Okay, so you've been a nurse for a year or so....now what?

Julie and I were sitting in the monitoring room the other morning before report, just enjoying the glamorous and exciting life of the nurse, when she made a comment that I remember making:

"I've been a nurse for a year, and I am so burned out. I can't wait until I actually know something."

(Now, before any of you older nurses snicker over the "burned out" part, think back: remember how it felt to be overwhelmed all the time? Yeah. Like that.)

I think everybody feels that way after the first year, and then again after the second. Not to give you false hope, or anything, but after the second year of practice, nursing gets a whole lot easier. The question of *why* it's so hard the first two years, though, is something that it might help to understand. Heck, it might keep you from flinging yourself in front of a fast-moving laundry cart, even.

The first year of nursing is a combination of one part sheer terror and two parts cluelessness. It doesn't matter how well you did in class with pathophysiology or nursing diagnosis; things are much, much different when seen in 3D. Looking at a lab report with wonky numbers and figuring out what's going on in the classroom is miles away from looking at the same numbers at the nurses' station as call bells are going off, doctors are rounding, and your patient has sixteen other things going on that distract you from those numbers. I like the simile that another colleague of mine came up with: Nursing school is like learning to put together a jigsaw puzzle of a cathedral, while practice is like being handed a bunch of stone blocks and being told to build that church.

"Burned out" isn't really the right term for it. Most of us still want to come to work, and most of us aren't especially depressed by our choice of career. It's more like your brain feels full all the time, and you never really get a chance to integrate things. You *know* you're learning stuff, but it's either not really sticking (even though it is), or things are happening so fast that you have a hard time with recall (even though you don't).

Plus, you keep feeling like you're totally ignorant. (You're not.) Again, it's that jigsaw puzzle versus cathedral-building thing: you have all the information you need, but it's hard to put it together on the fly.

And, if all of that weren't enough, you're refining your routine and your time management and the way you deal with people and doctors and other staff members and learning who to call in the pharmacy when the dadratted drug machine won't dispense and what to eat and what to stay away from in the cafeteria and where the best bathrooms are and.....*whew*.

The good news is that the feeling of being constantly overwhelmed goes away. The bad news is that it's replaced, during the second year, with "is this all there is?"

There's a good reason for *that*, too. During the second year of practice--and keep in mind that these timetables are fairly arbitrary and mostly based on my own experience--you've got the basics covered. You can make a bed with a person in it, you can lever a body up off the floor without hurting yourself or them. A crazy-low potassium or calcium level won't make you panic, and you know who to call at 3 am for those problems.

The trouble is that you're....well, you're kind of disappointed. Things seem a little dull.

That feeling passes, too. It's there because you've absorbed all the things you need to do your job *efficiently*, but you're not quite to the comprehensive detail-management, weird-complication-anticipating point. That comes during the middle or end of the second year, and things therefore suddenly get much more interesting.

The biggest change in my practice between years two and three was this: I began to be able to see, sometimes even days in advance, what might go wrong with a patient. My care up to that point had been competent, but shallow. After two-and-a-half years, it deepened, as everything that I knew and everything that I could imagine anticipating came together in a cohesive whole.

The human brain recognizes patterns. Part of the brain's development is the ability to recognize patterns *as part of a whole picture*. That's what happens during years two and three: the big stone blocks you've piled up begin to resemble a cathedral, because you're able to stand back and see the whole damn thing.

So hang in there. Don't feel like you're the Lone Ranger on this one--believe me, going from expert in one part of nursing to novice in another brings those feelings right back. If you're feeling overwhelmed still, remind yourself to look back in a year more and see how things have changed.

Because your brain will catch up and your practice *will* change. The stuff you need to avoid in the cafeteria, though? That stays the same.

Conversations with Ginny the Chaplain

Ginny stayed late tonight, ministering to a family whose father was out of his mind both with pain and with the effects of a glioblastoma on his frontal lobes.

We say the worst things to the people we love. We treat enemies better; we treat nurses best of all. Long ago I recognized this, and I try to reassure the wives and sons and daughters of the absolute faith that abuse implies, but sometimes it falls short.

Somehow, having a six-foot-four female Baptist chaplain tell you the same thing has more effect. I can't imagine why (she says, from her five-foot-two height).

They abuse you if they love you. That's a weird, twisted sort of love, and not one I'd like to champion even at the worst of times. Yet it happens, most often when people aren't in their right minds; aren't themselves.

Sometimes, blessedly, we get the chance to say: Do not love me. I cannot be the person you love.

I had that chance this week, both with a patient and with a person who was not a patient. In the first case, I was able to say it out loud; in the second, silence was the best response.

Do not love me. I will hurt you later, by sticking a heparin injection into your belly, or a cold shot of insulin. Do not love me: later, when you are not expecting it, I will not be able to be what you need or want; my brain doesn't work that way.

It's very simple, love, and it makes no difference at all. Sometimes, at 00:41, you're dealing with somebody who loves you simply because they're jacked up on pain meds and crazy from a tumor. Other times, at more reasonable times of day (for those of us who don't work nights), you're dealing with somebody who's totally with it and who has taken time out of a busy day to say, "You know, I do love you."

Either way, it makes no difference at all. Love is a changeable thing. It makes us capable of hurting the people closest to us. It makes us capable of making promises that nobody could ever keep. It makes us capable of acts of cruelty that we'd never consider if we didn't feel that particular way about the person on whom we're dumping.

At the end of the day, love makes no difference at all in the present moment. It's a nice memory, and it's a nice nostalgic thing to look back on, and it's a nice, sentimentally valued emotion, but it allows such violence, and such awfulness.

I am looking forward to the day when I'm not up in the middle of the night, blogging at my workstation, minimizing the page every time another nurse walks by.

I am looking forward to the day when I can live my life like I did in microbiology, all those years ago: without emotion, looking only to the evidence in front of me to tell me whether this thing the professor had shoved at me was TB or gonorrhea. Somebody get me the ethylene blue; I'm jonesin'.

Night nurses are the strongest people I have ever met. Remember this: the person who works with your family member overnight hears things, and sees things, that no other person ever does. And somehow, some way, they have to deal with it.

I have Ginny. She's a day person, and she's as clumsy with words as I am in motion, but she's almost enough.

A Beginner's Guide To Working Nights

(In that I am a beginner at working nights)

So: you just got your first assignment as a nurse, to work nights. Holy crapping monkeys, you say, what the hell am I gonna *do*? How will I live opposite the rest of the known world? What if I can't sleep? Auntie Jo is here for you.

Understand that some people are natural night shift workers, some can never adjust, and others can adjust fine but still hate working in the dark (I'm one of those last). If your preferred living schedule has you getting up at noon and staying up until four am, you're golden: nothing here will apply to you, and you can look forward to a long career of greater autonomy, bigger paychecks, and reverse commutes.

If you hate working nights and can't adjust, well, there's not a lot I can do for you either. Some people just can't do it; no shame in that. I have a number of colleagues who did their requisite two-to-eight months on night shift and were miserable the entire time. Some people just never do feel better about staying up until the wee hours.

But if you're determined to Make It Work, or if you're like me and can do nights with a little encouragement, here are some ideas:

1. Snacking is key. Seriously. Your metabolism is so whacked-out by going against your circadian clock that you'll probably pendulum between ravenously hungry and nauseated all night long. Don't expect to eat big meals; instead, take a variety of small, protein-rich, healthy snacks to work with you and munch. It'll help keep you awake, fast on your feet, and (if you choose beans rather than Bugles), keep you from gaining the dreaded Nursing Forty.

2. Sleeping is also key. Whatever it takes to get you to sleep during the day is fair game. For me, blackout curtains and a single beer put me down from nine a.m. to four p.m. Other people might need to add earplugs, white noise machines, or even prescription sleep medication: again, no shame. Do what you need to do to sleep.

3. Manage your expectations. A lot of new nightshifters try to "flip" on the days they're off--that means they try to maintain a normal daytime schedule after working nights. Most of them can't, and end up crashing around lunchtime. Keeping a regular schedule is important, especially if you get only a day off between shifts.

4. Get out in the sun when you can. I know this seems contrary to the previous piece of advice, but it's true: getting some natural light (not even sunlight, but natural, from-the-sky light) can do wonders for keeping you from getting depressed and frustrated.

5. That old saw about a fifteen-minute shower being equal to eight hours' sleep? Is true. Don't make any decisions about anything until you've poured a substantial quantity of hot water over your head. This goes whether you're working that night or not. It's amazing how far a little soap will go to make you feel Almost Human.

I'll be honest: I hate, hate, hate, hate, hate, loathe, and despise working at night. I have to, though, until a day-shift spot comes open. For me, the worst thing about it is the feeling that the crushing depression I've had to deal with in the past is just on the edge of returning. I'm snappish, bloated, grouchy, and weepy (Wow! Four dwarves at once!). I resent intensely having to be opposite everybody I know and miss out on stuff. I worry that my dog hates it, too.

Plus, it affects my brain badly, and thus affects my writing, and we can't have that. (The memory loss is a little unnerving. I hope it goes away as I get more used to this.)

But I'm doin' it. I'm doin' it by taking advantage of the small bursts of energy I *do* have. I'm managing to sleep all day, nap when I can*, and stay awake the rest of the time with B vitamins and caffeine. However long it takes, so long as it's not more than a year, I can manage. I may not like it, but I can manage.

I'll put it this way: working nights is less of a pain in the ass and frustration than having a sprained knee has been.

*The other night I had to go down to Radiology with a patient. The patient was getting an MRI that was scheduled to last 90 minutes. After the first half-hour, the MRI nurse (yes, we have one down there all the time) took pity on me and sent me off to the CT sled with a pillow and some blankets. I had an hour of blissful, lovely sleep while she watched the monitors for me. Thank you, thank you Emily, for that nap.

Rules for Residents Redux

Actually, let's call this Rules For Everybody. Auntie Jo has some bones to pick.

Number One: I do not intimidate well. Please don't try.

The night supervisor threw a pissfit at two o'clock this morning because I was sitting in His Chair, using His Computer. Silly me; I had thought that it was just another computer at the station, and just another chair.

Rather than asking me to please get my ever-widening ass out of said chair, though, he went on and on about how he hates it when people sit in His Chair and use His Computer.

"All you had to do was ask me to move, Mark" I said.

"I hate having to tell people to move!" he said.

"You just did. About six times."

Shit like that wears me out. I am not cute when I'm tired. Save us both the trouble and don't get all puffy-chested on me, okay?

In other words: the queen of passive-aggressive taught me well. I can recognize that shit a mile away, and Mama don't play.

Number Two: If you don't ask the question, I can't give you the answer.

I don't care how stupid a question it seems to you, or how stupid it actually is. If you don't ask me, I can't help you. Whether you're embarassed about your ignorance or you don't believe that a creature as humble as a nurse could actually know something you don't, you're tossing a shoe into the works if you hare off on your own. Just ask me. I won't laugh at you, I won't get annoyed, I won't sigh deeply and roll my eyes before answering. We are all here for one goal: to get these gomers out of the beds and up the stairs; anything that helps you helps me reach that goal.

Number Three: Say what you mean. Mean what you say.

Who'd'a thunk working at a hospital could be so much like working in government or dating? Not me, but it is. I guess it's just people that make living on this planet so difficult. It doesn't have to be hard, though: if you want something, ask for it (see above). Likewise, if you want something specific, ask for it directly, rather than bumbling around and wasting time. A simple order should be just that: a simple order.

Likewise, if you mean something specific, say what you mean. This is not hard. If I fuck up, tell me about it clearly and specifically and simply. I ask this boon not because I'm any dumber than your average bear, but because it saves time and makes life easier. Avoiding bush-beating also ensures that I won't make the same mistake twice.

Number Four: Just because we worked out that little problem doesn't mean I'm not watching.

Nurse Jo is like Big Brother: always watching. If you're the resident that lied about my calling and charting to both my boss and your attending, then you know that we've already resolved the issues of your idiocy and inelegant behavior. Don't think, though, that you get a free pass from here on out. I am not a vengeful Jo; I am, in fact, slow to anger and quick to turn again. I don't hold grudges, in other words. But I am also not an idiot; I know that if you tried undermining me once, you'll likely try the same thing either with me or with a coworker.

So don't.

Number Five, and perhaps most important: Never, ever, ever lie to me.

You would think, wouldn't you, that helping sick people get well would kind of, you know, push the whole issue of ego and self-aggrandizement out the window.

Well, it doesn't.

There are still people--mostly doctors, I'm sorry to say, although there are some nurses in there, too--who think that being busy or getting stressed or being unable to accomplish something is a direct reflection on their worth. It is not. Let me say that again: everybody gets busy, stressed, and overwhelmed. If you didn't manage something, or some test didn't get drawn, or you fucked up inserting that drain, it's okay. Tell me you screwed up, tell me you didn't get X done by Y time, and I will bust ass to help you out and make you look good. I look better when you look good, so it's really all self-interest.

That said, do not lie to me. Do not lie to me about why you didn't do something, or why something else didn't work out as it was supposed to.

Example: I had a patient who was on pressors to maintain blood pressure. I wandered into work, yawning, to find that the patient's blood pressure was not only sky-high--totally out of parameters--but also that her pulse was off the charts. The reason was that the nurse and resident together had hung a bag of a particular pressor, but used the IV pump settings for another, less-intense sort of pressor. These things require two signatures for a reason: if your eyes aren't good enough, another set helps to catch any mistakes you might've made.

The nurse's reaction was "Holy shit, did I ever fuck up." The resident's reaction was hemming and hawing, denying that she'd ever double-signed the checkoff, and blaming the nurse.

The mistake was fixed without harm to the patient, but the stuff surrounding it sticks in my craw: a mistake is no big deal. Everybody makes them. Lying to me about it, though, and attempting to blame the nurse/the phase of the moon/your mother? This is another one I'll be watching.

It's funny how, when I started the whole CCU thing, I figured that it would be a closer, more professional, less fraught environment. On many levels, it is. I'd already earned the trust of a number of the doctors and nurses down here; most of 'em have expressed surprise that it took me so long to move to the CCU.

On another level, though, it's much like living with somebody you don't particularly like, or with a brother or sister you don't get along with in such close quarters. Ego and emotion come into everyday interactions to a degree that I frankly find uncomfortable sometimes; there are turf battles and irritating complications that could be resolved with a little plain talk. Some mornings I come home feeling like I've just spent a long night dealing with an old boyfriend.

I had hoped to work in a place where brains mattered more than hearts. I'm finding that, even though it's still neuroscience, hearts (and egos) play into the whole damn thing more than I'd like.

The problem with the CCU.

They will not let you die.

That, right there, is the whole problem with critical care.

Regular readers here at HN are thinking, "Dude. Death again?" I say, yeah, death again. Because, let's be honest: it's not the people who get better and take two turns around the floor with the help of physical therapy that send you home at the end of the shift to stare at that six-pack in the fridge.

It's the purpose of a hospital to help people heal, and mostly we do pretty well. I'd say 95% of the people I've cared for over the years have gone on to have decent-to-exceptional recoveries, and that's coming from a nurse who works in one of the strangest branches of medicine. When something goes wrong with your brain, a whole lot of other things tend to go off the rails a bit, and when we get those fixed, well, there's still something wrong with your brain. Ninety-five percent is good odds, given those limitations.

And when you're used to seeing most of the people you work with get better, the ones who don't hit you particularly hard. Every death is a failure. Some are more FAIL than others; it's harder, naturally, to lose a patient who's younger than average, or nicer than average, or who just had a run of crappy luck.

Which is where the problem with critical care starts.

Critical care is, by definition, critical. Like, "anything could go wrong, so I'm going to be particularly paranoid" critical. Like, "let's hope this thing in your head doesn't bust loose all of a sudden" critical. Like, "we've tried everything, but the rare and aggressive blood dyscrasia that's killing your 25-year-old wife won't go away, so let's put her on three pressors and pressure-bag some fluids in and put her on a ventilator" critical.

That last is where my own personal sticking-point is. Sometimes, people have to die. I hate it as much as the next nurse, but I come from a background of watching people die on a fairly regular basis and mostly being relieved and happy for them when it finally happens. It's not a big, scary horrible monster for me, and mostly it's not an admission of failure by the time it comes about. Instead, midwifing somebody through the process, letting them take the lead while still responding to their needs, is a tricky, thoughtful business, and one I'm glad and proud that I can do well.

But the folks in critical care (especially the oncology guys, because really, that's a tougher call than seeing a black brain on a CT, right?) don't see it that way. Death is something that *can* be beaten, and *will* be, no matter the cost to the doctor, family, or patient.

So we keep the patients alive, no matter what. A nasty case of sepsis can be fought. A stroke or brain injury can be fought. Multiple broken bones and pneumothorax can be fought. Those things are reasonable and logical--the person with the problem will likely go on to make at least a partial recovery, so you're not wasting your time or torturing them.

But the ones who simply won't get better, who've used up all nine of their lives? Those ones bother me.

Honestly: if we have you on three different drugs to keep your blood pressure up and your systolic won't come up out of the sixties, or if you're so damn sick that you've got three different central lines running six different antifungals and antibiotics, and you're still not improving, it may be time for us to give up. You've probably left the building long ago and are waiting impatiently for the chance to get on with things.

It's hard to make that call, and I respect that doctors don't want to judge too quickly. We've all heard about or seen miraculous recoveries (or at least, unexpected improvements). It's not up to anybody to determine, actively, when another person's life should end.

Still, it leaves me with a nasty, metallic taste in my mouth that has nothing to do with the drugs I've been running into someone.

I wonder what it's like for the person in the bed, the patient. I can begin to appreciate what it's like for the family; I've fielded plenty of tough questions even in this short time. I know what it's like for us: a colleague of mine is getting the hell out of nursing and going back to accounting so she doesn't have to be sad every day.

Maybe we should be more accepting of failure. Maybe we should turn our attention to the whole situation, and realize that sometimes, that small failure in losing a patient can mean a huge comfort for the people who are left behind. They won't have to think about, late at night, whether they caused more misery than they prevented. And it would be better for that person in the bed, sometimes, to just up and say, "Look: we can bring her back, but it would mean that her intestines would be dead, that she'd be comatose, that she'd be dependent and in a nursing home for the rest of her shortened, sickly life. Is that worth it?"

We have amazing technology and incredible understanding of the body and the brain. Sometimes I wonder if our humanity isn't lagging a bit behind our understanding and technology.

Hi! My name is Jo, and I'm a moron.

This cat looks suspiciously like Flashes.

Yeah, so. I'm grumbling my way to work on the night shift the other night, wondering why it is that I have to put in some undefined time on nights before I'm allowed to work days.

After all, I'm an experienced nurse, right? I have my routine down; I'm afraid that I'll lose that rhythm on nights, because they're so different from days. And it's not like I don't know the surgical patients in the CCU; I've worked with them now for years and years. Besides, other nurses got to go straight to days, and I know there are openings on days, so why the hell am I messing with my circadian clock?

Grumble, grumble, grumble.

About two-thirty, just as I was meditating on how odd it was to be eating tuna and cauliflower in the middle of the night, another nurse came over and asked the nurse sitting next to me a question about positioning a post-surgical patient.

I realized I did not know the answer.

*Blink* *blink* *blink*.

You can say what you want about me, call me every name in the book, but don't you ever dare imply that I'm a quick study.

After only three soul-crushing weeks on nights, it became apparent to me why they put new CCU nurses on the overnight shift: It's because we don't know jack shit.

There's time on the night shift to think. On days, when I felt like I was slaloming down that double-diamond slope, I didn't have time to think. All I could do was react to things and *maybe* anticipate problems if I had a minute to clear my head. Now I have time to read the charts, form something resembling a synthesis, and actually plan for disasters.

I also have time to, you know, learn the niceties of positioning people with big free flaps covering their whaddyacallits or their humunuhas. I have time to replace the pressure tubing for central venous and arterial lines, over and over, until it becomes routine--and more importantly, I get fast at it. I have time to jack with wound-vacs and figure out how to troubleshoot them. It's not a huge deal if labs get done at four rather than at three. The fiddly business of sterilizing reconnecting a ventriculostomy tubing is less loaded when nobody's breathing down your neck as you do it.

That morning, when the day shift came in, I asked one of the girls who'd gone straight from her internship to day shift if my theory held water. "Oh, shit" she replied, "Starting on days sucked. I was never out of here before eight-thirty or nine at night, I never had a chance to eat lunch or even pee, and I was totally out of my depth from the start. It's only in the last year or so that I feel even halfway confident." So, um, yeah.

If I had the chance to give the internship directors three pieces of advice, those would be these:

First, split the neuro group away from the CV and MS groups. It's a great idea in theory to give everybody an overview, and there's a time and place for that, but it doesn't work to have us all together at the same time. Us neuro babies learned about pressor drips (which we use occasionally, but only occasionally) and nothing about things like hot-salt and mannitol, which we use all the freaking time.

Second, (and this is a subset of item number one) give us more than two days on neuro review. Anatomy and physiology review is all well and good, but the internship as structured gives us very little preparation for what we'll actually see in the CCU on a day-to-day basis. I left that internship with the feeling that if I ever got a patient with a Swan-Ganz catheter, I'd do fine (four days on that), but that if I hadn't seen a neuro patient with a bleed before, I'd be screwed (one day on bleeds).

And third and most important, don't blow smoke about *why* we're placed on nights. I got as many stories about that as there were instructors in the internship, and not one of them was actually the truth: They put us on nights because it's the only place we'll have a chance to really learn stuff. That business about "setting your routine" and "learning the flow"? Is bullshit. The two shifts differ so radically that there's no translating one to the other.

So for now, I'm approaching this whole thing with a new attitude. It may not last through the end of this week, which is crazy as far as my schedule is concerned, but I'll try.

In the meantime, I'm going to make plenty of vegetarian sushi and little bento-box-esque munchies for the middle of the night. After all, I do get time to eat.

Off the leash

Well, I'm done with my internship, off the chain, on my own, riding without training wheels, a danger to myself and society.

Six weeks ago, I felt like every day at work was like trying to climb up an escalator covered with bacon grease while somebody yanked on my shirt-tails at random moments. Now I feel like a barely-adequate skiier slaloming down a slope rated for Olympians. If I just go with what's happening, don't think about it, and don't try to look too far ahead, I do just fine. It's just a matter of not relaxing, of doing things right when I get the chance, and of being as efficient as possible.

Which is frustrating. It's hard to go from an area where you've been able to know without thinking what needs to be done, where the synthesis is second nature, to an environment where you have to stop, think, and double-check that you're even asking the right questions.

The head of the CCU internship program for Sunnydale and I had a conversation about that the other week. She wasn't exactly encouraging about my progress (though I thought I had done pretty well), and she expressed some serious doubts about my ability to form a comprehensive picture about my patients and anticipate/prevent problems. I left that interview feeling about three inches tall, until two things happened:

1. I realized that I cannot possibly be expected to think like an experienced CCU nurse yet. Fourteen weeks is barely enough time to review the things you have to review to keep from hurting somebody in the unit, let alone learn how to integrate all of those things into a cohesive whole. Everything right now is going to be task-based, and I'm going to feel like a complete idiot for a while, and that's just part of the learning curve.

2. The other interns in the program said that they'd had the exact same meeting with the head. The upshot of everybody's discussions with her was that she felt we're all safe nurses, but she's encouraging everyone to ask lots of questions and get help when they need to (collective "Duh"). In her defense, she's been a CCU nurse for about twenty years, so I think the thought processes involved have become so second-nature for her that she can't get into the headspace of a new nurse/new CCU nurse. Anyway, I felt better about the whole thing after we all got together and looked blankly at one another.

After the last couple of days on the floor, during which I had two not-really-critical patients who quickly turned critical, I feel more confident about my ability to at least keep people alive. Right now it's more a matter of being fast on my feet (as my Sainted Mother says) than of being a really good CCU nurse, but I'll settle for that for the moment. One patient yesterday shook off the propofol and Versed and tried to extubate herself in a particularly creative manner while shooting liquid stool all over the place, and the other had a fistula between an abscess and an artery break loose near the end of the shift, but I still got out on time and gave a good report.

As I was leaving work, passing the very last computer monitor on the very last computer cart near the furthest edge of the station, the monitor on that cart suddenly caught fire. I did not stop, I did not look back, I merely kept walking. That, my friends, is what the CCU is like.

As Pens the Lotion Slut says, "I AM DRINKING BEER."

It has not been a beautiful day in Nurse Jo's neighborhood. Not at all.

Because the person who directs my Clinical Experience is a little.... .... ....well, she's weird, I had got to go to a two-part ACLS class this week, rather than renewing in April at the six-hour test-and-megacode extravaganza that I'd normally do. That meant two days of long classes covering things that I really don't ever want to have to deal with, and then a megacode at the end of the day today.

Followed by another megacode.

Yes, my friends, we tested *twice*. Once on a nice, boring, nonanimated dummy, and once on an animated dummy that costs a gazillion bucks and has no bones to speak of (the dude running the lab got really exercised when I bent the dummy's leg backward and said "Look! Osteomalacia!") and could speak and blink and breathe and all that happy shit. This was because the group I was in got selected randomly for a study on who did better in a code--a group with a nonanimated dummy, or a group without.

My hands and shoulders are sore as hell, because there were two very capable women in the group who were both unfortunately the size of my little finger, one guy, and me. Guess who got to do most of the compressions on both code tests? If I tell you that my private nickname for the guy is "Mister Lazy ThinksHe'sAmusing," will you guess right?

And if I tell you that I was, at one point, stuck for more than an hour and a freaking half in a room with Mister Lazy ThinksHe'sAmusing and another classmate whose nickname is HandsyMan, will you pity me? Will you hand me another beer? Please say yes.

Oh, never mind. I just got one on my own.

For some reason, since I've been single again, I've been attracting the sort of men one usually only sees in sitcoms and bad Craigslist ads. If he's got a girlfriend, he's hit on me. If he's an instructor in a nursing program and has a Marine Corps symbol (although if he's been any closer to the Marines than I've been, I'll eat my socks) dangling in his chest hairs, right above where his potbelly begins, he's said something inappropriate to me. If he's married but handsy, I've had to duck out from under unwanted shoulder-rubs, Angela-Merkel-style, more than once in the last month. And the topper came, as I was telling the Brother in BFE the other week, a couple weeks ago at my favorite bar.

My favorite bar is a class establishment that attracts only the finest folks--dames like myself. I was minding my own business, tucking into a poblano-stuffed chicken breast or some of the shrimp enchiladas that Antonio makes, or maybe it was a burger, when a drink appeared next to me.

I looked across the bar. There were three possible drink-senders, none of whom looked real promising. So I asked the bartender, Ray, who'd sent it. "The guy with the bad hair" she replied.

"Which one?" I asked.

"The one who doesn't look like he's bathed for a week."

Yes, fiends and neighbors, the dude with the bad greasy black hair, the corduroy Sansabelt-wannabes with the patch pockets on the front, and the reindeer sweater had sent me a drink.

He'd asked Ray what I was drinking. She'd told him single-malt Scotch, so he'd sent me Maker's Mark.

Oh, dear.

Ooooohhhhh, deeeeaaaaar.

I smiled, toasted him silently from across the bar, and returned firmly to my book. A few seconds later, somebody cleared his throat right next to me. Damn. Sansabelt Reindeer Man. So I thanked him politely and looked interested politely as he proceeded to try to make conversation. After all, they know me there: if anything untoward were to happen, Ray and her barback would throw the guy out on his ear. And he was really sweet, if kind of inert in a geeky way, until--and here you have to take a deep breath--he comingled the Star Wars and Star Trek universes in a way that showed me he was ignorant of both.

The way I figure, if you're living in Mom's basement, you have time to study these things, to work them out. Don't try to impress the girl who knows Yoda's middle name (it's Heironymous). Don't try to snow me with yammering about how we could go where no man has gone before if I'd just take hold of your lightsaber. Okay, it wasn't quite *that* bad, but it was close.

I've learned a lot of things in nearly forty years. I learn a lot of things from each guy I date, and I learn a lot when I'm single, too. And I've learned a lot--a lot--from this internship.

What I didn't expect to learn at any time was how to avoid weirdos in bars and how to avoid ass-pats while doing compressions.

*sigh*

In Which Jo Feels Like A Real CCU Nurse.

Yank the blood out. Put the blood back in. Hook up the machine that scrubs the blood and yank out more blood. Make sure it's going back where it belongs: you don't want the patient exsanguinating all over the bed! God, lungs sound like crap. And sats are crap, come to think of it. And the vent's yowling at me.

Fiddle with the vent. Call RT. The vent won't stop alarming; could you please come help me out? The marvelous, marvelous RT department at Sunnydale dispatches one of their folks. She fixes the problem in about two seconds, helps me turn the patient, suctions him, and disappears in a golden cloud, angels following. (Have I mentioned how much I love respiratory therapists? Their motto should be: Removing Asses From Slings, One RN At A Time.)

Patient is hypotensive. Drop rate on bloodscrubber. Still hypotensive. Reposition patient. No go. Up the pressors. Hmmmm....better, but still not great. Best call the doc while I'm dropping the sixteenth blood draw of the day off at the lab. How the hell do you end up with a stage IV ulcer *there*?

Doc has no freakin' clue what to do; tells me to figure it out. Uh...yeah. Okay. *deep breath* Drop rate further, up that other rate a little more, cut back on this one and raise that one just a titch. Voila! A MAP of 68, just where I want it! Wow. This pressor stuff really works.

Wups! Bed and scrubber are alarming at the same time. Check scrubber first. Reposition patient. Figure out that their access is wonkily positional; deal with that. Deal with bed. Deal with cooling blanket. Deal with IV pump that has suddenly blown a gasket. Draw more blood.

Change a couple of ew yick dressings. Meditate on the enormous *thing* coming out of my patient's head and be glad they're not awake to worry about it. Wonder why the notch has suddenly disappeared from my A-line tracing. Discover that that, too, is positional. CVP and MAP look good, CPP is right where it should be.

Lunch.

Pee.

Up the rate on this drip, drop the rate on that one, change a bag on the scrubber, hang a new bag of stuff here and there. Check insulin drip. Check potassium drip. Check the anticoagulant infusion and the calcium infusion and that thing that's supposed to keep my patient calm. All good, all serene.

Don't kick that machine. It will make whooping noises for several minutes if you do that, and you won't be able to turn the alarm off. Wups!

CPP's okay, but MAP is dropping again. Am I more worried about kidneys or brain right now? Kidneys, actually (how odd, not to be worried about the brain). Cut back here, reposition there, up this, drop that. Patient suddenly isn't moving his right side. Well, that sucks rocks. Call doc. Too unstable to go for a CT; we can't do anything about that. Keep monitoring.

Right side comes back. So does bowel function (the patient's, not mine). Deal with that, change a dressing again, reposition. Make sure the wire coming out of the head isn't kinked. Pupils are still happy and reactive, right side seems okay, all good on the technical front. But those pressures still aren't where I want them. Fiddle some more.

Now patient drops *left* side. It's not ischemic, and I've never seen a bleed in an anticoagulated patient that simply resolves. In fifteen minutes, left side is back.

Docs rounding. Answer myriad questions, some of which are actually not covered by the paperwork they're holding. Get new orders. Change drips around. Change settings hither and yon. Make a couple of jokes with the pulmonologist. Glance out the window: when did it get dark? Grab lab results out of computer, ponder.

Charge rounds. Quick report, interrupted for bag-changing. Make sure all tubings are fresh. Make sure everything is clean, neat, stocked, and generally shipshape for oncoming shift.

Night relief arrives. *whew* Thank Frogs she's had this patient before. Head-to-toe together at the bedside, go over settings for one-two-three-four-five-six holy cow machines. Sign off. Remove self from computer.

Burger. Beer. Bed.

I feel kind of sorry for my preceptor.

Preceptor The First, that is. Because it's obvious our personalities don't mesh. At all.

Not that we don't get along; we do. She's a very good, very competent nurse. She's excellent with the patients, she never misses a trick, she can be relied upon in a crisis. It's just...well, she's from Venus and I'm from Mars. Or she's from Dubuque and I'm from Dubai. Or she's from Van Alsteen and I'm from the Van Allen Belt (holla!). You get the idea: both of us are pleasant, rational people, but we simply don't click.

Which means that in addition to those long, uncomfortable silences after which both of you turn to somebody else with a small-talk remark, there's a total lack of telepathy.

Those of you who've been nurses (or students, actually) for more than a week know how important telepathy is. It's the thing that keeps you from running into somebody who's helping you set up a monitor; it's that indefinable *something* that lets your coworkers know that you are totally in the weeds and good Frog could you use a hand. That is missing.

So, after I took on a third patient (sometimes they get tripled in the CCU, if one or more of the existing patients isn't complex), I was completely swamped. And the usual wild-eyed looks toward my preceptor as I was tied up on the phone or chasing down a doctor weren't working.

Finally, I went to her with a couple of requests: could she please take X, Y, and Z into room 4 for that patient, and please please pretty please could she do A and B for the patient in 6?

(For the nonce, Patient Number Four was uncomplicated but liked to chat. And Patient Number Six was stable, but had one of those oh-God-please-don't-let-the-pump-fail drips that you have nightmares about, with the extra added bonus of side effects like orthostatic hypotension combined with explosive diarrhea.)

She looked at me for a moment, her forehead wrinkling. "You want me to do *what*?" she asked.

"Take XYZ into 4 and help 6 to the commode. Please."

Another long moment's silence as she studied my face.

"You know, it would've taken you the same time to do that as it took you to ask me to. I thought you wanted some real help."

The new, snark-free Jo did not point out that the fifteen seconds PtF had just wasted in contemplation and in pointing out the obvious made the first part of her statement indeed true. Nor did the new, snark-free Jo retort that this *was* real help; that getting a hard-to-move patient with a tendency to crump while vertical was about the most important thing on my to-do list, lest I spend the next 45 minutes cleaning up one of the side effects of that drug.

Thankfully, another nurse had overheard that conversation and rushed into 6, managed to get the patient up and steady, and worked it so that I only had to scrub down part of one wall when that poor guy's bowels cut loose. (Note to self: explore side effects of any potentially life-saving drug before deciding to take it.) PtF then, to give her credit, hustled away to take care of Miz Chatty in 4, but yeah, that was thirty seconds wasted and another layer of stress I didn't need.

In short, I am not in the mood for philosophical discussions of time management when I ask for help. I *know* I'm snowed; if I weren't I wouldn't be begging.

At the same time, pity the poor preceptor who has to deal with me. I get scatterbrained and stressed easily, and my tone of voice at those times makes some people think I'm dealing calmly with a crisis. I tend to forget obvious stuff at weird times. I'm easily distracted by shiny objects and minor problems. I have a very, very short temper. And, worst of all, I get frustrated--quickly and seriously--by the fact that I don't know as much as I want to and can't do as much as I'd like to as well as I think I should.

So basically, what we have here is a failure to communicate. It's not anybody's fault; it's just the way PtF and I are wired. I'm sure she'll be as happy as I'll be to have the precepting part of our working relationship over and done with; things will be much easier once we don't have to be joined at the hip for twenty-four hours in forty-eight.

Meanwhile, back at Casa del Gato, I just spilled a half-cup of coffee everywhere and have to keep the gatos from drinking it. There's a crisis I can handle.

I could be bounded in a nutshell, and count myself king of infinite space....

It's the last month of internship, and I have been dreaming.

Most of the dreams involve the Old House. That's the house I grew up in, the house in which my sister used to say, "Here, Jo, smell *this*!", the house El Erstwhilo and I bought from my parents when we were first married. (Yes, before you ask, it was weird. I found myself looking for things I remembered Mom having, in the places where she kept them, before my brain would remember what my body didn't know: that those things weren't there any more.)

Most of the dreams also include tornadoes, or bad storms. Some of them involve El Erstwhilo and the woman whom he left me for, who doesn't get a nickname here because my mother reads this blog. In the latest, from this afternoon's nap, I was in the upstairs bath watching a tornado come rolling in while simultaneously trying to get Max in from the back yard and applying eyeliner.

The one last night had El Erstwhilo and La Cucaracha (hey, it starts with 'c') in it: they'd covered the outside of the house with ugly beige brick and had lined the insides with panelling. Furniture was floating in midair, suspended by ropes while a new floor got laid.

My dream interpretation book, published during the height of interest in Spiritualism after the First World War, tells me that houses, especially childhood homes, are symbols of my perception of myself. Storms and tornadoes ("cyclones") say that I'm either undergoing a massive change internally, or I'm unsure of whether my current relationships are healthy. Makeup means I'm either trying to hide my true self or put my best face forward. The books say nothing about ex-husbands or cuckolding best friends or large, shaggy blond dogs with a jones for kitty bellies.

And yet, the book is right. My perception of myself has changed considerably in the last few weeks. Although I probably couldn't handle a CCU-level crisis, I can handle a lot more than I could in September. F'rinstance: I know where all the cords go, who's likely to give me report on what, which doctor wants what (fer Godssake, don't put a three-way on Doctor X's patients! He hates those damned things!), and I can give a simple, plain-English explanation of What All Those Beeping Things Mean to the most freaked-out of family members.

In short, hugs are second nature now.

Hugs were never second nature on the floor. In the CCU, people need them. I am not--despite what casual observers might say--naturally a very touchy, affectionate person. These families *need* it, though, as when a family member misread "ARTIFACT" on a monitor as "ARREST" and fled the room in a panic. A side-hug calmed her down when no amount of intellectual explanation would.

So my personal perception of Jo is changing, fearfully changing. I'm still not sure whether I'll be a *good* CCU nurse as fast as I'd like to be, but I have no doubt I'll be an *acceptable* CCU nurse.

I have one more month to commit to memory whether it's atropine-bicarb-epi-what the hell or whether it's epi-atropine-bicarb-oh-scruit. I have one more month to try to memorize what color tube gets what blood for what test, and to remember that levelling an A-line means turning it *off* to the patient and *open* to air, and why (thank Frogs for my Holy Kamole preceptor, who explained that!).

Jo is totally, completely, unironically ordinary in real life. Maybe I can move from being ordinary and acceptable in this job to being extraordinary, as I did in my last one.

We'll see. Three more weeks to go, and we'll see.

Newsflash: Some Nurses are Assholes!

Okay, okay. Some people are assholes. And some assholes are nurses. I expect assholishness in the general public, but I don't always expect it from nurses. When I encounter a nurse that is unprofessional, it always shocks me a bit.

I spent the day at Holy Kamole, orienting to their CCU, which is much different from Sunnydale's. For one thing, the folks at Our Lady of Perpetual Propofol see many more heart patients than we at The Brain Barn do (ie, we see exactly none). They also get fresh transplant patients, folks in end-stage whatever disease, people with flaming CMV infections everywhere but their brains....you get the idea. The patient population is varied, totally not brain-screwed, and very, very sick.

So: Imagine a freshly-scrubbed, almost-recovered-from-her-weekend Jo bopping on to the floor a bit early. (I always get where I'm going a little early, so I can orient.) The night charge was kind enough to take me around and show me the various cubbyholes, then show me where they hide the snacks, and get me into the computer system. Then the day charge showed up.

And promptly completely ignored me when I ventured to introduce myself. No, seriously. I walked up to the desk, made eye contact with him, said "Hello-my-name-is-Jo-I'm-from-Sunnydale-and-I'm-orienting-today" and watched in disbelief as he looked levelly at me, then turned his back and walked away with a heavy sigh.

Um. Okay.

Sorry to be using your oxygen.

The day improved after that, as my preceptor was one of those fantastic teachers who never gets tired of explaining *why*, exactly, you need to level this line here or give these medications in this order. I love whys and wherefores. She gave me oodles of them. She also sent me hither and yon to see things like pacemaker interrogations (for non-medical folks, that involves a computer, not tying the pacemaker to a chair and threatening it) and emergent intubations and the nastiest case of scabies I've have EVER seen (the dude's right chest was covered with crust and his nipple was totally gone). So, all in all, a good experience--if you ignore the charge nurse, which I did.

Until emergent intubation number two, for which I was the runner. The charge turned to me and said, "Get saline."

"What, exactly?" I asked. "Bag? Flush? Bullet?" (Any one of the three would've been logical.)

He sighed deeply again (good thing he's well-perfused) and said, as though I were Forrest Gump on a bad day, "I need a bag of saline. You know, the big one. The liter one. With tubing. The kind with the spike on the end. You think you can do that?"

I did not shove the bag of saline (the big one, with tubing) into his ass. Instead, I brought it back in record time, considering that the bags of fluid and the spikes are kept in totally different places across the unit from one another, and handed it to him without comment.

Then we went back to ignoring one another for another few hours.

When the night nurse who was taking my patients arrived, she looked me up and down and said, "Oh. You're a new nurse. From Sunnydale." You could've cooled beer with her voice. Again, resisting the urge to put her into one of her own beds, I gave her the most thorough report-by-system I've ever managed to pull out of my hat, without comment. (And thank Frogs I had managed to do everything including fluff-and-puff for my patient, thus leaving nothing about which she could complain.) New nurse, yes. Stupid nurse, no.

Asshole? God, I hope not.

Well, that was a bipolar two days.

Gracious.

I have two preceptors. I worked with one on Wednesday and the other on Thursday of this week.

Preceptor the First is....difficult to approach. She's a fantastic nurse, a very nice person; I like her a lot. I'm nervous about working with her, though, because she combines OCD-ness with such a huge amount of personal reserve that it's difficult to approach her with problems or questions. We're in the middle of testing a new computer system in the CCU, so a lot of the questions I had for her were computer-charting-related. Instead of having me fly the box and learn by doing, she would simply take over and chart *for* me as I watched, then expect me to be able to replicate the motions when it was time to do so.

I don't learn that way, sadly. I *used* to, but seven years of hands-on learning has ruined my brain for anything else, and it's probably too late to get a brain transplant and still pass my classroom final exam.

Wednesday ended with an emergent intubation to which I was invited (like Queen Victoria "invited" people to show up in the throne room) by the charge. Rudely. As in, I was in the middle of something else that was just a little bit important, there were already eight people in the room (two docs, three RTs, three nurses), and I got snarled at to come in and start an IV.

Which is fine. I can start IVs all day, with my hands behind my back, in my sleep, you name it. The particular IV I had to start was in the hand, and the dude I was starting it on was elderly, very fragile, and had extremely large veins. In a situation like that, I use the technique I learned years ago of putting the hand way below the heart and starting the IV without a tourniquet, as filling the vein tends to make it easier to blow.

I had gotten a nice, fat, 18-gauge IV into a hand vein when the CN rushed over, grabbed the dude's hand, and said sharply, "What the hell are you doing?" The vein, of course, blew. She then reminded me how to start an IV properly (ie, her way) and gave me a lecture on not losing my head in stressful situations. I looked at her levelly and said, "I have led a code before, you know."

Then I went away after the dude was intubated, started two impossible IVs for another nurse, and was told I needed to apologize to the CN by my preceptor.

It was a bad day. It was such a bad day that I vented to both my Brother In BFE and Sister Rat about it, then went to bed in tears. It was one of those days when you feel you're trying to run up a staircase coated with pig fat while somebody yanks on the scruff of your neck at odd times, making you lose your footing.

Thursday was different. Preceptor the Second is a total goofball. I am a total goofball. Neither one of us have any filters to speak of, so we'll talk about farting over lunch (note: I thought the nurses on my old floor were filterless. I was wrong), do yoga poses in the nurses' station, and eat cake when it presents itself, then be sugar-rushed all day. Besides that, she's detail-oriented in the same way I am, without being totally OCD about small things.

It was still a day when I felt like I was completely behind. I would've drowned had it not been for her help entering orders and turning patients and dealing with the second-largest bowel explosion I've ever seen, but it was a *good* day. A patient who'd been heavily sedated and intubated the day before got better, and I admitted-then-discharged one patient and admitted another (and actually got the swing of getting somebody into an ICU bed, wahoo!).

The charge nurse from the day before was mercifully absent, so I got to send her an apologetic email, doing the last ten meters on my belly.

It is hard to learn new things when you're a new nurse. It's harder--*much* harder--to go from being an expert to being a newbie at something. Your pride takes a hit, your ego gets involved, and you end up trying to prove things when you really don't have to. That much I learned from Wednesday. I learned from Thursday that a preceptor who's just as loony as her intern can make a hell of a difference in terms of that intern setting her (massive) ego aside and actually learning stuff and being humble enough not to freak out about it.

It's amazing what a difference personality makes. With Preceptor the First, I'm a little afraid to ask questions, for fear that she'll swoop in and just plain take over. With Preceptor the Second, nothing's off-limits and I have no fear of looking stupid. Both of them are excellent instructors; there's just the ease of meshing personalities with PtS. I'm learning two different ways of going about things, which is valuable: if one thing doesn't work, I can try the other and it might just make things happen. I certainly don't want to drop PtF as a trainer, but I do find myself a little more tense on those days and a little more wary of what might happen.

Years ago when I was first starting nursing, I got a crazy patient--and I mean *crazy*, as in, I've not had anybody to match her since--and she and I did not get along. This of course caused much hand-wringing with my boss, my preceptor, and the educator for the department. Because I was a new nurse, I couldn't simply say, "This person is a fucking nutjob and I refused to play her game, therefore, she decided to report me." Instead, there was a long meeting with all three of my superiors during which I finally had to come up with some deep psychological reason why I couldn't get along with this person (I said she reminded me of my then, now thankfully dead, mother in law) and listen to a whole bunch of bullshit about how I needed to set personal feelings aside in dealing with people who were nuts.

I had worked for three years at that point in an industry known for being a target for wackjobs, and had actually been a target, personally, for some of those wackjobs. Yet none of that counted. I was PISSED. I was treated as though this job was my first rodeo, and none of my previous experience was taken into account. The ability to call out a nutjob and treat that nutjob as such was taken away from me, and I had to take the fall for somebody else's inability to be a sane human being.

That's kind of what's going on now. It's assumed that I have the technical skill to deal with any number of problems. In terms of the personal angle, though, pretty much everybody assumes that I'm a complete n00b with no clue. It happens more with PtF and the charge nurse than it does with PtS, but that's not their fault; they're trying to make me the best critical-care nurse I can be. It's up to me to lose the ego, gain the patience, and prove that I can do this without completely losing my head and holding somebody's smoking entrails up before their dying eyes.

Which means I will need much more cake.

As my pal Mazen says from time to time,

"Deez? Eez bool-cheat."

Yes, it is. It is indeed bool-cheat.

I fear my gallbladder is on the fritz. (Slightly used, low-mileage gallbladder: anybody got one?) After my twice-monthly cheezburger last week (nom nom nom nom), I was down for two days with abdominal pain, nausea, vomiting, a low-grade temp, and other things you really don't want to hear about. Since then, my right upper abdominal quadrant has hurt like a son of a bitch, and I really don't have a lot of appetite.

Friends came over last night for homemade bread, beef stew, and apple crisp, and I didn't want any of it. That, my friends, is how bad it is. That is how much bool-cheat we're dealin' with: When Mama don't want to eat, you might as well kiss the world goodbye.

I see the Muppet Doctor tomorrow for what I hope will be a diagnosis. I sincerely hope it's not a toomah.

So I wasn't in the best of moods when I showed up to work today.

I was in even less of a good mood once I saw my patient.

Eight drips.

Eight. Freaking. Fluids. Going. At Once.

Lasix. Insulin. Levothyroxine. Bicarb. Two pressors. Fluids. And a rider for the mag and potassium and everything else we had to hang.

My bad mood turned worse when I found out why this poor guy had eight drips on him:

One of those "devastating" bleeds.

Young kid, mid-thirties (anybody younger than me is a "young kid"), two little children, loving wife, close enough to his coworkers that they consider him part of the family.

And a devastating bleed with no history of anything: no hypertension, no diabetes, no nothing. He was brain dead when I showed up, and did not improve.

It was a bad day for me and for him.

It's gonna be a good day, though, for a whole bunch of people, and here's why:

His kidneys are going to two different folks who have both been on the transplant list for a couple of years.

His liver is going to a guy who was sent home on hospice last week.

His heart is going to somebody.

His lungs? Going to somebody.

His pancreas, amazingly, is going to somebody else. (Pancreas transplants usually work best when the donor is very young; this guy was in great shape, so we can use his pancreas.)

Bones? Skin? Tendons? Intestines? Nerves? (They transplant *nerves* now? The transplant coordinator assured me they can.) Corneas? Check, check, check, check, check, and ditto.

There are going to be at least ten people, by my calculations, who have this one person to thank for their lives, their vision, their ability to produce insulin, and their ease in walking. Never mind the at-least-five people who will have skin grafts thanks to him. Never mind the folks who will get bits of intestine that will allow them to have something close to a normal life again.

It was horrible, and it was wonderful. In the middle of drawing the nearly forty tubes of blood that needed to be drawn prior to "harvesting" (or "retrieval", as some people call it, but I prefer "harvesting"), I realized that this one man, though he was lost to his family and his friends, would *literally make living possible* for any number of people.

Young people make fantastic donors and really, really crappy patients. Inertia will only take you so far, and sometimes the dead are harder to keep breathing than the living-yet-very-sick. This guy, despite all the odds, managed to get off his pressor drips and his insulin and everything else well within the time limits specified by the transplant experts; he ended the day on nothing but plain normal saline. That means that he'll be scooped out (to put it bluntly) like a melon, with wooden dowels replacing his bones and clothing covering his skin donor sites.....

....but there will be a handful of people who have him to thank for their lives. Their LIVES.

Most of us, me included, can't guarantee we'll touch that many people in a lasting way in the course of a career that stretches twenty years. He did it in one day.

It was sad. It was happy. I watched the transplant nurse's computer, and saw how all the acknowledgements came in from various transplant centers. I imagined how it would feel to have that beeper that's stayed silent for so long finally go off, and to know that your second chance came at the expense of somebody else's.

When, not if, but when my aneurysm blows and I infarct at least one half of my brain, do this:

Take what you can. I don't care how tricky or political or corrupt the system is, the ends justify the means in this case. Use my kidneys, my heart, my cruddy lungs, whatever.

Donate the rest to a medical school. They can have fun studying my muscles and my skull, if nothing else.

Compost the rest out in the back yard, and plant a garden over it. In the high summer, when the produce is ready to pick, go out and grab a tomato off the vine, polish it on your shirt, and bite into it. My epitaph will read, "That Jo! She was one heck of a tomato!"

Tales from the CVCCU

As part of our training, we interns have to go to the cardiovascular CCU at Holy Kamole. They deal with things there that, thank Frog, I will never have to see. Bone-marrow transplants gone wrong I can handle; neurological disorders hold no sway in my nightmares. But heart and lung and kidney and what-have-you transplants? Are the stuff of horrid, horrid dreams.

I am meant to do a thorough neuro exam every hour. I am meant to understand dermatomes, Brown-Sequard syndrome, and incomplete cord transections. I am not meant to handle eight vasopressor drips on one patient.

So it was with fear and trembling that I got to the unit to follow an experienced CV nurse. The patient she had was one of those who requires two nurses: every once in a while, you'll see a one-on-one (for instance, if somebody's undergoing continuous, slow dialysis), but two-to-ones are very, very rare.

What does it take to be a two-to-one patient?

Let's start with a rare genetic disorder that only about a thousand people in the world have, and make it one that only, say, vegetarian left-handed expatriate Iranians living in Hungary are prone to. (Of *course* that isn't the real disorder. Do you think I'd violate HHIIPPAAA that way?) Be certain that your patient fits none of those categories.

Add on the necessity of not one, not two, but three--so far--solid organ transplants over the lifespan of this particular patient. If you can make one of them a re-transplant, so much the better.

Make sure that that weird genetic disorder isn't diagnosed until after the first solid-organ transplant; that way, you'll stand a good chance of ruining whatever organ you transplant the first time with the complications of said genetic disorder. (As an added bonus, make sure that the patient's sisters and brother all find out that they're carriers of this nasty disease, and fuck their brains, their future plans, and their reproductive decisions up as a result.)

If you can manage a rare-but-dangerous viral infection, tack that on as well.

Oh, and be sure you put in for an order of adult respiratory distress syndrome, with a side of sepsis.

What you end up with is an absolutely beautiful young woman on a ventilator, with a midline incision that runs from belly to brisket, six pressor drips, and very little chance of ever waking up.

I left my job at Planned Parenthood the day that a twenty-seven year old woman came in with her pregnant thirteen-year-old daughter. The woman asked me if I expected her to cry over her daughter's being pregnant; the idea that any other possibility would present itself showed me such a huge gulf between her experience and mine that I could no longer deal with the disconnect. I had thought that that was as bad as it got.

Until I saw a smart, funny, gorgeous girl of twenty-three hooked up to hinty-bazillion machines, all of which were dedicated to keeping her body alive until, frankly, her parents and siblings could work up the courage to say goodbye.

The day wasn't made any easier by the fact that I had known her before, years ago, when she came in to our floor and ended up being diagnosed with that crazy genetic disorder. I thought then that she wouldn't make it to nineteen; I was wrong. Her parents showed me the pictures of her on the campaign trail for Obama, the snapshots of her hanging out with Sasha and Malia and Michelle and Barack. They told me about how she felt so strongly about particular issues up for debate in the Texas Legislature that she disregarded the advice of her doctors and went to testify as an advocate for battered women, how she ignored the symptoms of organ rejection in order to go to a conference on providing health care to uninsured people. There was a framed picture of her getting her Master's degree on the table by the bed.

And two pumps with three channels each, a balloon pump, a ventilator, and three pages of IV drips that had to be administered at exactly the right times.

I guess it bears mentioning here that her parents and older sister recognized me the minute I walked into the room and called me by name. It sucks when people you have to disappoint remember you so well.

We walk a fine line, nurses and doctors. On the one hand--and I think this is more true of nurses than of doctors, except in rare cases--we gain a degree of intimacy with families that would be inconceivable in most settings. On the other, we have to maintain that professional distance that allows us to advocate, to educate, to break bad news.

Sometimes, that last is easy. You can manage, even with people you see more than once or twice, to keep your distance. Sometimes it's very, very hard. And sometimes, despite your best intentions, you fail completely at being a detached professional person.

I was not the person who extubated her. I was the person, though, who turned off all of the drips, and hung the morphine up, and titrated it so that she didn't show any distress, and who laid my useless expensive stethoscope against a chest in order to hear what wasn't there.

I was the one who had to look across her body and tell her parents and her brother and her sisters, "She's gone, now."

And I was the one who broke every professional boundary imaginable by standing in her room with them and crying over the loss of a reasonable, decent, driven young person who had bad, bad genetic luck.

In a way, I'm glad it was me. I was there when she found out she had this thing wrong with her that would shorten her life; I was there when she told her parents, quite matter-of-factly, "This won't change any of the plans I've got." My ability to translate medicalese into English eased their transition from normal family to family with dangerous medical condition; it helped that I could put things in every-day language and thus calm some of their fears.

But even two nurses, six drips, a balloon pump, and all the translation talent in the world can't save somebody, sometimes.

Still, I'm really, really glad I was there. I'm glad I got to see what she'd done.

I'm glad I got to say goodbye.

How I lost two-and-a-half pounds this week, gained it all back without trying, and ended up with a potscrubber on my head.

I knew when I started this internship that ICU would be an educational experience.

What I didn't know was how educational it would be, and in how many diverse ways.

So I finished helping Brenda bag-n-tag her dead patient, checked on my dude who no longer has a larynx, a neck to speak of, or a right chest muscle, and levelled the ventriculostomy on my woman with the bleed, and wandered back out to the desk, chart in hand.

The girls were discussing interesting euphemisms for bizarre sex acts. I wasn't really listening, so I didn't notice when the conversation veered sharply toward hair and eyeliner. Hair and eyeliner don't interest me any more than euphemisms do; I normally let both my hair and my eye makeup do whatever they're going to do for the day, as I don't drag up well. I was charting, not listening.

Next thing I know, Katie's fingers are in my hair. Brenda and Dawn and all the girls are gathered around in back of me, and Katie is taking my hair down from its barrette and combing through it with her fingers.

I should point out here for any latecomers that my hair is crazy, crazy curly. Katie had been demonstrating a hairstyle with her own long, straight, naturally golden-blonde hair when somebody asked her if the same style would work with curly hair. Katie, not being a fool, did not grab Dawn or Brenda, both of whom have hair at least as curly as mine, as she thinks they're more intimidating than I am.

Or maybe they were both just less involved in something else. At any rate, here I was at the station desk, charting away, with somebody doing... ... ... something to my hair.

Katie is the MacGyver of hair.

I was in trouble.

Next thing I know, I've got a *thing* on top of my head. I guess you'd call it a high bun, and it's really pretty, don't get me wrong: it looks like somebody's interwoven a hundred tiny strands of crazy-curly hair into a complex and lovely rose shape, with little curly tendrils hanging down from the back. If I lean waaaay back in the chair I'm in now, I can just see it in the mirror. Lauren pulled out little tendrils from either side, and Chris poufed the front up very nicely.

It's a gorgeous hairdo. It just looked, for the last two hours of the shift, like I was going to the prom in scrubs. It's hard to have a serious conversation with a doc when he's known you for seven years with your hair scraped pack into a no-nonsense ponytail, and all he can look at is the springy curly tendrils escaping ever-so-casually at your temples. And the back of your neck. And a couple falling carelessly over your left eyebrow.

She did it all with one rubber band, in under five minutes. The woman is a genius.

I am in trouble. Next thing you know, I'll be learning how to put on eye makeup correctly. That seems to be almost as important as levelling an arterial line on this unit.

Oh, and the 2.5 lbs? I lost them because I am no longer working with people who bring Big Food to work three days out of five. I gained them all back today because the respiratory guys had a big lunch hoo-hah, complete with brisket.

I brought home a styrofoam coffee cup full of brisket. (It was the only empty container I could find; I covered it with paper towels and hid it in my lunch bag after ditching the fat-free yogurt and the low-fat cheese stick.) I ate at least a pound of brisket for lunch, and then went back for thirds.

Basically, I was a prom-bound, cow-filled, ventriculostomy-managing fool today. All I need now is the eyeliner, and I'm in like Flynn.

I lived in a different universe this weekend.

And it was really nice.

For a whole day and a half, I had nothing to do but eat good food, yammer at interesting people, and listen to Neko Case and Fountains of Wayne on the car stereo.

Meanwhile, the family of a patient I had last week was discussing whether or not to turn off the vent and make Grandma a DNR. Grandma is not going to wake up, sadly; she had one of those intracerebral hemorrhages best described as "devastating". Oh, and she infarcted both frontal lobes. And then, because she was stuck in a tiny hospital with no neurosurgeon or neurologist, she herniated just enough to screw up her brainstem. Apparently she'd had a headache for a day or so, but being a tough mother, she didn't say anything to anybody. Her husband found her facedown in the living room one morning last week.

I also did not have to live the life of one of my former patients, who's back. We took a metastatic melanoma out of his brain about a year ago, and he's gotten to the point where he needs Interleukin-II therapy. That's the last resort for people with Stage IV melanoma and kidney cancer. Without it, five-year survival is about two percent (for renal CA) to four percent (for metastatic melanoma). So he's in the unit for the first round of fourteen days of IL2, if he can tolerate it, and we'll all see what happens after that.

And, finally, I do not have to be an old friend of mine who's currently in the unit with a galloping case of GVHD (graft versus host disease: it's what happens when you get a bone marrow transplant and the transplant, with its new and marvelous immune cells, turns against your body) after a matched, unrelated-donor bone marrow graft. That was a shock: I walked onto the unit this morning to see his name on the board and stopped dead. He was a sponsor for my church's youth group when I was a teenager, and I went to school with all three of his kids.

Now he's in a bed, so badly screwed-up that we have a specialist in burns taking care of his skin, on a vent, with constant drips going to try to save his kidneys, his liver, his lungs--*any* part of him, really. His doctor considers it a hopeful sign that he only had three liters of diarrhea yesterday.

Tonight it's raining. It's chilly and foggy and misty, so Max and I will have a cuddle party on the floor of the living room after I dry him off. I'll go to bed early, and wake up early, and head to the grocery store at the time of day when the horizon is bleeding into the sky, so you can't tell where the trees end and the clouds start. Then I'll run for a while, and lift heavy things, and give thanks that I can do that and still have the wherewithal to start a big pot of bean soup.

I live in a different universe from a lot of people every day. Sometimes there's overlap; mostly there's not. Mostly I'm thankful there's not.

Starting over maybe isn't so bad after all.

Yeah, well, parts of it aren't so bad.

Relearning acid-base balances and hemodynamics and learning about Swans and pressor drips? That kinda sucks. But other parts? Not so bad.

I was thinking yesterday (which is why you smelled smoke) that the best thing about being an established nurse moving from one place to another is this: I already have people's confidence. I don't have to prove myself to anybody; they all know me already.

That doesn't mean that I'm gonna get all puffed up and forget to read my charts, but it does mean that I don't have to go through that awful eight-to-twelve month period that new nurses have to go through, when everybody including you is trying to decide if you really ought to be doing this in the first place. That's already done. Everyone I work with knows what I can do and knows that I don't, say, panic over nothing.

The flip side of that, of course, is that they also remember every screwup I've had in the last seven years. Which, surprisingly, is actually a positive thing. If Resident A or Nurse X remembers that I'm a little goofy about lab results, they'll be watching too, for the patient's sake. It's nice to have people at your back that know all the bad things about you; it means they don't panic unnecessarily.

And, of course, there's the beauty of knowing your own ignorance. When I first started nursing, every day was fraught with peril because I simply didn't know what I didn't know. Now I do: I know nothing at all about cardiovascular stuff, because a) I was asleep that day in school, and b) I haven't used it in umpteen years. I know nothing about complex neck dissections, open sternums, open bellies, or fresh amputations. I know next to nothing about new neobladders, ileal conduits, pulmonary edema, and free flaps that have just been placed. Although it doesn't sound like it, that helps narrow down what I have to woodshed.

And finally, there's the whole neuro side of what I'm doing. It amazed me to find that I know more--a *lot* more--about how brain injuries affect function than some of the CCU nurses do. That's because I've been working with people who are already on the way to recovering. If you have a left parietal bleed, for instance, it's not logical to expect that the CCU nurse will know that that'll likely translate to you ignoring your right arm. She or he has been too busy keeping your ass alive to worry about what you'll do later. It *is* logical to expect that I'll know it, since I've been getting those folks with bleeds ready for rehab for years and years. That helps a lot with family and patient education. It's nice, too, that I can warn them what to expect when they get to the floor and what they'll do in neuro rehab.

So, yeah. So far, so good. This week will bring rotations in the CVCCU, which fills me with terror. I don't know that I can keep six or eight drips straight in my head (which, I guess, is why you write things down) and I'm still not clear on how or why a balloon pump is a great idea, but I guess I'll find out.

Maybe this won't be so bad after all.

Day One of !!!Touching Patients!!!

Critical care?

Rocks.

My.

Socks.

Okay, okay. It was a fantastic day. I know there will be days when things don't go so well, when people code and die or I get shat upon or I can't keep track of my fluids or don't run a bolus and I'll end up not feeling so swell, but tonight?

I left work with a smile on my face. This has not happened in, oh....four years?

And *everybody* who found out I was moving to the CCU--from the attending physician who's spoken to me exactly twice in seven years, to the respiratory therapists, to the other nurses--said almost exactly the same thing. "What the hell took you so long?"

The MEDICAL FUCKING DIRECTOR, who is also a surgeon, and whom I've worked pretty closely with for the last several years, looked me up and down after I said I was in my CCU internship and remarked, "It's about damn time. I always knew you were a CCU nurse."

The best part of it? If you talk to the nurses in the CCU, they get all excited about their jobs. Like, one nurse's nose and ears turned all pink as she told me how cool it was to work with really sick people and know--rather than feel like--you've saved a life. There is none of that on the floor from whence I came; although people do love their jobs, there's no freshness any more, no enthusiasm.

I have tons to learn. Absolute tons. I've never worked with cancer patients undergoing treatment; I've never seen a really huge radical neck dissection fresh out of surgery. I know almost nothing about immediate postop care of urology patients. But I can learn. And I will.

Why didn't I do this years ago? I always knew, deep down, that I was a CCU nurse.

The gloves come off.

Let's talk about touch:

Humans want it. Humans *need* it; without touch, human babies die.

Let's talk about what kind of touches we give as nurses:

Starting IVs. Inserting God-Knows-What into God-Knows-What orifice.

Changing dressings.

Changing Wound-Vacs.

Repositioning postsurgical patients who are in pain.

Helping people get out of bed--who are in pain.

Taking out staples, removing (or placing) stitches, putting on TED hose, adjusting traction, cleaning wounds, flopping back gowns so we can see incisions.

How many of those touches don't hurt? Not a one, that's how many.

I came to a horrifying realization several years ago: that I had spent an entire day with sick people, and yet not one time did I touch any one of them in a way that didn't cause them pain. With that realization came the memory of my most kick-ass instructor: she would come into a room, introduce herself, and--without putting gloves on or flipping out--simply *touch* the person she was talking to.

You could watch their faces ease, watch them relax. Here was a human contact that wasn't frightening, didn't bring the promise of pain, meant nothing except "You and I are both human and here's my hand on your wrist." She didn't talk about what was wrong with them, or how their night was, or anything else related to them *as a patient*--instead, she talked about them *as a person*. When their kids were coming to visit, or how the food was. They bloomed.

The most important part of that whole interaction? Warm, live, human skin on warm, live human skin.

We get so scared, as caregivers, of infectious nasties and incurable what-have-yous that we glove up the very second we walk into a room. I'm of the opinion that you can always wash, use alcohol foam, and glove up *after* you've had a little skin-to-skin contact that isn't scary.

I've held hands with my patients--not often enough, but I've done it. Occasionally, at the end of the day, I'll go into a patient's room without isolation gear on (please note that I know I won't have to see anybody else that evening) just so they can see, and touch, somebody who isn't dressed head-to-toe in plastic. I've touched people who were dying, without gloves on, because everybody else was somehow afraid to--and, dammit, if you don't need the skin-to-skin contact of another human when you're dying, when will you need it?

There is no substitute for touch. There is, likewise, no substitute for touch uncontaminated by and unconnected with fear. You can't get better if you're always afraid of what the next person is going to do with you. If you have that one tactile memory of connection with another person, one that's not overshadowed by pain or the anticipation of pain, it'll make you better.

My goal as a new CCU nurse? A minimum of one human, unscary, unpainful touch per person per day. If that means I scrub the skin off my hands between patients, so be it. It might be the only warmth they get that day.

I would prefer to be Harlow's Soft Mother any day.