A well-oiled machine.

"What you need to do," the house supervisor said to me, "is learn to lower your expectations."

"Fuck you," I replied, with a sunny smile.

We'd just gotten a patient in, a guy in his fifties who was, according who what we'd heard from the house soup, status post-TPA, hypertensive as a habit, with a dense left hemiparesis. We'd heard that from the house soup because there had been no report from the outside ED from which he'd come. There had been no warning that the patient was on his way; we'd been waiting since early afternoon and it was now five minutes from the end of the shift. Of course.

Luckily, the dude could talk. Peej and Bethie moved him on to the bed and Peej took a first set of vitals.

His blood pressure was 80 over 44.

(Note for the non-medical among us: 80/44 is a perfectly respectable blood pressure for, say, a teenage girl who runs track. It's not good for a guy in his fifties, and it's *especially* not good if said guy has been running, since time immemorial, in the 150's over 90's or higher. Your body gets used to a certain amount of blood going at a certain pressure to all your organs, and something much lower or higher than that usual can cause problems.

A low BP, in particular, can lead to hypoperfusion of the brain, especially after an ischemic stroke. That means that all your stroke symptoms come back and further damage is done because there simply isn't enough blood, at high enough pressure, to fully supply the brain tissue.

To give you some idea of how important perfusion is, we normally allow our patients to run as high as 180 systolic [the top number in blood pressure] and 110 diastolic [the bottom number] after a stroke that's been treated with TPA. We definitely want to keep them above 100 systolic.)

Peej read out the number. I called to Bethie to bring a bag of normal saline and tubing, and started to trend the bed such that New Dude was lying with his head down and feet up. After determining that he didn't, as far as he knew, have congestive heart failure or any allergies, Peej started a bolus of fluid. Bethie called the doctor's lounge, trying to raise somebody--anybody--with an MD after her name to come and check New Dude out.

Just then, New Dude's left side started working again. He said, "Hey! I feel less dizzy! And I have to pee."

And with that, Doc Paul showed up and the night shift took over.

The unusual part of all of this is that both Bethie and Peej are new to stroke. Peej is a new nurse, flat out, having just finished her internship. Bethie did epilepsy stuff for years and worked on an HIV unit in the bad old days before protease inhibitors, so she's experienced, but strokes aren't her thing.

Peej is tall and slender and graceful and serene. She wears her hair in a bun, but that's not why people ask if she's a ballerina--it's her unshakeable poise and excellent posture that makes them think she dances. Bethie is me in a few years: foul-mouthed, fratchety, sarcastic, and with an amazing collection of weaves and wigs. Nobody, looking at the three of us, would ever suspect that we could work together well, let alone be friends.

But we did and we are. It was a minor crisis, not somebody spraying blood all over the walls, but Peej especially handled it beautifully. When I was six weeks out of my training, I panicked when faced with the same situation. Peej never broke a sweat, even taking time to explain to the recently-arrived family what was going on. I am very proud of her.

And we are, in my words, a well-oiled machine.

Or, in Bethie's words, "A fuckin' well-oiled fuckin' machine, man."

The Human Body: Major Design Flaws Edition

Knees: Why do knees have to bend the way they do, and why are they so out-there and unsupported by something stronger than ligaments? If you go sideways just once, everything stretches out of shape and you're left with a dicky joint forever. Plus each joint has to handle all the weight of the human body on an angle (especially if you're female).

Elbows: Same thing, but with a really limited range of motion. Silly idea.

Temporal Bone: Why such a thin casing over the brain in just a couple of spots? If you're gonna have a solid barrier of bone, make it thick all the way around.

Cervical Spine: "Hey! Let's put an eight-pound lump of bone and meat jello on top of this stack of bones filled with meat jello, and make it really vulnerable to breakage or stretchage!" As an extra added bonus, nothing else in the body will work if you fuck part of this system up.

And we can't turn our heads 270 degrees the way owls can, and we have a bad layout of large vessels in the neck. It's just a fail all the way around.

Urethra, female: Who thought of putting the opening to a system that must remain sterile in the middle of a soup of bacteria, some good, some bad? Who, having done that, would think it wise to make the entrance to that sterile system only a few centimeters long? This is, mind you, without the acidity of the mouth or the protection of mucus to keep bad bugs in check.

Prostate, male: Oh, come *on.* How did "secretory gland inclined to swell and block the flow of urine" get design approval?

Any area through which a nerve has to pass: Let's make it really, *really* small, then add a bunch of stuff around it that's likely to swell and irritate the nerve. Brilliant.

The lack of regenerative capabilities: IKEA could design a better body overall. If something breaks, you just limp on in to the Meat Part Store and buy another bit to screw on with a teeny Allen wrench.

No, I'm not feeling bitter today. Why do you ask?