Wednesday, March 30, 2016

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.

Wednesday, March 16, 2016

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.

Tuesday, March 08, 2016

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.

Friday, March 04, 2016

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:

Thursday, March 03, 2016

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.