Sometimes I get very sad and have to drink lots because people are dumb.

Today, between snorgle-waffleonium 327 test draws (get it in that orange-topped tube that gets specially shipped from Kyurgistan! Don't rotate it counter-clockwise to mix! Don't refrigerate it! And for God's sake, don't feed it after midnight!) and helping a very nice, very old woman to the bathroom, I was reading one of those websites that I used to like but don't really any more.

I wonder why I do that. I really do.

Anyway, there was a complaint from the person in charge of this website I don't much like any more about how meeeeeaaaaannnn and anti-child and awful people in the hospital industry are, because somebody wouldn't let her special little snowflake onto a critical care floor to visit a family member. Her child is well-behaved, and attractive, and eloquent, and generally a good kid. I believe that wholeheartedly.

But I still agree with the evil hospital industry's stance on not letting your kid onto the CCU.

I dunno.....maybe it has something to do with the horror of watching two people die of a common, highly contagious, mostly harmless childhood illness because their immune systems were shot (because we'd recently transplanted new shit into 'em to replace the old shit that wasn't working no more). Maybe it has to do with the knowledge that neither death had to happen, had people simply followed the rules. Maybe it has to do with frustration at how everybody in the world--even me, yes--thinks that rules shouldn't apply to them in whatever circumstance.

I'm afraid I left a comment. In it, I described the last few days of one of my patients, who ended up hemorrhaging from a newly-transplanted organ. I talked about how the family of the person who'd died too soon and thus provided that organ were comforted by the thought that a new liver could make the difference for a stranger, then horrified beyond belief that the transplant recipient would die so soon. (Yeah, they stick around sometimes, the families, and find out things we'd rather they not know.) I wrote a little about what it's like to hold a nice, decent guy in your arms, who's bleeding out as you're doing that, and how the only clue you had to how sick he was--since his numbers looked okay early on--was that he didn't want his sheets changed.

I talked about the difference in deaths: the man who didn't want to be resuscitated, and the woman who did, and ended up being coded five times in twelve hours.

All because of a kid with the sniffles.

Your kid's inability to be inside the hospital is an inconvenience for you, yes. It means you have to drive X number of hours home and line up a baby-sitter, and may not get to see your mom this evening. But it is a matter of life and death for any number of people who come into contact with your kid, or things your kid has touched, or people who have done either.

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

Meanwhile, back at the ranch, I had a very nice patient (female, age 95) who couldn't understand why she'd been spared to live so long, albeit with weird chronic health problems, at the same time that I had a patient who was dying far, far too young.

His kids couldn't come in and see him, which was probably best. They'd moved him up to my unit from the surgical critical-care unit primarily because his family needed more quiet and more one-to-one attention than they were getting in a unit with twenty-nine other very sick people.

He'd bled. It always starts the same way, with a horrible headache. This one progressed as it always does with the young and healthy: nausea, vomiting, the decision to stay home from work with the predictable migraine. And half an hour later, his wife had found him unresponsive, breathing agonally, and called the ambulance.

He was my age; she was a little younger. Today was all about "what's going to happen" and "is he hurting" and "what can you do for this or that minor problem", with me being as competent and calm as I could be while I looked at a patient who could've been a friend or a colleague or even an old lover.

It's hard when they're your age. It's hard when they're young, but at least then I have the luxury of fighting with God over the unfairness of it. This? Not so much. Had we been able to do something about the bleed that crushed his brain up against his skull, he would've been a vegetable, even if his organs had survived the massive doses of pressors we'd had him on for two days.

He went to sleep, and quit breathing, when she left the room to get a cup of coffee. I had warned her that that might happen; that people who looked like he looked had, in my experience, merely been waiting for their loved ones to leave the room. She came back in as I was waiting for the last rattling breath to be followed by another.

When it wasn't, I shot her a quick glance and took my stethoscope off my neck, then put the bell against his chest. She didn't break eye contact with me. I had to say, "He's dead" to a woman who already knew what was going on.

(I never say, "He's gone" or "She's passed" to a family. The person in question is not "gone"; they're still watching and waiting--as far as I know--to see what happens next. And "passed"? Passed what? The test of life?)

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

My other patient saw the gurney leave the room opposite hers, and knew what had happened. When I came back into the room, professional expression firmly in place, she did exactly what people in books do, and stretched out one hand from her bed.

"Honey? Do you want to talk?"

We sat for about an hour and a half, just talking about why life seems so unfair, and how it seems less so as you get older. I'm trusting her nearly-hundred-years of perspective over mine. As she put it, "The people who die too young are the ones who miss all the inconveniences of getting old. My husband had the chance, twenty years ago, to say 'C'est la guerre' and let me go, but he didn't. Now that I'm past ninety, it doesn't seem so unjust that I would've died at seventy-three."

She's funny. She's sharp as a damn tack, and aside from needing the occasional tune-up at the geriatrician's office, she's in pretty good shape. She'll probably go on, with her Kindle and her iPhone and her water aerobics class, for another five years.

I'm not sure if I want the peace that her perspective would give me. I talk about death a lot here, because midwifing a death is an honorable, amazing, incredible thing to be a part of. Once I know more and have more experience, I might go into hospice. I feel the same way about my dying patients--protective and gentle and more human--that I once did about my very poor, very scared teenaged patients.

But at the same time....being able to look back over a life that spans all but a bit of a century might not be such a good thing. I'm not sure I'm capable of the peace she's managed to achieve. I think I might keep fighting and cussing and being pissed off into my nineties.

I hate nursing. Now what?

You're a nurse. You're paying off student loans with interest rates so high they make you dizzy. You're a new grad, probably working a crap shift in a crap unit, because that was the only job you could find. You're dealing with sick people every day, bullying coworkers, crazy family members, and inscrutable doctors.

And you hate it. You fucking hate it. Your life is a misery; you dread punching in. You lose sleep over having to return to work this weekend (because you've got the crap shifts). You obsess over how miserable you are, but you don't feel like you can quit.

Because of money. Because you've invested all this time. Because the loan guarantors are coming after you for payments, and it hasn't even been a year yet. Because you'll disappoint your family and your friends. And, most of all, because leaving a field that is widely seen as a Fulfilling, Sacred Calling That Only A Few People Are Suited For carries a huge stigma.

Y'know what?

It's okay to hate nursing.

Really.

It's okay to do something else with your life.

Sometimes *I* hate nursing, and I do it and think about it and blog about it and get quoted in books about it and sometimes lecture about it for pay and for free. The key, though, is that I only hate it sometimes. Most of the time, I'm as happy as a baby elephant in a kiddie pool. As messy as this job might be, it keeps me coming back, because it does something for me that nothing else does.

If you hate it all the time, it's time for a change.

I got a BA with a double major in music and sociology. I had no idea what I would do with it; write protest songs, maybe? I hated studying music. Hated it. I have a fair-to-middling voice with no real ability to act or interpret what I'm singing, and I barely scraped through on piano class because I hated screwing up so badly, I could barely practice. It cost my parents tens of thousands of dollars and untold worry to finance my degree, and I ended up doing everything from working in a bookstore to doing voiceovers and voice-mail mazes until that fateful day that I walked into a Planned Parenthood, asked for a job, and discovered what I'm really good at.

And you know what?

My folks, and my husband-at-the time, were baffled by my decision to go to nursing school. Not a one of them could figure it out. Not a one of them understood what it was that got me so het up over nursing, though they could appreciate that I was het up. My father finally said to me one day, "Johanne, I've figured out why you like nursing. You're the only one who was ever good at math."

The point of all this is, she says, taking another swig of Hardcore IPA (quite nice, by the by, if you like a fresh-hopped, dry, strong beer) is that you don't owe it to anybody to stay in a field you hate. Presumably you've done enough of it by now to understand what it is about it that makes you unhappy, and what it is about nursing that's a bad fit.

Eventually, the people who love you will realize that you're happier being a bank teller or a firefighter or an airline attendant, and everything will be fine.

I'll miss you. I'll throw you a huge party when you leave to go to firefighter school, and we'll keep in touch--and I'll be really proud that you decided to do what makes you happy.

Because, at the end of the day, you cannot compromise your own happiness for a paycheck (or to save face). You have to do what it is that you know in your gut will send you to work every day without feelings of dread and horror.

It's okay to hate nursing. Nurse Jo hereby gives you absolution, a blessing, and the help-wanted section of the local paper.

Yeah, yeah, Nurses' Week. Whatever. Blow me.

It's National Nurses' Week! Everybody get down! Celebrate! Wahooo!

They're celebrating Nurses' Week (an aside: why is it that, after nearly ten years as one, I still type "nurse" as "nruse"? Damn) at Sunnydale right now. Matter of fact, it's being celebrated all over the country, by gum, as the hospital- and clinic- and school-going public bows in honor of our awesomeness.

Mostly, NW at Sunnydale is being celebrated with food. Yep. Potlucks ("Happy Nurses' Week! Bring your own food!"), ice cream socials, breakfasts, snack times. A couple years ago, we celebrated with food. Last year, food. And massages, which were nice.

I propose a different sort of Nurses' Week observation for next year.

For Nurses' Week 2011, let's start paying nursing professors what they're worth. Let's make their wages better than those earned by the most entry-level nurses at the bedside, for starters. When I graduated with a two-year degree and started working at the bedside, I was immediately earning thirty percent more than my highest-paid professor, who had a PhD.

Paying nursing professors fairly would bring people who really want to teach into the field. Right now, they look at the starvation wages, long hours, and piles of paperwork and decide to bag it and stay at the bedside. That's led to the shortage of class space and contributed to the nursing shortage--plus, it shows how little we really value a good nursing education.

For Nurses' Week 2011, I want a commitment that hospitals in particular will be safe, healthy places to work. Too many nurses and ancillary folks are subjected to the sort of abuse from patients and family members that would get you thrown out of the skankiest bar in Bigtown.

I've had problems personally with patient-on-nurse violence, and it raised its head again a couple of weeks ago, when a patient's family member got up in a colleague's face. She did what I'd told her would work: called 911, turned the family member over to the cops, and then filed charges. That made Manglement pay attention and deal with the situation, but it should not have to go that far. I want a commitment from managers all over the country that nurses should not have to make a federal case of violence and threats to get relief.

For Nurses' Week 2011, how 'bout we quit cutting budgets for support staff, too? The patient care techs and housekeepers and lab staff and radiology folks are all vital to the jobs we do. I can't monitor a patient with a bleeding problem if I'm busy cleaning a room for an emergent admit. Likewise, sometimes it's better to have a tech bathing patients than a nurse, because--frankly--not only are the techs better and faster at it than I am, but they're likely to learn something from the patient that the patient won't tell me.

We do incredibly important things, but those important things are dependent on the work that the invisible people in the hospital do. Let's bring those invisible people out into the spotlight for once, and make it clear how much we depend on them.

And finally, for Nurses' Week 2011, let's you and me talk about what we actually do as nurses, and get the word out.

We dare to care, yes. I don't know about you, but I personally also dare to interpret lab values, take calls from pathologists, arrange meetings between family members and doctors, push the occasional dose of epinephrine, hug people, wipe ass (yes), act as a care coordinator, take responsibility for my own and others' fuckups, and generally herd cats.

We're not just warm and fuzzy: we're scientists, we're social workers, we're personal counsellors. If we can give the people we talk to about nursing a complete picture of what it is we do--rather than focusing on things like nurses eating their young, or crappy doctors, or how fulfilling it is to wash a back at three a.m.--we're likely to find many more smart, motivated people who are suddenly interested in becoming nurses.

I wish you all a very happy Nurses' Week 2010: old nurses, new nurses, nursing students, nursing professors, ancillary staff, respiratory techs, radiology guys, the dude who deals with the red-bagged stuff, unit secretaries, transporters, EMTs. I'll bring the queso and chips; the rest of the feast is up to you.

For Nurses' Week 2011, though, let's plan a real celebration and appreciation of nurses. Let's plan something meaningful and push for changes that'll really make a difference for us and for our patients.

And let's all get massages. That was really, really nice.

The comfort of other nurses (and nursing students)

Nursing is hard. (cf Barbie, "Math is hard!") It can be lonely, overwhelming, frustrating, irritating, enraging, satisfying, thrilling, scary as hell, and sometimes hilarious.

Nurses need nurses. Back when I started nursing, I was so burned out on the whole "talk about nursing all day/dream about it all night" thing that I'd done in school that I made friends who weren't nurses, on purpose. Then, about two years into the deal--about the time I started the blog, not coincidentally--I realized that there was a shortage of people I could talk to who would really understand what I did for a living. In one sense, it's like being a veteran or having lived through a natural disaster: explaining the backstory for everything that happens would take too long for a civilian audience, and dilute the power of the stories.

Once you've had somebody die with your hands on them, or brought somebody back to life with a combination of chest compressions and epinephrine, your life changes. Your worldview is never quite the same, and you never have a truly bad day again. After all, you're vertical, right? And you're not in the bed. And there are no tubes in your bladder or throat, so it's all good.

There are very few people who really *get* that. Most of 'em are other nurses, or nursing students who have seen a few things.

Abilene Rob has a brilliant description up on his blog just now about what it's like to watch a heart bloom in the cath lab, once the dye is injected and goes through the heart. Watching a brain bloom like that is what made me first believe seriously in God. (Sometimes that belief gets tested, as in cases of GVHD, but that's another post for another time.) He and I have had some nice chats about watching doctors tear open an incision line with their hands in order to evacuate clots that were cutting off important avenues for blood and air, or folks with such serious jaundice that they're dark orange.

Other nurses have consoled me when they've sensed that I've been less-than-myself. They've sent emails, or funny e-cards, or just let me know that they're thinking about me after I've, say, lost a patient in a particularly brutal way.

Sometimes I get an email from a civilian who says, "My mom was a nurse, and what you talk about is what she talked about at dinner when I was a kid. It makes me feel closer to her to read about what you do. Thanks for doing it." That helps immensely, knowing there are non-nurses out there who really get it.

We need to take care of each other. We need to take care of the students who depend on us to learn not to kill people. I'm incredibly fortunate to work in a place where nurses don't eat their young, but those places still exist. Cannabalistic nurses need to be called on their behavior and told it's not acceptable; new nurses need to be nurtured and toughened up and cut some slack. Students need to be shown all the cool shit we do, and how vital even the most boring stuff is, even at the same time they're shown why we still smile after years when we say "I'm a nurse."

Never say "I'm just a nurse." What we do is trench work: difficult, dirty, sometimes heartbreaking, occasionally dangerous. It requires skill and brains and an ability to deal with people that is tested every damn day on the job. We--you--are not "just" anything.

Be careful out there. Watch each others' backs. And pat your own for the job you do. I'm proud to call you a colleague.

The morning after the nights before.

Holy crapping monkeys, as my coworker Kathy would say, it's been a week. Working four nights in a row leaves you in much better shape than, say, working two nights, being off for a day, and then working two more....but HCM, what a mess I was this morning.

I'm finding that I really like becoming a generalist. Though Sunnydale is primarily a neuroscience facility, we also see what are called "complex" patients. Those are folks with massive, complex medical histories that wouldn't normally be able to get the sort of surgical or medical care that we provide in the itty-bitty towns where they live. As a result, this week I've taken care of a patient with a neobladder (so freaking cool--hey! Let's make a new bladder out of this piece of intestine! How about it?), one poor dude with some whacked-out chest surgery, a woman with an incredibly complex breast reconstruction that involves moving some bits here and other bits there, and a couple of people with your average, every day, run-of the mill stuff like aneurysms and infiltrating sinusitus, who also have X, Y, Z, and Z to the X wrong with 'em.

My eyes still glaze over when I see an EKG rhythm other than normal sinus, but I *really* dig seeing fresh post-op patients and their various problems.

Sometimes those problems require more of a light touch than at other times.

I was settling in a fresh post-op last night whose angiogram had run later than we'd expected. They'd managed to coil the dude's aneurysm, but one of the coils had gotten loose and had had to be retrieved, which took a little longer than usual. He was fine--grumpy about having to lie down flat for six hours, but otherwise okay--so I was able to take some time between hourly neuro exams and chat with him.

He started talking politics. Now, regular readers of this blog know that I don't talk politics or religion with my patients. If they ask, I'm a Democrat, a conservative Republican, a Christian, or a Blorgian yak herder--whatever gets me out of the room and doesn't raise either of our blood pressures. So this time, as in the past, I kept my eyes down, my hands busy, and my mouth shut while Aneurysm Dood bloviated.

Health care, as it turns out, is not a human right. Nope, no sirree. Health care of any sort is one of those things that the deserving work for, by God, and no socializt preznit is going to tell *him* any different. Why, if you need something, you should just go to the emergency room, right? (I didn't say a word. I swear.) Nobody should get what they haven't earned; if they take something for free, like health care, they're nothing but a drain on the system.

(Parenthetical note: why did this guy assume that I would agree with him that health care isn't something that everybody ought to get? I mean, did he not realize that I see the effects of untreated hypertension and diabetes every day? I know, I know; rhetorical question.)

In fact, that's what *he* did. He had a terrible headache, and some vision changes, and drove himself to the hospital--no socializt ambulance for him!--where it was discovered that he had an aneurysm that was just about to go nucular, if you'll excuse the term.

Whereupon he was airlifted, on a two-hour whirlybird flight, to our fine facility. We called in the neuroradiology fellow, a couple of CNAs, the radiology techs, a nurse or three, and promptly coiled his aneurysm. We then moved him to the CCU, where I was busy dealing with his incredibly labile blood pressure.

Where, glory be to the Great Watchmaker and technology, he was well enough to bitch about socialized medicine and the takeover of our good, clean American society by left-wing radicals interested in running our lives to the nth degree. He'll spend the morning in the CCU tomorrow, then be ambulanced home to Teensyville, where he'll return to normal life, except for a checkup in six months.

I was glad we were able to help him out, even if his particular views were odious to me personally. I was even more glad when I saw his face sheet, with the code next to the financial number that means his care was paid for by the hospital as a charity case. Everything, from the airlift to his breakfast in the morning, will be financed by Sunnydale; it's part of our commitment to provide free care to one in five patients.

Those damn socializts. By which I mean us.

Well, that was an interesting phone call.

Dear Doctor Dipwad:

If I call you several times in the course of a night, warning you about subtle neurological changes that your patient is having, please don't blow me off.

Because, if you do, I will be forced to call your attending at oh-damn-thirty and let him know that the subtle changes you blew off have become something truly horrible. By that time, of course, the patient will be already on the way for a stat scan, and I will have alerted surgery. 'Cause I'm good like that.

So when your patient (whose changes you ignored) is going to surgery for an emergency skull-chop, and your attending isn't happy about that, and I'm running mannitol much faster than it probably ought to be run, and there are intubation trays all over the place, just remember: dealing with it now means you'll have less to deal with later.

And, dear Doctor, once it's been established that you were indeed a Dipwad about things, please please please don't try to blame it on me. Don't tell your attending that I didn't notify you when things started to go pear-shaped. Don't tell my boss that I failed to catch the subtle changes that I called you about four different times. There's this little thing called charting that I do that will put paid to your story. Also, the page operator has a computerized record of all the times that I tried to make you see reason.

All that being a further Dipwad will do is make my boss call me in the middle of a nap to make sure it's okay that she accesses my charting. I'll say it's fine, and you'll be sitting there in a conference room with my boss and *your* boss, and I'll be on speakerphone, and then things will begin to get very depressing for you.

I'm just sayin'. You interrupted my nap like I interrupted yours, but the consequences were very, very different.

(The patient will be fine, by the way.)

The stupid: It BURNS.

This has been One Of Those Weeks. The level of Stupid has gotten to the point that, if somebody doesn't do something soon, the Stupid will all roll together into one big ball of Damn That Was Dumb and there'll be a cataclysm.

For instance, Doctor Fuquad, you should probably not put a luer-lock access on to an arterial line. (For you non-medical types, an arterial line is just what it sounds like: a big IV-type thing that goes into an artery in your wrist so we can monitor your blood pressure directly during surgery.) For one thing, if you're monitoring pressures with an A-line, the luer-lock access will screw things up and make it look like the patient is running a blood pressure of 264/264. For another, and here is where I start to get all-cappy, YOU ARE NOT SUPPOSED TO PUT ANYTHING INTO AN ARTERIAL LINE EVER EVER EVER AND PUTTING AN ACCESS ON ONE MIGHT CONFUSE PEOPLE.

Let's make it simple, Doc: arterial lines are to be flushed only with pressure bags through pressure lines and are supposed to be directly connected to whatever they're going to. Luer-lock IV accesses are only for intraVENOUS access and are meant to allow you to shoot drugs through them. YOU ARE A MORON.

Gracious. Was that a rant? I think that was a rant.

*ahem*

Okay, boys, second thing: If you've done belly surgery on a patient, and that patient has developed a rigid abdomen and a sharply falling hematocrit about two hours after surgery, please don't keep that patient in the CCU for eight more hours to see if the bleeding will stop on its own.

(Yes, I just said that. And I just put my head in my hands In Remembrance Of Things Stupid.)

Ten hours after surgery, things were going.....badly for that poor bastard. Dr. Fuquad's brother, Dr. Diqhed, looked with some surprise at the lab values that were incompatible with life. A hemoglobin of five-and-a-half and a pH of seven-point-one? (For you non-medical types, these lab values are both fatal and entirely preventable. If you're not STUPID.) Well, then! Let's pour eight fucking units of blood into this guy using pressure bags, and if we don't have enough pressure bags, let's have Jo just stand there and squeeze!

And let's watch the blood we pour into the patient pour straight out into his already board-like belly!

Dr. Diqhed stopped by the unit after his patient's second surgery and expressed surprise at how well the patient looked. I couldn't stop myself--I hate this guy; he's an attending who should be weaving baskets--and said, "Yeah, it's amazing how great people do ONCE YOU STOP THE BLEEDING." (YOU MORON)

Uh, oh. Ranty again. So very sorry.

*koff*

And, finally, Manglement At That Other Hospital? It doesn't matter how sick your immunocompromised patient is with his widely-disseminated herpes simplex: you probably shouldn't put him into a unit meant for people who are seriously immunocompromised. Because if you do, all those poor bastards will be showing up at Sunnydale's CCU, medevaced in with screaming disseminated herpes simplex infections. It really doesn't matter how much negative pressure you have and how much your nurses scrub; that shit will travel.

Herpes encephalitis is bad enough. Herpes encephalitis combined with a cutaneous herpes outbreak bad enough to obscure major anatomical landmarks is worse. Like, if I can't see the person's navel for the blisters, that person is fucking SICK. And, if not for the level of MORON at your fine establishment, this could've been prevented.

*rubs eyes*

Every morning between three-thirty and five I get a little shirty and short-tempered. This week's been worse. I only cry when I'm angry or frustrated, and today I found myself sitting in the locker room on a bench, facing the wall, trying to decide whether breaking my hand by punching that wall was worth it, or whether I should just sacrifice my mascara to the Stupid.

I ended up having some Gatorade and a chicken sandwich and going back to work. Sometimes there isn't enough time to get upset about The Stupid; you just have to try to fix it.

Live in a swamp and be three-dimensional.

Good advice at any time, but particularly now, when "be oblong and have your knees removed" sounds really, really good.

The original title of this post was "*thud* POP! AarghFUCKFUCKFUCKAARGH", but I decided not to go with that, as it didn't get to the real heart of the matter: the fact that I sprained my right knee during my workout with Attila last night.

Yeah. Sprained knee. Not badly sprained, as I can walk on it, provided I keep it wrapped up tightly with an ACE bandage, but sprained. It's not exactly painful, but it's a weird feeling, not being sure whether or not the lower half of your right leg is going to shoot off in some random direction without warning. I'm walking like I'm eighty and taking my own weight in naproxen sodium at the moment. If things don't improve markedly by tomorrow, it's off to the Doc-In-A-Box I go, for better bracing and a note that says that yes, I can work, really and truly.

Friend Suzie, who seems to have lots of time while wrangling rats and pigs to think up bons mots, asked me in a concerned tone, since I'm reaching "that age," if I was sure I hadn't broken a hip. I would kick her, but I can't manage that much movement with the bum leg.

For the first time, I am truly grateful I'm still on the night shift and in the CCU to boot. Were I still on the floor, I would have to chase around five or six rooms, move people, help them out of bed, and generally be active. With any luck, my assignment this week won't involve a lot of gymnastics.

Before I sprained the knee, I had plenty of gymnastics going on. One of my patients, who has the deep misfortune to have a number of bacterial and fungal infections going on in about six different places at once, suddenly became unresponsive the other morning, just before the docs started rounding. (I suppose that's more convenient than three ack emma, but not by much.)

She had been fine all night. Ten minutes before, she had been fine. Then, as I was walking past her room on the way to pick up some drugs from the pharmacy, I heard her snoring. My first thought was, "Thank God she's finally getting some sleep". My second thought was, "Um....that doesn't sound right. At ALL."

I went into the room to find her blowing spit bubbles, eyes rolled back in her head, and not moving anything, even to pain. Her pupils were uneven and oval--and that's a bad, awful, panic, horrible, hair-on-fire, Jesus Christ you stupid lazy nurse you missed an earlier neuro change sign.

Somebody called the resident. Somebody else called the radiology guy and woke him up from his nap (sorry, Scott!). I had the fun job of calling the family, and of having an audible code called while I was on the phone with them. We never lost a pulse, but we did end up intubating her, as we couldn't trust her to protect her own airway.

Thirty minutes later, she was back to neurological baseline. Was it a seizure? I have no idea. A cardiac issue, caused by heretofore unknown vegetations on her heart? I would think so, but her enzymes stayed fine all day. Hydrocephalus? Pneumocephalus? Maybe, but neither one of those do what whatever-it-was-she-had did. Plus, her CT was totally clean, totally unchanged.

The upshot of the whole trauma-drama was this: both the intensivist and the neurosurgical attending agreed that I had not missed anything prior to The Event. (This was a huge comfort; I had broken my own rule earlier in the day and had stayed up worrying about her rather than going to bed.) The attending confessed with a shrug that he had no clue what had happened. The intensivist opined, in his heavily-accented way, that sometimes strange things happen. Coming from a fellow nurse, that's nice, but coming from a six-foot-four Sikh with a blue turban, it's comfort.

We'll probably never know what really happened in her brain to make her go bad like that. We'll probably never know what happened to make her come back, just fine, and be extubated a bare six hours after she was intubated. All I know is that, the next night, when I asked her to show me two fingers and she grinned and flipped me off, it was the best feeling ever.

IT LIVES!

The first night was weird. My brain and my body disagreed vehemently on what time it was, and I felt very odd all night.

The second night was torture. I didn't know it was possible to feel that bad physically and still be vertical and productive.

Last night was...not so bad, actually.

I might just be able to do this working nights thing for a little while. I'll never be a natural night person, as my body-clock says "Wake up at 0400; go to bed at 2100", but I think I can, I think I can, at least until somebody goes on maternity leave, or something.

The possibility of having to work nights during the summer leaves me cold with fear. How anybody could ever work nights in a state with the hottest and brightest sunshine I have ever seen is beyond me. But for January, February, and probably a little of March, when it's rainy and cloudy most of the time anyhow? Count me in. I can doooo eeeeet!

Nights are weird, people. In a hospital, you're insulated from the rhythms of the outside world anyhow, but at night, it's even more pronounced. The morning rush starts at 0130 down at Big Brother Bruce's Bargain Brain Barn, with CT scans and MRI and morning labs and what-have-you. That means that the first hour of the shift is busy, the middle of the night is most definitely not, and the last six hours of the night vary from steady to downright insane. That's the opposite of how it works during day shifts in the Sunnydale CCU, and that's been the hardest thing to get used to.

Night people are weird, too. There's a certain breed of person who's meant to stay up all night and sleep all day. They don't do well on days (can you imagine? I can't) but are cheerful and helpful and ready for pizza at two ack emma. And they're all a little off. Intelligent, pleasant, good company....but a little weird. They don't see anything odd about listening to Morning Edition when they're on the way home from work, or buying beer at 0700. (That was my greatest discovery: at the end of my second night, when all I wanted was a beer and my bed, I discovered that you can buy beer here before sunrise on weekdays. Alors!)

The trick is going to be sticking on this schedule when I'm not working. Attila is coming over this evening, after which I plan to take myself out for a celebratory dinner. Tonight I'll sleep; tomorrow, I'll take a nap in the afternoon and stay up all night (thank God for 24-hour grocery stores), and Sunday I'll sleep all day. I work again Sunday night.

Oh--did you know (again, a revelation to me!) that there are BARS that open at SIX A.M. and serve BREAKFAST and have HAPPY HOUR?? I mean, I'd read about that in books, mostly books set in London near the docks, at the turn of the century, but I had no idea that the Green Door or Louie's served eggs-your-way and a vodka martini at eight in the morning. Monday morning, since Sunday is a one-off, I'm going to hit Bigtown's most venerable lesbian bar, which serves a breakfast buffet on weekday mornings, then go trolling salvage shops for 1/2" knobs for my desk.

It's like a vacation in a foreign country, but I'm getting paid. Very, very weird.

My plans for tomorrow night:

How Jo Plans To Stay Awake During Her First-Ever Night Shift; or, Disaster Comes On Little Cat Feet

1. Nerves. I figure nerves will carry me from 1900 until about 2200.

2. Coffee. I can drink a cup of coffee at 2230 and stay awake until well after 0200, at which point there are...

3. CT scans and MRIs to haul patients down for.

4. And when I get back from those, there are baths to do.

If all of the above fail, then....

1. Food. I've been warned by a number of people not to forget to eat while I'm on nights; apparently, this is a big problem for some folks. Not sure Mama's gonna have a problem with that, but I'm taking an omelette and a salad with me anyhow. (Actually, that sounds pretty good right now, too.)

2. Sports. Everybody on night shift is on some sort of fantasy football team. Even though I don't watch sports or follow them at all (except for Olympic curling, which I love because it's just so weird), their chatter will keep me awake.

Which brings me to the fact that our CCU is essentially oval. On the back wall is a single automatic-open door leading to the back hallway, which has things like the dialysis rooms and outpatient lab collection and the lab and so on on it. The front side of the oval, as it were, is the CCU. With an oval floor layout, you can have....

3. Curling. Steal a whisk broom and a push broom from Housekeeping, snag the tea kettle from the break room, and put some tape lines on the floor. Presto: your own indoor, ice-free curling arena! And if that's too north-of-the-border for my colleagues, an oval layout also lends itself to....

4. Roller Derby. This might be the opportunity I've been waiting for all my life. I'd make one hell of a blocker and might even work as a pivot, you know? Plus, I have a name all picked out: Miss Ann Dree. Get it? It might be a little work to get Steve, the six-foot-five ex-Ranger to play on a mostly-girls' team, but I think we could make it work. If all else fails, we could have two sides of three each and he could referee.

5. Boys! And girls! The nurses at night play "Which resident is least loathsome?" (answer: Not Dr. Dweebo) and "Which movie star makes you want to stab your eyes out the least?" Most of the day-shift CCU nurses are gay; most of the night-shift CCU nurses are straight. Do not ask me why this is, and don't ask if it's a common thing; I don't know. Anyway, going from one to the other should give me plenty of thought-provoking answers.

6. FORKS IN A DISPOSAL!! This is the favorite game of the nurses on days. Whenever things get too rough, too tough, too stressful, or too emotionally-charged, we all go into the back and do a quick run of Forks In A Disposal. Essentially, you hop up and down with your hands in the air, yelling "Tink-a-tink-a-tink-a-tink-a!" and going in circles until everybody falls down laughing. I look forward to introducing this concept to nights.

7. Tooth-Whitening and Cuticle Care. I once asked Friend James how his night was, and he replied, "Oh, great. I got to do my tooth strips and a manicure, see?"

8. Boomshine, Bubble Blaster, and Bejeweled. 'Nuff said.

9. Facebook. I mean, what was Facebook invented for, if not long night shifts when both of your patients are on floor orders and everybody else is intubated, including your coworkers?

10. ...aaaaand here is where I run out of ideas.

I'm really kind of nervous. I mean, on the one hand, it'll be nice to get to nap frequently and well tomorrow, with the excuse that I'll have to be up all night tomorrow night, but on the other...working nights is a different feel, a different schedule and rhythm. I'm not sure that my natural hyperactivity will work well with night shift.

I've never been happier than this past week at work, when I felt like a barely-adequate skiier confronted by a double-black-diamond slalom. I had everything just barely under control--with a whole, whole lot of help when the shit hit the fan--and was loving every second of it. Long stretches of not a lot to do is the primary reason I left the floor for the CCU.

Oh, well. Attila's been kind enough to give me a list of easy-to-do, no-equipment-necessary exercises that are guaranteed to wake me up and make me a laughingstock, so maybe I'll just do those in the middle of the night. Hell, maybe I'll haul in my twenty-pound bells so I can do oblique crunches and lower-back exercises at 1 am.

Wish me luck, Fearless Readers. I think I'll be needing it.

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.

Holes, part two.

They don't tell you these things when you're in school. They don't tell you these things when you start out. You have to find them out for yourself, the hard way.

Two deaths this week: an old patient and a young coworker.

The old patient was the first person I'd ever put Buck's traction on. She and her partner had been together for something like 70 years and were both doctors. They were doctors at a time when women either weren't doctors at all, or were doctors in something nonthreatening, like pediatrics. Not these women; they went into internal medicine and orthopedics and proceeded to kick ass in the research and practice departments.

They showed up after my patient broke her hip in a fall. They stayed for a week after her hip replacement, then went to a rehab closer to home. They sent Christmas cards every year, thanking the nurses for their work. I was a brand-new nurse when I cared for her, and I learned a lot: like how Buck's should be put on, what output on a CHF patient looks like, how to prevent shear injuries in moving orthopedic patients. Every time I get a CHF patient, I think of her, still, seven years later. That is her life-after-death, and I think she'd like it.

The young coworker?

He was younger than I am. Most of 'em are, these days, but it doesn't lessen the shock. He'd gotten bloated over the last few months and had seen a doctor about it, only to be--finally--diagnosed with by-then-far-advanced liver cancer. He died barely two months after diagnosis, sadly compos mentis to the end and well aware of what was happening. Rumor has it that he was giving tips to the nurses' aides that took care of him up until the end.

This is what they don't tell you: That, if you have nobody at home who's willing to listen, or nobody at home at all, you'll walk around feeling the hole.

Remembering people to somebody else keeps them alive. It does what we fail to do all too often. When you can't remember somebody in person, you either drink, or take Vicodin to the detriment of your liver, or you blog. Of the three, blogging might be the least harmful but is certainly the most annoying.

Eventually, it gets to you. I put my hair up this morning in its usual bun and wondered whose obituary I'd read today, rather than wondering what's in store in the marvelous healing and miraculous recovery department. That's temporary, of course; I'll wake up next week optomistic and energetic again, and forget what it's like to wait at the elevator for somebody who's not going to show up.

The bitch of it is--the truly real bitch--is that so few people share your experience. "Someone died," you say, and they say, "Oh, so sorry". It's not the same as saying "someone died" and having the other person say, "was it under your hands? 'Cause that sucks." You realize, the longer you do this job, that you live on the other side of a vast gulf of experience, separated even from your best friends and your parents and your lover.

Well-meaning people try to cheer you up, when what you need is to sit out on the porch and pour one out for the homie who's no longer there. They want to listen, but you find yourself explaining things in too much detail, too carefully, and somehow the sheer raw power of life and death gets lost. It's not the same as it is on TV: it's not pretty, it's not accompanied by a feeling of closure and two thirty-second commercial breaks, and it's sure as hell not done in company of a bunch of good-looking residents.

This, friends and students and neighbors, is the hard part. This is the time when what we do, no matter how much we love it, gets lonely and empty and strange. This is the point at which we survey groups of people and wonder who's going to be alive in a year, simply because we've seen so many young, healthy, old, intelligent, marvelous, funny, grouchy people die.

They all leave holes in your soul. Some of them are big holes, some of them are small. Some people you see die and feel nothing but relief and thankfulness. Others, you wonder why the hell the good not only die young, but die young of horrible things. Eventually, you look at your own self, not with shock that your essential person-ness could've survived so many leavings, but with wonder, at how long it seems to be taking to disappear.

The human brain is an awesome thing: I mean that in the original sense of "awesome". It is also a terrible thing: ditto. The human soul? Is equally as awesome, equally as terrible, equally as deserving of respect. And it is, thankfully, infinitely more elastic than the brain.

If what happened to my self had happened to my brain this week, there would be no way I could've gone to work today.

Those who are not here any more eventually, and irreversibly, define what I am.

Auntie Jo's Rules For Decent Behavior, Inside The Hospital Or Out.

1. Bathe.

I don't care if you paint your toenails, shave off every last bit of your body hair, or are covered with tattoos (am I the only person in America without tattoos? Sometimes I think so). If you're not clean, I care. I care deeply. As long as you bathe regularly, like at least once a week, I'm happy. If you stink the stink of the deeply, chronically unwashed, I am bothered.

2. Don't threaten violence unless it's absolutely necessary.

There is no need to tell me that you'll "fuck me up" if I don't do something right. I'm going to do it right without your threat, because I'm ethically obliged to, and besides, your grandma is a much nicer person than you are. If you were my patient, there might be a few instances of fuckupery on my part; as it is, there will be none. So STHD and STFU.

3. Please don't ask me if I want to date your cousin/grandson/uncle's sister's stepchild.

It's not exactly a welcome question at the bar; when I'm doing a tricky dressing change or assisting with a bedside procedure, it's even less welcome and more distracting. Subsets of this behavior include: stalking (you're not going to be able to stalk me very efficiently if you're ataxic, so don't try), giving me your number on a piece of hospital stationery, or trying to pull me into bed with you for a little kiss. I don't care if you're eighteen or eighty; knock it off.

4. Do not, ever, press me for my opinion on political matters. You won't like it.

I'm a big ol' flamin' feminist socialist. And, since I can actually define "socialist" correctly and use it in a sentence, I get annoyed by those of you who can't (and who further equate socialism with Communism, Stalinism, Nazism, and Glenn Beck's Flavor Of The Week). Please don't ask me what I think of health care reform, universal sufferage, the plight of immigrants (legal or il-), or whether women's shelters ought to be defunded. I might tell you, and then your aneurysm would grow, and you'd have to go to the ICU and would be deprived of the pleasure of my company.

5. If you're a racist bastard, come right out and say it.

I had a guy do that once, and it made things much easier. I was able to reassign nurses and nurses' aides and read the guy the riot act in the meantime. If I'm forced to interpret your Birther mumbles through the tiny hole in the sheet that you're wearing, it's going to waste a lot of my time. If you're an asshole, own up to it. We'll get along fine once you understand that it's my way or the quick ambulance back to Hicktown highway.

6. Tell me about your animals. Or ask me about mine, though I'll probably tell you anyhow.

I want to hear all about your critters. I may disagree that your Corgi, Chihuahua mix, or Siamese is the best animal ever, since my critters have the top three spots and my nephew the fourth, but I'm interested anyhow. We can discuss grooming aids and kibble while I'm resiting your IV, and I'll take you down in a wheelchair so that you can see Spot or Fluffy. You might even be the person to hook me up with the nonaggressive, big dog I've been looking for to be pals with the Max-Zoats.

7. Don't pretend that that dude on the couch is your wink-wink "friend". It's cool.

I'm just glad you have somebody here with you. I don't really care if you're straight or gay; the important thing is that somebody loves you, and that you love them. Likewise, it's not really necessary to show me your POA or living will; I'd happily break the law to allow a life partner into the room, and damn the consequences. It's a hard enough world out there; love like that is something to cherish, not block.

8. Ask questions. Really.

I'm not going to be threatened by you asking questions, double-checking the bed angle, or otherwise sticking up for the patient. In fact, I'll welcome it: I make mistakes, especially toward the end of a long run of work days. Two heads are definitely better than one in this business, and I'm just grateful that you're paying attention. Besides, education is my all-time favorite part of being a nurse, and I like to hear myself talk, so you're golden. If you're considering emailing me for advice on being a student/nurse, feel free! I'm always looking for excuses not to do the dishes. Likewise, if you just want to hang out, that's good too.

9. If you really, really like the care I've given you, tell the boss.

A couple of times, people have left me money (donated to Sunnydale's Christmas Angels program) and once, a bottle of really good single-malt Scotch (hidden under my voluminous lab coat and taken home in defiance of hospital policy). I'd much rather you tell my boss, though, as it helps temper the image of me as some sort of lunatic loose cannon let fly on the medical world.

10. Finally, let me know if there's something wrong.

Again, this goes for both friends and patients. I am not psychic. I can't tell automatically if there's something I'm either doing wrong or not doing at all; you have to tell me. My fee-fees aren't going to get hurt; instead, I'll take the check and use it the best way I know how. And be grateful if, in future, I have reason to recall the lesson and use it again.

See? It's easy. All you have to do is do things my way and the world is a better place.

PS: You're a moron.

Part I

Dr X: "Why hasn't the Argle-Bargle T380A test been run on my patient yet?"

Nurse Jo: "Because it's a timed test that has to be done by the lab. It can't be drawn through a central line."

Dr. X: "Why haven't you drawn it yet?"

NJ: "Because...it's...timed. As in, it shouldn't be drawn until a...specific time."

Dr. X, growing upset: "But you could draw it right now! Out of the central line!"

NJ: "No. I can't. It can't be drawn through a central line. The heparin lock we use will screw up the test results, and besides, it's a timed test. It's not due to be drawn until 1630."

Dr. X: (incoherent ranting about incompetence of nursing staff.)

NJ: (finds herself on the opposite end of the hall, unsure of how that bruise got on her forehead. Oh, wait. It was Head-Meet-Wall again.)

Part II

Dr. Y: "Why did you change my patient from calcium gluconate to a calcium citrate and magnesium supplement?"

Nurse Jo: "Because that's our protocol for people who have had gastric bypass surgery."

Dr. Y: "But this patient didn't have a gastric bypass! She had a parathyroidectomy!"

Nurse Jo: "Yes, I know. However, the patient's history shows that she had a bypass six years ago, and her blood calcium levels have been low enough to warrant IV repletion. Therefore, according to protocol, we changed her over to citrate and mag, and her calcium levels have come up."

Dr. Y: "Are you a doctor? I didn't write that order!"

NJ: "It's the standard hospital nutritional protocol for patients who have had bypass surgery. Here it is on the computer (clicks twice)."

Dr. Y: "I didn't write that order! You had no right to change that patient's medication!"

NJ: "Her calcium has been stable at 9.2 for three days, after being between 2 and 3.5 for the proceeding week. Is there a problem?"

Part III

Dr. Z: "Why didn't you replete this patient's magnesium and transfuse blood?"

Nurse Jo, looking worried: "Because I didn't see an order for it."

Dr. Z: "Her hemoglobin is ten! TEN!! Why didn't you transfuse her??"

NJ: "Um... ... ...because her hemoglobin is ten. And has been ten for the last four days. And her magnesium is 2.0 and has been for the last four days."

Dr. Z: "But I always transfuse patients with a hemoglobin less than twelve!"

NJ, taking chart in hand: "See this preprinted sheet? You filled out this preprinted sheet. It says right here that if hemoglobin is less than nine or crit is less than 25, we transfuse. It says we replete magnesium for mag levels of less than 1.7. Her crit and hemoglobin and mag have all been above those levels for four. days."

Dr. Z: "But that's not how I do it!"

NJ: Considers banging head on desk, then decides that the bruise that's already there is enough, and wonders why on EARTH the new docs in rotation aren't briefed on our protocols.

Super freak. (Composed Saturday night; posted Sunday morning.)

Oh God, oh God, oh God.

I start the CC internship in a month. A month. What was I thinking? What the hell am I doing, leaving what I'm used to? What happens if I hate it?

What happens if I can't do EKGs? I've never been good at EKGs. And all that other CV stuff; I haven't done that in years. I can't remember what Vfib looks like. Blocks...blocks...I can't remember blocks. What's the normal for mag? I can't remember. I've been off work for too long. I'm only back for a few weeks, and then I start the internship.

Holy crap. What if I hate it? What if they hate me? I'm going to have to work nights. I've never worked a night in my life. What if I can't stay awake? What if I can't sleep the day before my first night? Oh, God, oh, God. Nights. What am I going to do about feeding the dog? How long will I have to work nights? When will I start? What if I hate it?

Seven years. I've worked on the same unit for seven years. Why did I have to go and make a change now? I wonder if it's too late to back out. It probably is. What if I hate it? I'm going to feel like a complete idiot for at least a month, and pretty stupid for at least six months after that. Ventrics. I haven't dealt with a ventric in...what? Four years? Five? I've forgotten how to level them. I mean, I know this is what an internship is for, but they'll expect me to remember this stuff.

Oh, geez, and ventilators. I wonder how much ventilator stuff we'll have to do. RT is right there, but will I have to troubleshoot? What about extubation? What about intubation? What about code team? When do you use bicarb, again? Isn't bicarb, like, your last resort? Shit. And open bellies. Open. Bellies. Covered with plastic wrap. That's insane. What am I doing, changing units?

We're gonna see a lot of flu cases this year. Probably some of 'em'll be on vents. I hope I don't get the flu. What'll I do about vents? What if I have to go to Holy Kamole and work on vents there? And what about all that damn CV stuff? Geez, I hate counting out rhythms. I need to get a better stethoscope. I need a set of calipers. My feet hurt. It's the last night of my vacation, and my fucking feet hurt. I can't sleep. What about EKGs? I wonder when they'll have flu shots for us. I wonder *if* they'll have flu shots for us. Maybe I can tell 'em I'm pregnant, and get a flu shot that way. But then I'd have to produce a baby.

Which would probably be easier than starting this damn internship.

*toss*

*turn*

Friday night musings

"The thing you must remember," (said my friend Paul the Pastor the other day) "is that David danced naked before the Ark of the Covenant."

Workplace bullies tend not to be bullies if a) you call 'em on it; or b) you just look at them with wide eyes and then laugh in their faces.

If you feel like you're about to start crying at work (see above), go work out some tricky drug dosage calculations and you'll feel better.

Cats are annoying. That is, they're annoying until they start doing something incredibly sweet without reservation. At which point they become adorable and you have to snorgle their bellies.

Always read the concentration on the Narcan vial. The two different concentrations are packaged in ampules that look exactly the same.

There is always time for freshly-picked home-grown tomatoes, blueberries, good Swiss muesli, or coffee.

The look on your dog's face when he realizes he's going on a WALK is the best thing ever.

If it's a full-body rash with blistering, five gets you ten it's a Dilantin rash, no matter what the dermatology consult says.

Bamboo cannot be killed. Don't even try. Find a way to incorporate it into your landscaping.

And, for God's sake, don't plant wisteria where it can pull down large limbs from old pecan trees. The neighbors and I have had this problem lately.

Hummingbirds occasionally perch. If you're lucky, they'll perch on the arm of the chair next to yours on the deck. Breathe quietly.

Seeing ants crawling over the walls of the hospital room is, usually, a reaction to narcotics.

If in doubt, change the Foley. If in doubt, change the peripheral IV. If in doubt, administer oxygen and fluids.

But, for the love of Mike, don't touch the Quinton.

I was driving down the street, coming back from Home Despot the other day, when I saw a navy-blue Chrysler New Yorker zipping along. Following it was an orange International Harvester truck. I was suddenly thrown back into the past, when You Could Do Anything In A Chrysler. Getting older is like that; the oddest things trigger memories.

Nothing is ever lost, only changed. That's both the first law of thermodynamics and faith.

The lunatic is in the hall. And, sadly, the break room.

One of the things that happens when the management of a place starts to break down is that the weirdos come out of the woodwork.

It doesn't happen immediately. Sometimes it takes a while, as the nice, normal, everyday people in the place get replaced by nutjobs. Eventually, though, when things get weird enough, the weird (as H.S.T. said) turn pro. And, oh my children, it has been the Masters' Tour of Wack on the unit lately.

The ontorexics and tanorexics I can handle. The woman with sixteen fluffy little dogs (I exaggerate; it's really only something like four) is no problem. The nurse who wears what is probably the entire stock of Sephora and jumps like a startled rabbit every time you speak to her doesn't bother me a bit. The golf-obsessed? I don't turn a hair. The Cultist, though, really threw me for a loop.

He doesn't wear white robes and Nike sneakers, at least not at work. I've never caught him offering any sort of sugary drink to anyone else. And, for a while, I thought he was okay, if a bit overbearing and loud. Well, and self-righteous. And strange. Until, that is, he started talking about religion.

(Rhetorical question: What *is* it about religion and politics? I mean, I get weird too, if I start talking politics. Anyway.)

We had a run of people who had just been diagnosed with HIV the other week. Two things about the epidemic are really fucking depressing: the fact that AIDS is the leading cause of death for African women, and the fact that HIV infection is beginning to increase again in the very young and the older-than-40. We were seeing a few of all of those groups. It's a shock to be transported back to the bad old days of the late 1980's when you see a 20-year-old who's just been diagnosed with full-blown AIDS and had no idea he's positive. It's depressing to have the second immigrant woman in a week come in who contracted HIV from her husband. And it's difficult to have to talk to a guy in his 60's about how, exactly, he managed to get this infection that "only" young/gay/Black/whatever people get.

So we're talking about this over lunch (because we know how to have fun) and The Cultist pipes up that HIV is a reason he's glad *his* wife was a virgin when they got married.

Pause for contemplation on the part of the rest of the crew.

Sweet Loretta asked, carefully, if he thought that lack of virginity was the issue with the two positive women on the floor. Well, of *course* it was, silly! Because everybody knows that only nasty, dirty strumpets (and, I guess, Godless pervs) end up with nasty, dirty diseases.

Longer pause as we all digested this.

The Cultist took the longer, more aghast silence as an invitation to explain why and how this was a fact, and how it was supported by Biblical texts, and how the truth of the matter (about the nasty, dirty strumpets, I mean) had been covered up for years by a secret cabal involving the Pope, the government, and the WHO.

It was like a combination of Monday morning at the health department and "The DaVinci Code". I think the Illuminati actually got mentioned once; I wasn't paying that much attention. I was too busy checking to make sure that the world was still on its axis and gravity was still working.

I'm still not sure how we all got out of there. By some miracle, beepers started going off and people started remembering meds they had to pass; within about five minutes, only The Cultist was left, eating his sandwich and muttering about the Four Horsemen. I've never been so grateful for patients who call every ten minutes, let me tell you.

That was, of course, before I walked 'round the corner and smack into The Bully....but that's a different post.

I got nothin'.

The blogging gods are angry with me.

There has been exactly nothing that's been crazy, out-of-line, or nutso that's happened this week at Sunnydale General. Everybody's been well-behaved, the pharmacy has gotten us meds on time, nobody's brought in livestock or tried to steal a TV. There haven't even been any Resident Follies to speak of.

I hate weeks like this. It does not bode well for the next month or so that nothing tremendous has gone wrong. Any day now I expect the power will go out, the generators will fail, the cafeteria will catch fire (okay; that wouldn't be so bad), the director of nursing will finally completely lose it and run naked and screaming down the halls, and six patients will have seizures at the exact same moment.

This week has been the hospital equivalent of that scene in a horror movie during which one character turns to another and says, "Gosh, I'm glad that's over" or "We've seen the last of them!" Next week, I'll probably have plenty of fodder. But for now, I'm going back to bed.

Welcome, new residents!

He came out of the isolation room in full isolation gear, strode to the nurses' station, removed one glove, and began to return a page.

"Hey," I said, "Take off that gown and glove and wash your hands before you use the telephone."

"I don't have time for that" he said. "Besides, I took off this glove." He waved an ungloved hand at me.

"Dude. You're not Michael Jackson. Get that gown off, go wash your hands, and don't come out of an isolation room with gear on again" I said, feeling a little growly.

"They let me do this on the cardiac floor!" was his parting shot.

"You gotta be a grown-up over here!" was mine.

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

The neurosurgery residents aren't bad at all. Neither are most of the other residents. All of 'em have been on our unit before, because of the weird residency program we have. It doesn't matter what service you're with; you're going to round with psychiatry, neurology, neurosurgery, or internal med at some point, and that means you'll end up with us.

The two exceptions to that are urology, for some strange reason, and cardiology. And, given that the head of the urology department was a nurse before he was an MD, we don't have too many problems with those residents and things like respect and infection control and signing orders in a timely fashion.

Cardiology, though? Makes me want to tear my hair out.

They're nice people. Really. They're not the arrogant assholes portrayed on popular TV shows. There's not a prima donna in the bunch. They're very hardworking (almost as hardworking as the junior residents on neurosurgery), polite, knowlegeable, thoughtful folks. But they've been spoiled by the nurses on the cardiac unit, who don't care what you do as long as you keep the patient alive.

I, personally, care a whole lot what you do. I'm not going to go through every chart you've touched to make sure you didn't rack an order; I have better things to do, and besides, that's on your watch. And it doesn't make much sense to me to keep one patient in isolation alive if you're going to transfer bits of that isolated bug to other patients and the nurses' station. By the same token, I know a little about drug interactions, but it would probably be a fine idea to consult the pharmacy if you have questions. And, for God's sake, don't attack me because a patient's on a particular antibiotic for which you have a personal antipathy. (Not coincidentally, that was the same resident who didn't take off his isolation gown. Hmmm.)

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

Other than that one service, whom we thankfully don't see much of, things have gone smoothly. We have two new residents in surgery and two in neurology. The surgical residents look, as they all do, about twelve years old. One walks with his arms straight down by his side, peering short-sightedly through granny glasses, with his shoulders a little hunched. I want to feed him sandwiches and pinch his cheeks. The other has such an unfortunate surname that a nickname is superrogatory. That'll save us some time, at least.

The neurology residents may take some getting used to. The senior this time around is a brilliant woman--one of the smartest, most well-rounded people I've ever met--and a total bear to work with. Like a lot of geniuses, she's impatient with us normal folks and doesn't bother to try to hide it. The junior will be a whole lot more pleasant to work with once he gets over his shyness. Speak to him and he jumps. With the patients, though, he's great--he's careful, friendly, explains stuff in English, and never seems to be in a hurry. He's also trilingual in Spanish, Arabic, and English, which will be a huge help. He speaks a smattering of French, Farsi, German, and Russian as well. He's promised to teach me how to cuss in Farsi, which'll be my sixth obscene-word language.

So. All things considered, it's been a better week than I could've hoped for. Nobody's gotten horribly sick, my dehydrated patient with CHF didn't fill her lungs with fluid, and the number of racked orders hasn't been so large that we've had to mount a full-on offensive.

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

In non-work-related news, it's one hundred and bloody four degrees here just now. The projected high for today is 106 to 107. The only things moving are the cicaidas' vocal apparatus. Max is sacked out on the kitchen floor, just in front of the air vent. For those of you without a good idea of what 104 feels like, I offer this: I just went outside and hung up a load of wash on the line. It was scrubs and jackets. After I finished hanging up the last pair of scrub pants, I went back to the first ones I'd hung up and took them down. They were bone-dry.

The kittens, apparently unaffected by the general heat-related malaise, have destroyed a makeup box, my CD player, two shelves full of books, a hot-pan-holder, a box of drill bits, and two stuffed animals (those last are theirs to destroy) in the last three days. I'm going to have to bolt the bookshelves that my grandfather built to the walls, as Notamus is such a fatass he's going to bring them down one of these days.

Friend Elizabeth has a 1949 stove to get rid of. Does anybody want it? It lacks a thermostat for the oven, but is otherwise in good shape. It weighs about three hundred pounds and is currently in Manhattan, Kansas. Anybody in the area from Wichita to KC who might want a vintage stove and oven, please let me know. We'll work something out.

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

"Why are you leaving?"

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

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

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

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

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

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

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

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

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

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

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

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