to have at least an outline to pencil in in the mornings.

Here are the people who love my hair:

1. Black women of any age. "Rockin' that 'fro, Boo" is what I hear from Friend Lisa at work, and I hear its equivalent from other Black women of varying ages, all day long.

2. Black men in their 60's. On Sundays when everybody comes to visit their fellow parishioners in the hospital, Black men Of A Certain Age are complimentary of my buzzcut.

3. World War 2 veterans of any ethnicity. It's surprising how many centenarians and men in their 90's comment favorably on a woman with really, really short hair.

4. Punks, people with excessive numbers of tattoos, and people with piercings in places you wouldn't necessarily want piercings. The fact that I have no hair breaks down barriers.

5. White women who've had cancer and who miss the ease of a buzz, but who hate the psychological implications of no hair. I can totally understand that. After my surgery, I grew out my hair to prove to myself I could, then cut it off on my 43rd birthday because I hated having to keep up with it.

And here is a comprehensive list of those people who hate my hair:

1. My dad. Bless his heart, I don't think he'll ever imagine me with anything but the curly, wild, shoulder-length red hair that I had in my early 20's. I feel bad for him. Not only is curly, wild, red hair a distraction and a pain in the ass to take care of, it's just. Not. Me.

Sometimes I wish I could go back to the days when Beloved Sister took a picture of me, all hair blown by the wind, on the beach near San Francisco. What that picture doesn't show, though, is the stress and horror of being in California when I didn't want to be, the stink that came from my hair not reacting well to California water, and the exhaustion of trying to keep together a marriage that was coming apart.

Mom is undecided. I think she thinks something chin-length with waves might be more flattering, but she understands the discipline of long hair and why I can't deal with it.

Here is why I love my town.

If you were to look at a map of Texas, you probably wouldn't notice Littleton at all. It's not one of those places where a river runs through downtown, free to everyone, or where huge concerts take place or where there's even a top-ranked university. It's just a small town, kind of stuck on the outskirts of a big city, but emphatically not a suburb. It's its own place.

That's why I love Littleton. The rents are cheap and there's a big airport nearby, yes, and the air is clean and coyotes and foxes and various other small animals roam through downtown (somebody found a litter of bobcat kittens behind a bar a few weeks ago and turned 'em into animal control, who is rehabbing them and re-wilding them), and it's peaceful and bucolic. And it's determinedly independent.

There are trains that run through the middle of town, just two blocks from the courthouse, every night. And every night, pretty much, you can hear the train horns blowing in some new and interesting signature way that the guys who drive them have developed. Yes, it's policy that they blow a short-short-long prior to reaching a level crossing, but the engineers have ditched the computer-programmed horns for Littleton and do their own thing. At Christmas, they blow "Jingle Bells" and "Rudolph The Red-Nosed Reindeer" rather than the usual signals.

The H.E.B. here (that's a local grocery chain) plays KISS and Ingrid Michaelson and the Bee-Gees over the speakers in the store. Rather than the usual boring "come get our chicken it's fresh between eleven and four and only a dollar ninety-nine" announcements, the staff say things over the PA like, "Is your life missing something? Do you feel empty inside? Try some CHICKEN! Fried or baked, it can bring new meaning to your existence!"

The Boyfiend's lawnmower was stolen last week and returned within three hours, thanks to the efforts of the local PD. Though they have pursuit cars and a bomb squad and a mobile emergency management truck, the officer still responded with "That sounds like Steve. Dammit. Steve needs to stop stealing lawnmowers" when he took the report. Despite technology, our PD is still small-town enough to be exasperated with the one crazy guy who makes a habit of liberating lawn equipment.

The city fathers decided to lock up the free public electrical outlets around the courthouse, but only after people started pitching tents there and setting up full-sized refrigerators that ran off the city's electricity.

We get the traffic from South By Southwest, but none of the other headaches. Bars that have live bands put up signs that say "OH MY GOD BECKY LOOK AT HER BOOKING" for that week. Gas is cheaper here, and the gas station is likely to have Mexican, Indian, or Korean home-cooked food for sale. The place I buy my beer smells of incense and kimchee.

There are four terrifying barbecue places where the meat melts off the bone and you're not advised to ask about preparation, and three terrifying Mexican places that have excellent strange salsas you've never tried before. Oh, and that little Japanese restaurant that will serve you amazing sushi if you shrug and say, "Whatever the chef wants; I'm not particular."

Soul food is cheap here. Grits are an option with everything. You can be literally thrown out of a bar, onto the street, on your ass, if you misbehave. Yet the patrons of the local gay bar will leave you alone if all you want is a beer and a book. There's a running club that meets at a local bar, three bike clubs (road, mountain, and casual), and a bird-watching group. There are two breweries and a dude who bottles home-made ginger ale and flavored seltzers. There's a soap company, two of those places that will sell you boxes of vegetables every month, and some guy who runs a barber shop out of his pickup truck and specializes in beards. Drag queens are an everyday sight. Nobody turns a hair at people of different/the same ethnicities/sexes holding hands in public. The library is one of the finest I have ever seen, and is enthusiastically supported by the locals. The city council is made up of a lawyer, a stay-at-home mom, a guy who runs the vegan restaurant, a history professor from one of Bigton's universities, some woman with oil and gas ties who is retiring this year thank God, and a couple of random business owners who want to legalize pot and skateboarding.

I was shopping today and had to do the excuse-me-I'm-in-your-way dance with a seventy-ish man in the soup aisle. It turned into a full-on dance-off and ended in a tango.

I love my town.

Happy Lumpiversary and 'Bye, Felicia.

Five years ago I was sitting in my dentist's chair when his hygienist found a lump on my hard palate. The lump, known as Cap'n Lumpy after that, turned out to be a rare-ish form of minor salivary gland cancer called polymorphous low-grade adenocarcinoma.

It started a year-long freakout on my part, most of which is documented on this here blog, that culminated in my wearing a cool plastic-and-metal prosthetic to replace the chunk of my mouth that a surgeon removed.

I'm not sure how I feel about this, so I'm gonna just mark this lumpiversary and leave it be. I have the latest set of scans (CT and MRI) coming up week after next. I'm not sure how I feel about that, either. Maybe it'll be easier once I transition to once-a-year rather than once-every-six-months scanning; maybe it'll be a whole new kind of hell. We'll see.

In other news, Keith is gone. I don't know the details, having been on vacation this last two weeks, but he's been relieved of his duties at Sunnydale and has gone back to the pit that spawned him. It probably had something to do with a patient decompensating to the point that she had to be intubated on his watch, with nobody but him being aware of it. I don't know. All I know for sure is that I can work now without having to worry about somebody else's patients as well as my own.

So. One okay thing, one good thing. Not a bad way to start off the new year.

The best new nursing blog out there is "Florence Is Dead."

If you want smart, funny, badass commentary on the nature of nursing today, go read Florence Is Dead. It's a brand-new blog, but already it's creating waves. The Diet Coke Incident has some of the most bloviating ridiculousness in the comments section that I've ever seen.

In case you couldn't guess, I agree with pretty much everything Dead Florence writes. The one place we differ is on the scrubs issue: she'd like to see professional dress for nurses, while I stand firmly on the side of scrubs. The primary reason for that, you understand, is that I cannot dress myself. Other than that one disagreement, though, I'm firmly in DF's camp.

Go check it out. I got very excited when I stumbled across it (can't remember for the life of me how that was, sadly). Give her some love in the comments section.

Let's talk a little about patient satisfaction, shall we?

About a year ago, after Eric Duncan died at Texas Health Presbyterian Hospital in Dallas and two nurses who cared for him were hospitalized with the same disease that killed him (Ebola), Texas Health Resources got an independent committee to review what went wrong. It was like a root cause analysis, but more so: these were outside doctors and one nurse, they weren't paid, and they were given access to everything that was charted and all the folks involved in the Presby debacle.

They came to a number of conclusions: first, that education was lacking--the staff wasn't aware of what exactly to do in case of a person with Ebola coming in; second, that communication was poor--the nurse who took Mr. Duncan's health history didn't communicate verbally to the doc that he'd come from an Ebola-affected area; and third, that the fear of poor patient satisfaction scores led the doctors and nurses to rush Mr. Duncan through the ED that first time, in order to keep other patients from waiting and getting mad.

The fear of poor patient satisfaction scores caused the staff and doctors to rush the diagnosis of a man who had been in an Ebola-affected country.

Read that again. The fear of poor patient satisfaction scores caused the staff and doctors to rush the diagnosis of a man who had been in an Ebola-affected country.

I don't know what it's like in Dallas, but here in Bigton, every medium-sized hospital and most of the smaller ones have billboards touting how fast a person can be seen in their various EDs. Some of them even have big neon numbers that show the current wait times outside the hospital itself. A few even have those big neon numbers on billboards on the highways.

The entire focus of emergency-room care has become, at least in this area, about how fast you can be seen for belly pain. Or a broken arm. Or allergies. Yes, they advertise ED services for seasonal allergies. And it's all about the time it'll take for you to be seen. Come in with a head injury following a fall or a sore back that's been going on for a month? Doesn't matter--our goal is to have you back in a room in ten minutes or less and have you out the door in half an hour.

At the beginning of flu season here in Texas, that emphasis on speed, which is translated to patient satisfaction by administrators, contributed to already-stressed doctors and nurses missing a diagnosis that turned out to be fatal.

(There's a lot to be said on the communication front as well--why was the flag in the chart that the nurse filled out not enough to alert the doc? Was he, perhaps, rushed? Why the emphasis on verbally informing him of something, when the nurse might not actually see the doc face-to-face all shift because they're both busy? That'll have to wait, though.)

Let's take this down a notch. At Sunnydale General and Holy Kamole, there's a big push on to satisfy patients in every way possible. Press-Ganey cards are sent to each and every in- or out-patient within a week of their leaving the hospital or clinic, and the results are taken very seriously.

I work in a critical care unit. It's likely that the patients that I see will go on to spend a few weeks either on a floor or in rehab or both, and may or may not remember their time with me. Brain injuries tend to wipe out short-term memory. Even if they do remember the NCCU, they probably won't remember me by name. All this leads to a very minor chance that they'll be able to fill out a card that mentions me specifically.

Yet if I'm not mentioned by name by at least one patient in a year, preferably by two or three, I won't get a point on my employee review. It doesn't matter how many students or new nurses I precept, how many errors I catch, or how often my patients have good outcomes. What matters is that somebody who's stressed or ill, possibly without family support, remembers my name (perhaps weeks or months after seeing me for a day or two) and takes the time to mail back a postcard with my name on it. Missing that point can make the difference between a raise and no raise, or between a satisfactory or unsatisfactory review. It's weighted that heavily.

We no longer track how often certain nurses' patients get bedsores or UTIs or end up going back to the CCU. What we track now is how often they're praised by patients or family members.

As a result, I find myself doing all kinds of crazy shit to get people to remember me. We're not allowed to hand out the Press-Ganey cards or special-mention cards ourselves, so it's up to us to do everything possible to make ourselves stand out. Most of the time, for me, it's staying at the bedside a little longer to explain what's going on with the care plan, or the physiology of the disease we're dealing with, or why the patient is on a ventilator or has this or that tube.

Sometimes I have to sweeten family members or patients who are determined to be upset. I act as counsellor, waitress, and gofer. A lot of times, those patients or families take me away from jobs I ought to be doing just so I don't end up with a complaint--I didn't get them a cup of coffee, or something. If I have a patient I'm worried about because her neuro status is changing, I have to weigh the consequences of letting her go for another ten minutes versus the consequences of being seen as not "patient satisfaction oriented" enough.

The worst example of this happened after a patient, who was fully in command of all his faculties, took a swing at me. Only a complicated move reminiscent of the "Matrix" movies kept me from a broken skull. Afterwards, the assistant manager told me I had to go back and make nice with the guy. I told him no, that I would not, and further, that if he or any other patient ever tried to hit me again, I would be calling the cops and pressing assault charges, and maybe suing the hospital for making my work environment unsafe. I refused to reenter the room.

I got a note on my review that year that said "Jo is an excellent clinician but needs more work on her relationships with patients."

For all you folks who want to point out that service is part of nursing, and that serving is a holy and higher cause, you go right ahead. I serve every day that I work, from before the time that I punch in to whenever the job is done (whenever that is). Service to my fellow humans, though, does not mean martyrdom or risking personal injury. It certainly doesn't mean putting a patient's satisfaction scores ahead of their health or safety.

If you, Administration, want me to be a good nurse, then let me be a good nurse. Let me educate and comfort and calm. Let me commiserate and be compassionate and do all the things that I was trained to do, including catching med errors and fixing problems. Don't push the patient satisfaction side of the equation so hard that you forget what you hired me to be: the first, last, and best guardian of my patient's health and safety. Don't confuse happy people with good outcomes.

And for God's sake, and the sake of your patients, don't push my profession into waitress/hostess mode so hard that we all forget what nurses are here for.