Pseudephedrine-induced silliness....

Part One:

I'm thinking of changing the tagline of this blog. It's gone from "Adventures of a dilettante in neuroscience: this won't hurt a bit" to "Brains. Spines. Goo." (a little underdescriptive) to "This won't hurt a bit."

Candidates:

"What do I do with this thing, exactly?"

"Scotch: It's what's for dinner." (Sister's Boyfriend, the one who fell off the ladder, sent me a dozen tiny bottles [5 centiliter] of odd single-malts for my birthday. Lest anyone think his middle initial is E-for-Enabler, 70 centiliters of Scotch will keep me drunk for 70 months. We're going through it *very* slowly. But still.)

"Will drain CSF for food."

Part Two:

I'm trying to decide what to take to Canada. That is, I'm trying to decide how many pairs of long underwear, how many pairs of wool socks, and how many long-sleeved shirts and sweaters I can fit in one duffle bag and still have room for the bottle of tequila that Pal Joey has requested. Apparently the liquor-store employees in Montreal are all on strike. (???)

You cannot buy, for any price, a wool sweater in this part of the country, regardless of the time of year. It doesn't get that cold. I managed to find a couple of wool "blends" (angora, cat hair, rayon, steel wool, asbestos) at 75% off the other day, and so picked up those. One is black; the other is the ugliest shade of green I've ever seen. It's so completely misbegotten that it looks marvelous with a pair of brown corduroy pants.

I'm also wondering how easy it would be to cook a Tex-Mex dinner for my Polish and Canadian friends, some of whom are vegan and others of whom are scarily fit. Perhaps I should make room for sopapillas and tortillas in my luggage. I really, *really* want to teach the Artistic Canadian Man With His Own Website how to do tequila shots the right way (lick coarse salt off hand, shoot tequila, suck lime), but I'm not sure I can get limes in Quebec in February for under CN $400.

And should I wear the stitched black cowboy boots with tooth-picker toes that I have, or pack them? And will my new jeans arrive in time? (Having lost some weight, hoorah, I find I now have to buy size 12s to get the properly baggy Midstate Hippie Look.)

Part Three, in which our heroine attempts to forestall the inevitable:

I bought some of that Neutrogena Dangerous Face Resurfacing Stuff the other day. You know what I mean: 1.7 ounces comes in 45 pounds of packaging, but the contents of the jar are supposed to Turn Back The Clock when it comes to facial skin.

I was desperate. I would say "I was drunk" but a) it was 1:30 in the afternoon, and b) I don't *get* drunk; I get sick. So I was full of pizza and fears of looking my age.

(Note: I notice now that when I say "I'm 35" or "I got fat" nobody corrects me or protests at either one. Oh, dear.)

So I get this jar of stuff. I slather it on, let it dry for ten minutes, then use my fingertips, moistened with warm water, to buff it off my face.

I will not lie to you, sisters. My skin looked and felt like absolute shit after I was done.

However....the next day, I got many compliments on my skin. The pebbly texture that I've grown used to, the signal of PMS-under-skin-zits, was gone. Fine lines were Honest-to-Frog Diminished. Makeup went on more smoothly. There was nary a sign of redness.

One of my patients (given, he was on Ativan at the time) said, "You look so innocent."

Part Four:

I'm honestly, no-joking-here worried about how long I can keep up this work. Neuro nursing is notoriously hard on the body; you have to lift people who have no idea that they have a right/left side. Lately, I've started noticing that I creak interestingly when I turn over in bed (I need a new mattress anyhow, but this is on top of that), that I can't check my blind spot as easily as I used to, that I get out of a low chair without pain.

Having lived with chronic pain in the past, I'm in no hurry to do it again. I'm looking hard at leaving the high-control, high-prestige world of University Nursing and going to the Community Scary Hospital About To Open In The Spring in the hopes that I'll have some variety.

Any input is welcome. Click on "Speak".

The name is "Jo". Not "Job", *JO*.

This is ridiculous. I thought, after dealing with The Real, Live Flu, that my immune system would be fully cranked and happy. I was wrong.

Thanks to the vagaries of viruses, I now have a head cold. (See why I blog? I can whine to thousands of readers [actually both of you] about this and spare my family and friends.)

Yesterday I woke up with one of those horrible sore throats that makes one unenthusiastic about swallowing. I also had no voice. None. Not even a croak, squeak, or growl. I'm not sure where the voice went; in twenty years of singing with choirs and on my own, I've only lost my voice that completely once before--and that was when I coughed it out with bronchitis.

Anyhow, no voice. Sore throat. Vaguely stuffy head. Gotta go to work anyhow. So what does a nurse with no voice do?

She communicates in squeaks and growls to her patients and with sign language and flashcards to her co-workers. This was, of course, a source of endless amusement for said co-workers, especially as the ol' speechbox started to rev up about 1100 but wasn't totally reliable 'till about 1500.

I managed to trade off a patient assignment with a coworker, too. Although I'd had him the day before, there was no way I could take him back yesterday--he's stone deaf. And his wife takes his hearing aids with him whenever she leaves. (Side note: why do family members do this? I understand that there's a problem with dentures, glasses, or hearing aids getting lost or stolen in healthcare facilities, but you'd think that the risk of that would be outweighed by the benefit of Grampa or Grandma being able to eat, hear, and see while you're not in the room.)

(Speaking of which, I had a patient whose daughter used to take his top denture plate with her when she left, but not his lower one. This meant that for about eight hours of the day, he was reduced to "grphmmrrr fffllllrrrp ggg rrrphlllllllmmmm" instead of actual speech, and that he couldn't eat. What's up with that?)

Anyway. I was getting ready to discharge one very understanding and amused patient at about noon. Walked into the room with all the requisite paperwork and Soforth and So-on, and she asked, "How on earth are you going to do this if you can't talk?" By that time, I had a sort of Eartha Kitt/Katharine Hepburn growl going, so I just said, "I'll do an interpretive dance about how to take care of your incision."

I'm off for three days, Thank Frogs. That'll give me time to go from Really Supremely Congested to Unbelievably Gross and Snotty, catch up on some other blogs, and maybe do some grocery shopping (chicken soup with rice. Chicken soup with noodles. Chicken soup with vegetables. Chicken soup with roasted garlic. Chicken soup with mushrooms).

How much Mucinex can one person take before they start to rattle? Stay tuned.

Free association

So my beloved sister mentions in an email that her boyfriend fell off a ladder.

Not, as she put it, by slithering and grasping, but by becoming completely airborne, backwards, off the top of a six-foot stepladder. He apparently brought down the ladder, the bookshelves, and a computer desk with him as he fell. The boyfriend, incidentally, is in his fifties. Sister said the impact noises that his limbs made as he tumbled down were quite impressive.

I had a patient two weeks ago in his fifties who became a quadriplegic through missing his chair and sitting down hard on the floor, then whacking his head on the desk. And Sister's Boyfriend does a credible imitation of the Jamaican Bobsled Team and is okay.

Which leads me to pondering this: could it be that he's from India that contributed to his relative lack of injury? Bear with me here.

Sister and I are Northern European. Fair skinned, blue-eyed, red and blond hair. We break easily. We scar easily. Toss one of us off the top of a six-foot ladder (I have done this, in college) and we're lucky if we break only a few ribs (as I did). If we'd tossed our father off a ladder at age 50, he'd likely have ended up like my chair-missing, floor-sitting patient.

Now, then. You can maintain as much as you like that we're all brothers under the skin, but a quick study of comparative anatomy will reassure you that it simply ain't so. African-American leg bones have a different ratio and thickness than Caucasian-American leg bones. In the same vein, African-American women are much less likely to suffer from osteoporosis than their brunette, brown-eyed Caucasian sisters, who in turn are luckier than their Scandanavian relatives in that department. It's a matter of bone density that relates to ethnic background.

I hear tell from my pals in the ED and the labor unit that they hate to see redheads coming; the rumor being (although I have no clue if this is true) that we carrot-tops have less collagen in our skins than others and are therefore more likely to scar/rip/wrinkle/you name it.

There's a movement afoot in the African-American community nationally to raise awareness of the need for donor organs--especially kidneys. Again, although non-Black and Black donors and recipients share a good number of characteristics, there's something about the differences in donated organs which (as I understand what little I know) makes it easier to cross-match all the zillion factors when the donor and recipient are of the same ethnicity.

This all sounds like the worst racist hooey if you aren't careful. Still, I wonder. Could Sister's Boyfriend's lack of injury--aside from a few bruises--be partly attributable to some difference in bone density between his ethnic group and ours that I'm not aware of? Or is it just that his top is made out of rubber and his bottom is made out of springs?

Anybody got any nice studies they'd like to pass along?

Things that bug me

I'm not normally a pessimistic person. Yesterday, though, I forgot to take my usual allergy medication. I ended up grumpy and snotty by about 1700 and so made a list of Things That Bug Me About My Job.

Abusive patients and patients' family members top the list. For some reason, it's seen as okay, in the hospital world, for patients or relatives to shout at, curse, or insult nurses. I've been told in the last week that I'm incompetent, that I'm robotic and lack a sense of humor (okay, that was from a woman who was clearly off her nut, so I'm ignoring it), that the patient in question could get better care at Podunk General. Given that Podunk General was the facility where that particular person had a completely jacked-up surgery she didn't need, I doubt that last.

What do you do when this happens? In nursing school, there's a lot of talk about "setting limits", "defining boundaries", and "therapeutic communication." Sometimes that simply doesn't work and you have to get out of the room. Other times, setting limits with a patient is harder than you think.

For instance, I once had a guy who was a professional curmudgeon in for knee surgery. He complained about *everything*--the way the bed was made, the sex and size of the physical therapists (both small, wiry females), the food, the nurses. I finally rested my arms on his bedside table and we had this exchange:

Me: "Sir, have we done anything since you've been here that is up to your expectations?"

Him: "Oh, you can't take my complaining seriously. It's just my personality; the way I am."

Me: "Well, I've had it up to my moustache with your personality. Something has to change, and change *now*. There is nobody except me who is willing to walk into this room. Be nice."

No, that communication wasn't therapeutic. But it worked.

Second on the list comes the Insulting Doctor. Be he resident or attending, some of these folks (both male and female) think it's cute to call nurses dumb. Two examples, the first from two days ago and the second from yesterday:

Male resident: "Can you tell me something about Patient A?"

Me: reels off pertinent history, recent vitals and chem results, and general information of interest.

Male resident: "Gee, that's a whole lot better than a nurse's usual reaction of (screws up face, shrugs shoulders) 'I dunno'".

Me, with blank stare: "Well, you know, we're just here to train you guys."

Which, though sad, is often true. I get asked at least once a day what to do with a patient with intractable pain or a low Dilantin level.

How about....

Female attending: "God, it's cold up here. Why don't you people turn down the air conditioner?"

Me: "Because we're comfortable."

Female attending: "Turn it down right now. I'm cold."

Me: "No."

Female attending, switching tacks: "Where's my patient who was in 24?"

Me: "We moved her to the pulmonary unit."

Female attending: "Oh, you guys didn't *like* her? (sneering)"

Me: "No, she's a pulmonary patient. She never should've been admitted to this floor in the first place."

Granted, I'm fond of this attending, and she, in her cold-hearted and snippy way, is fond of (or at least amused by) me. I was able to ask her later when she changed sticks. You know, the one you usually keep up your ass. It seems bigger this week.

Third on the list is management. Hospitals are the only places, I think, where you'll find managers who haven't done the work in question in years. Okay, maybe car companies are the same way, or large manufacturing concerns. But this is a hospital we're talking about--most of the folks coming up with Brilliant New Ideas have never worked in direct patient care, or haven't done so in years and years.

Middle Manager: "Here's our new piece of extra paperwork. It's brilliant! All you have to do at the end of every shift is fill out this two-page form on each of your..."

Me, breaking in: "No."

Middle Manager: "But this is brilliant! It breaks down the..."

Second Nurse, interrupting again: "No."

Middle Manager, looking confused: "No?"

Third Nurse: "All of this information is reproduced in the chart here, and here, and here. There's no need to transfer it at the end of every shift to yet another piece of paperwork."

Middle Manager: "... ... ..."

Me: "No. It won't fly. It's a bad idea."

Blessings be upon the head of this particular Middle Manager, who realized that we were right in our protests. MM looked at the chart, realized that what we were saying was true, and scrapped the idea.

Things that comfort me, post-shift:

The sound of my cat drinking out of her water glass (she's finicky; doesn't like bowls): she's the loudest drinker on the planet.

Getting a Valentine's day present so tacky, so over the top, for my boyfriend that he screamed and threw it across the bar. Perfect.

Opening the file folder of thank-you notes and props I've gotten from patients over the years and rereading them.

The scariest thing anybody's ever said to me

Came today from a neurology attending at work.

"The best time I ever had scuba diving" he said, "was out in the kelp forests off Monterrey. You can find these big bunches of sea hares [large sea slugs with long eyestalks] and they're all copulating, you know, 'cause they're hermaphroditic, and then you grab a great big starfish [here he used the scientific name, which I do not know and do not want to Google], and drop it on 'em, and they're all, like, yanking their various bits back and inking all over the place, trying to get away. It's fun with invertebrates!"

A Compleat Guide To Tonight's Dinner

You will need:

About a pound of fresh asparagus, as thick as your thumb at the base
Half a pound of whatever mushroom is cheapest this week
A generous handful of oil-cured black olives
Half a ball of fresh mozzerella
Two handsful of cherry tomatoes
Five cloves of garlic
A serving or two of linguine
A couple of shots of good single-malt Scotch
Nickel Creek's "This Side" CD

1. Put on the CD. Put asparagus into a preheated 400* oven with salt, pepper, and maybe a little oil. All on a baking sheet, of course.

2. Slice mushrooms thickish. This should take you all of "Smoothie Song".

3. Pit olives (if they're not already). Slice garlic thinly.

4. Rinse olives under hot water in a colander to remove excess oil. You should be well into "Speak" at this point.

5. Heat olive oil in a large skillet over high heat. Shake the asparagus, then put it back in the oven.

6. Toss sliced 'shrooms in there. You want them to brown around the edges, not sweat out their juices. You should be doing a little hip-shake to "Should've Known Better."

7. Pour a generous dollop of your favorite single-malt and sing along with "Hanging By a Thread". Start water to boil for linguine.

8. Add olives and garlic to mushrooms, turn heat down to low. Slice tomatoes in half. Dice cheese.

9. Sing along to "Green and Gray."

10. Toss linguine into boiling water. It should boil about the time you hear the line "notebook and Discman for friends."

11. Finish first dollop of Scotch and send a mental shout-out to Rob.

12. Now we're into the home stretch, with "Beauty and the Mess". Quit blogging and go drain linguine. Toss tomatoes with cooked mushrooms and olives and garlic, then pour over pasta.

13. Add cheese. Watch as it melts.

14. Yank asparagus out of the oven. Arrange asparagus and pasta attractively on a plate.

15. Eat.

Total unapologetic fluff

Things you wouldn't know about me unless we worked together:

1. I wear thematic socks and sushi-print scrub tops on a regular basis.

2. I once performed the part of Rizzo in a stage production of "Grease". My rendition of "Sandra Dee" still brings down the house.

3. I have a bad attitude and a really foul mouth.

4. I have no automatic respect for doctors.

5. My air-guitar version of The Knack's "My Sharona", performed in absolute silence, is a huge hit with nursing students.

6. I walk 4.5 mph at work.

7. I'm incredibly clumsy. The physical med & rehab docs nicknamed me "Grace" after I walked into a room, tripped over the floor, bounced off a wall and two pieces of equipment, and ended up in the MD's lap.

8. I have learned to cuss in Greek, Russian, Armenian, and Italian in the last three years.

9. I will eat almost anything from the hospital cafeteria. (This alone ought to inspire both awe and fear.)

10. After three years, I'm still not proficient with the computerized order-entry system.

Dammit.

The new line from management to the community is "Patient care is our first priority."

The new line from management to us on the floor is "If you have a bed, we'll put a patient in it, even if you don't have a nurse."

Yesterday I started with five patients. One of them was way-high-acuity (a fresh neck dissection without a trach tube). I discharged three and got two in. Then I closed charts on all four of those and picked up two ICU overflows.

If you're still with me, that means I opened, assessed, and closed on nine patients in seven hours. The last five hours were spent with those two ICU overflows.

For five hours, I said things like "You must turn off that cell phone in this room" to one patient's wife and "Don't try to stab yourself with that butter knife, dammit" to the other patient.

Still.....one postop patient who was mostly intact and one patient with EEG monitoring beats SEVEN patients per nurse, which is what the rest of the floor had. Seven. Patients. Seven high-acuity neurosurgery and neurology patients. People on seizure precautions and confused people. Per nurse.

Oh, my God. We've turned into Enormo County Hospital Lite.

Just to give you some idea, I also:

cleaned two rooms
discharged one patient, including a fifteen-minute wait for the taxi
called over an interpreter twice for a patient who spoke no language I speak
dealt with post-lithium tremors in a patient
thwarted one case of suicidal gesturing
answered phones for a half hour
missed lunch
drank four pots of coffee in short order

*sigh*

Sometimes I wonder: A Rant.

So we have this new management team at work.

About a year and a half ago, there were massive layoffs at my facility. A consulting group was brought in, at huge expense and with great trepidation, to tell us how to fix our hospital. They came, they saw, they left reams of paperwork in their wake.

(All of this, by the way, was occasioned by something so silly I can't even blog about it lest my head explode again.)

So in comes the new management team, right? They're all nurses and doctors who've left active practice in favor of management. And they have great ideas about Improving Customer Service. Yes, that's how they put it.

I had to sign a form at my last employee review that said the following things about Good Customer Service:

1. The nurse will introduce herself at the beginning of the shift to each patient in her care. (Check.)

2. The nurse will perform a complete head-to-toe assessment of each patient at least once a shift and more often as circumstances dictate. (Assessment? Like I don't already do that?)

3. The nurse will outline, with the patient, goals for treatment for that shift. (Check.)

4. The nurse will answer questions to the best of his or her ability. (Duh.)

Point being, I already do all that. It's called basic nursing care, not good customer service.

I really believe that anybody who has a medical or nursing degree who's in management should be required to work, or at least follow a nurse, for an entire shift before making recommendations like these.

That way, they'd see that the layoffs of nuts-and-bolts staff like cleaning folks and transporters have occasioned such things as nurses cleaning rooms and running patients across the medical complex (thus leaving their other patients un-nursed). They'd understand that those Four Bullet Points are things that we do anyway. They'd see the difficulty of working a shift when you don't have enough urinals, or NG tubes, or wheelchairs, or Lortab, and are constantly having to steal said items from another unit.

Another fun case in point:

A Highly-Placed Member of the Management Team showed up unexpectedly on the floor the other week. She was exercised to see that there were five people in the breakroom eating lunch at once.

Here's the breakdown: Two were unit secretaries, one not from our unit. One was a transporter, also not from our unit. One was a nurse's aide, not from our unit. One was a nurse from our unit.

It was two o'clock in the afternoon. We had had an almost-complete turnover of patients that morning, with fifteen discharges and fifteen admissions before noon. The folks in the breakroom were the first to eat lunch that day; the other nurses were attending patients.

There was one nurse (the charge) at the desk, answering call bells and trying to chart on her own patients. (Note that we are a high-acuity unit, yet our charge nurse still gets stuck with one to three patients daily as a result of staffing changes recommended by management.) A patient called for help with a bedpan, and apparently the charge nurse didn't move fast enough away from the desk to help the patient.

The Highly-Placed Member of the Management Team Went Ballistic.

Without assessing the situation, without asking why there was only one person at the desk, without discovering what on earth could induce a nurse to eat at two pip emma, the HPMMT stormed off to the floor manager and hollered about our not caring for our patients.

At that point, the Credibility Meter in my head goes past zero and the Bullshit Meter is pegged on redline.

We already have five-liter capacity bladders. We already work sick, hungry, dehydrated, underslept, and injured. And we've got a good floor with almost enough staffing to handle the patients.

Here's a person who's been at the facility a matter of weeks, who walks on the unit and makes assumptions about the quality of care based on three minutes' observation. That's their right, I suppose, but it's equally our right to inform them that their assumptions aren't valid. Instead of then trying to find out why a nurse had to scare up help for a patient with a bedpan, the person then got very upset and made *further* assumptions about the quality of care on our unit.

(For what it's worth, the charge nurse estimates that it took her two minutes to wrap up a phone call, deal with two other call bells, and get into the room.)

I would love to invite that particular manager to come follow me for a day. If the manager's license is up-to-date, I'd even invite them to come work with me for a day. I think--no, I know, having been one myself--that managers tend to forget what it's like to work on the floor every day.

The trick is not to blow a gasket and theorize ahead of your data. If you do that, not only are your management skills suspect, but nobody will listen to you.

Our manager's solution to the Enormous Lack Of Concern For Patients On Our Unit, as seen by the HPMMT?

Close the breakroom door.

I believe my neighbor has a peahen.

Nothing else makes that noise, save a lone raven with laryngitis, and there aren't any ravens here. With laryngitis or without.

It's been a nice two days off. Latest on the reading list is "Restoration London", by Liza Picard, which details (among other things) the story of a man named Nicholas If-Jesus-Had-Not-Died-For-Thee-Thou-Hadst-Been-Damned* Barbon, son of Praise-God Barebones. No kidding.

And that thing about the four-and-twenty blackbirds baked in a pie, that all fly out and frighten the king? That was apparently a common joke in the Restoration period. A pie crust was blind-baked (that is, baked empty), the birds inserted in the bottom, alive, the top stuck on, and then the dish brought to the table. When the guest of honor whacked off a piece of top crust, out flew the birds to general merriment. Those Restoration Londoners sure knew how to have fun, huh?

*My sister's comment: "I want a name that has the correct use of subjunctive case!!"

Insomnia project: The Nurse's Survival Kit, Revised and Updated.

1. Good shoes. I don't know how many times I have to say this. Good, heavy, LEATHER shoes with closed toes. And don't buy backless clogs unless you've proven in the past you can run in them.

Dansko, purveyors of dangerous Professional clogs, also makes a sort that are much more sane (with a wider heel base). They're called Dansko@Work.

2. A little tube of Lamisil, for when the skin between your toes begins to crack. This will happen, no matter how careful you are with cotton socks.

3. A little jar of Vicks Vapo-Rub. Good for achy feet, good for smearing under your nose or in your mask before that nasty dressing change. Trust me on this one; you don't want to be without it.

4. Good hand cream. Not that Corn Husker's crap; *good* hand cream. Like ShiKai or Burt's Bees or even Neutrogena. Use it every night when you get home.

5. Belgian ale. I strongly recommend Orval.

Tomorrow, a discussion: Does being in management automatically decimate your IQ?

The shutters come down.

Remember the patient I talked about with possible metastatic breast cancer to the brain?

Well, it might be breast cancer. It might be something else. Uncharacteristically for our facility, pathology is taking a long time with this one--reviewing slides and frozen specimens, sending bits of them out to different labs--in an attempt to figure out just what the hell is going on and how to treat it.

Meanwhile, the patient's lost quite a lot of weight and is still unable to swallow. She had a G tube (a tube that runs through the skin into the stomach) placed the other day for supplemental feedings, but she's been so nauseated that she hasn't been able to tolerate them. Her voice is almost gone--dysphonic and scratchy, so she talks in a whisper. She has pneumonia in one lung, since everything she tries to swallow heads down the wrong tube.

I've seen patients with metastatic brain cancer or even gliomas live for a couple of years after diagnosis, enjoying a fairly good to excellent quality of life. This is not going to be one of those patients.

When the doc found the lump in her breast--two months after a clean breast exam during her annual physical--the first thing the patient said was "it's gone to my brain." At that, the shutters came down.

You can tell when it happens. It's not necessarily that the person turns their head away or refuses to make eye contact or participate in care any longer. Sometimes they seem all right at first, and it's only after talking to them for several minutes or interacting with them through a shift that you notice something's wrong.

It's not depression. It's the decision to die. Or maybe it's the decision that nothing that you or the doctors or they themselves do will make the slightest difference. Either way, their eyes get shuttered. You watch them slog through day after day without hope or interest or the slightest bit of pleasure.

In this case, it's pissing me off royally.

This woman has (of course) a loving partner, a good career, dozens of caring friends, a *good* life. I say "of course" because it's always the people with everything going for 'em that get the worst prognoses.

I'd like to light a fire under her ass and get her to fight. Just a little. I can see that she's tired, that she isn't feeling well...but the total unwillingness to even entertain hope has got me peevish.

Nurses and doctors live on hope. We're the kings and queens of denial, when you come right down to it. All the treatments that we order and perform, all the surgeries, are based on the knowledge that, statistically, this thing has worked to solve that problem, and we hope it will on you, too.

When somebody just plain gives up, we tend to take it as a personal affront. It's a defeat of sorts. We spend our days fighting against death and disease and all that noble b.s., and we assume that the people we're working with and working for have some interest in the outcome. When that person doesn't, it's hard to understand.

Hoping is hard. Slogging through is harder.

For the next two days I'll be thinking about this woman, about her dogs and cats and other family. I'll be wondering if she'll be there when I get back and if she is, what fire I can kindle under her hopeless butt.

Queen of Denial, that's me. Sometimes you win, sometimes you lose...and in this business, we tend to lose badly and take it hard.

You, too, can join the crew...

Tippecanoe and Nixon, too/Back with Barry's/Not with Lyndon, Ike, or Harry's/Back with Barry's Boys!

(Thanks to the Chad Mitchell Trio)


You are a Folkie. Good for you.


What kind of Sixties Person are you?
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On to the topical stuff:

Steroids, or, How To Have Fun With Potentially Only Minimal Bodily Damage

Steroids are versatile things. There are several different sorts that we medical types use all the time, for all different purposes.

Generally, corticosteroids (as opposed to the other sort, that build muscle and make you kinda grumpy) relieve inflammation and swelling, act as immunosuppressants, and can be used as diagnostic aids for things like Cushing's syndrome (where your body produces too much cortisol, a naturally-occuring steroid).

That's why I, who have the flu, am taking a prednisolone taper (a Medrol Dosepak). Even though prednisolone has immunosuppressive qualities, those are outweighed (at this dosage) by the anti-inflammatory effects. Meaning, in short, that I'm no longer walking around whimpering because my muscles and joints hurt so much.

It's also why I'm up at 3:37 a.m., typing on the computer, but more about that in a second.

In neurosurgical patients who've had bits of their brains removed, the usual starting dose of dexamethasone (Decadron) is four milligrams every six hours. Sometimes we'll go higher, sometimes lower, depending both on the patient and on the bits of brain removed. After a couple of days of that, we'll taper. It's amazing what that amount of anti-inflammatory can do; I've seen patients who weren't able to swallow improve markedly after 24 hours on Decadron.

You see a lot of steroids used in treatment of asthma and allergies, as well. Advair inhaler? Steroid. Big nasty rash I got those months ago? Treated with steroids. Certain types of arthritis can be treated with 'em as well.

Which brings me to the up-at-three-am-part.

There's a nifty little condition called "steroid hypomania". What happens in a person who's taken largeish doses of steroids (say 60 milligrams of prednisone a day) for a time is this: something flips over in the brain that makes them manic. Not leap-out-a-window, I'm king of the world manic, but pretty manic nonetheless. They get up early, the buzz around like bees all day, they tend to have insomnia.

Strangely enough, a milder version of that side effect happens in almost everybody I've seen who takes steroids. The other, nastier side effects like steroid-induced diabetes or weight gain or bloating tend to take a while, but push four milligrams of Decadron into somebody's IV and you can almost guarantee they'll be up at one a.m. humming old Madonna songs.

Which is why I'm blogging this early, when by all rights I should be lying in bed feeling as though I've been hit by a truck. A combination of steroids and aspirin has brought down my fever and taken away my aches and pains, and the steroids have done their magical work and made me peppy at 3 a.m.

This side effect will be gone by Wednesday, when my taper will have worked from 24 mg (yesterday's dosage, humming Madonna songs) to 12 mg.

Why do we taper? Ah, this is a good one. When you take steroids, even for a short period of time, your body gets lazy. Note that laziness is an evolutionary advantage: it keeps you from having to expend energy on things when that energy could better be used to reproduce or just hang out. Anyhow, expose the human body to steroids and it slows down production of its own steroids. Cut off the steroids abruptly and the body gets all grumpy--the steroid-producing bits act as though they've been shot with a rubber band.

So as you cut the dosage gradually, it's giving your hypothalamus etc. time to ramp up again.

And it gives your right temporal lobe a break from rerunning all those mid-Eighties MTV hits, too.

Fascinating, Doctor.

I have the flu.

The real, live, honest-to-God flu. The sort that gets you a prescription for Tamiflu and a little mask to wear out of the minor emergency clinic. The sort that lets you know it has you the moment you wake up in the morning and start to move--or start to *try* to move.

It surprises me not at all that people die from this. I was wanting to quite enthusiastically while in the doctor's office. When the nurse practitioner walked in, I had just burst into tears, I felt so incredibly bad. She was very kind and swabbed my throat, gave me a Sprite, and sent me on my way.

Two aspirin, a Tamiflu, some toast and guaifenesin and a nap later, I feel almost human. What gets me is that this is apparently one of the mild strains that showed up too late, or something, to be included in the flu shot this year. I'm glad I didn't get a *bad* case.

Please disinfect your computer now.

A PSA, of sorts

This is a handy-dandy link for everybody who's currently asking themselves the question "Is it a cold, or is it the flu?"

Of course, the symptoms described here might not apply if you've had a flu shot, or if you actually have a sinus infection, or if you've just got some sort of gark that nobody's bothered to catalogue.

My current list of symptoms range from the nasty to the really sort of cool. The nasty include a moderate fever (100.5 F), a hacking cough that's soothed only by ice cream and some leftover Tessalon Perles (bad nurse, keeping Rx meds around! Bad nurse! No donut!), and general body aches, headache, and malaise. The kinda cool symptoms are the hallucinations out of the corners of my eyes (is that really a binturong on my couch?) and a voice that rivals James Earl Jones's. I'm walking around saying "I find your lack of faith...disturbing" a lot.

The fact that I sound like Darth Vader, complete with breathing, almost makes up for the small furry things that keep darting around at the edge of my vision. Almost.

At least there's plenty of bad TV on, and nice guys down at the Quick-E-Mart who say things like "Helllooooo, dear! My, my! You look not so good today! And how are things?" as they sell me NyQuil.

This is why work-hour limits are a good idea.

I worked a sixteen-hour day--or what would've been one, had I not fallen over after the fifteenth hour--the other day. We were short-staffed and overrun with complex patients, so I stayed on for the first three hours of the night shift.

And gosh, am I ever tired. Tired, and running a low-grade fever, and with the sort of general achiness and coldness that makes you feel nasty. Not nasty enough to take medicine that might cause sleepiness, dizziness, sleeplessness, seizures, spontaneous amputation of your head, or palpitations, but nasty just the same. It must've been the schedule disruption that laid me open to this bug.

I got to thinking at about 2130 (9:30 pm for the civilians) that I'd been up since 0420. I'd commuted 45 minutes in the morning and had at least that long to go home. I'd been running my ass off all day long with five patients with fairly interesting and complex problems. My last admission needed transfusions of clotting factors, the close monitoring that goes with that, and every-two-hour pulse checks on one leg. And I was exhausted.

I was so exhausted that I forgot which medications are routinely kept in our lockup. I fumble-fingered equipment and misread orders. I stared with incomprehension at a ringing phone and cursed when my beeper went off. When I did finally get home that night, about 11:30 pm, I fell straight into bed and slept for ten hours.

Which makes me wonder how the residents do it. In the past there were no limits to how long residents could work in a week. It wasn't uncommon to hear tales of 20-hour days, week after week, with a brief break or letdown in the summertime or when a resident switched to a less-demanding schedule for a bit. Now, technically, residents are limited to 80-hour work-weeks.

Some of the older attendings are grumpy about this. They say that it makes residents soft, that they never learn how things Really Are in the Medical World. For the most part, our residents--especially the ones in orthopaedics and neurosurgery--are still tired enough to occasionally sleep straight through constant paging in the call room. I've not heard them celebrating the shorter work week. I have the distinct impression that a number of 'em just keep on working, technically breaking the law, when they're supposed to be off the clock.

I still think it's a good idea to limit the amount of time somebody can or should spend taking care of sick people. For myself, I get idiotic after about fourteen hours straight, and I'm not even incising people's bellies. I shudder to think what an underslept neurosurgeon could do.

For another thing, you get emotionally exhausted as a caregiver after a certain amount of time. Most patients aren't going to confide in their doctors the way they do in their nurses, and most doctors don't have to spend twelve hours answering call bells, but the point remains: If you're caring for people, you have a responsibility to them that's gonna weigh more heavily on you during Hour 14 than it did during Hour 1. And the more Hour 14s you have under your belt, the harder it is to be responsive to another person's needs.

And finally, if you're going to be a decent caregiver, whether it's as an MD or RN or LPN or whatever, it helps to have a life. Nobody wants a robot to take care of them. Even if you can't switch easily from discussing sports to discussing opera (depending on the patient), it's nice for the patients to get the sense that you don't spend *all* your time up to your elbows in other people's guts. Gives 'em confidence.

I'm going back to bed. I'm going to wonder as I fall asleep how on earth those residents do it. And I'm going to be thankful--*very* thankful--that I can punch out at the end of twelve or fourteen or sixteen hours and go home, leaving my beeper on the desk.

First Full Week Back At Work

Holy. Mary. Mother. Of. God.

I was off a lot--a LOT--during the holidays. So much so that the week between Christmas and New Year's, and the weekend after New Year's, was spent lying around in bed, reading mystery novels, eating good South American food, and generally Hanging Out.

In other words, mama lost her groove.

Wednesday kicked my ass. Thursday kicked several asses. Today kicked our collective ass, then pasted its remains to the wall.

For those of you versed in hospitalese, we have a floor of 28 beds. We started with 18 patients, sent five home, and got sixteen admits. I'm not entirely sure where we put that last extra patient; there were apparently fistfights going on in admissions over our beds.

My day was crazy enough that I'm sitting here typing, eating slabs of cheese and Fritos, drinking a beer, and wishing desperately that I'd caught the hang of smoking as a teenager.

My first patient came from the rehabilitation floor. We'd sent her there two weeks ago. Night before last, the nurse had given her enough oral morphine concentrate for pain that she'd become nonresponsive and Narcan (a drug used to reverse the effects of narcotics) wasn't enough to bring her out of her stupor. She also had a temperature of 102 and pus leaking from her scalp incision.

No, not leaking. Oozing. Ooking. Yarking me out at 0700.

Anyway. She had a sodium of 126 (135-145 is normal), so off she went to ICU. We can't replete sodium with a high-salt intravenous solution on the floor; we have to do it in ICU. She was out by 0800.

Second patient is 42 with metastatic adrenal cancer. His prognosis is grim, to put it nicely. His pupils were two different sizes when I walked in, but the rest of his exam was okay, so we put it down to the morphine he'd been getting for pain. Luckily, we were right.

Third patient is 43 with what looks to be metastatic breast cancer to the brain.

Fourth patient is so manic I nearly killed him. Who on earth has myasthenia gravis and still files paperwork all day?

Fifth patient is a long-term IV drug abuser; smack and crank are drugs of choice. Guess who wants her two milligrams of morphine every hour?

We, as a floor, pride ourselves on getting out on time every night. It's rare that somebody has to stay to chart past the end of the shift. I was the first nurse out of there, having had one very early and one very late admit, and I got out at 7:30 pm. Everyone else is probably still there.

Best moment of the day: A surgery resident of the unusually arrogant type keeps answering the phone, then hanging up on the person when he finds that it's not the person he wants to speak to.....

Nurse Jo: "I need you not to hang up on my consults."

Resident: "Well, I paged *my* consult to this phone; what do you want me to do?"

Nurse Jo: "Let me answer the phone. And keep your paws off our snack foods."

Silly quiz of the day, since I am off work:

Which Extremity of the World Are You?
From the towering colossi at Rum and Monkey.

I'm apparently somewhere in Libya.

Happy Christmas!

What on earth are you doing here? Go drink some eggnog, or something.

Best wishes for a peaceful and happy Christmas.

Advancing the profession

I had a conversation about Advancing The Profession two days ago with a friend and colleague at work. Advancing The Profession is, for those of you who aren't nurses, a Big Thing in nursing circles. Nurses who bother to answer surveys report dissatisfaction with their careers, frustration with their practice limitations and paperwork, and anger at how they're perceived and treated by both the public and the other professionals they work with.

There are as many ideas for improvement as there are problems. Many nursing professionals want to change scope of or requirements for practice. Still others want to educate the public. Some want to raise the consciousness of those other professionals with whom nurses work.

Raising Conciousness was the focus of my colleague's and my conversation. I had spent a good part of the morning cleaning up the mess that a group of lazy, ignorant physicians had left and I was frustrated. Being sniped at by everybody and his dog is part of being a nurse, as is cleaning up loose ends that others (usually "too busy" residents) leave lying...but it gets old.

My colleague, who works ICU on the weekends and is an educator during the week, suggested that I devote a little time to Raising The Consciousness of the physicians I'd cleaned up after. And even though it was a good suggestion, I couldn't take it to heart.

Why? Because I was tired. I can see where conciousness-raising would be a brilliant idea: take a resident who's disrespectful aside and talk to him calmly about professionalism and hope for a change. But most of the time, we nurses are so frazzled, we simply don't have the energy to devote to educating the odd Neanderthal who comes in with a medical degree.

I'm lucky on a number of points. The floor where I work is well-staffed. The doctors are, for the most part, good colleagues. My specialty is such that I don't get a lot of jokes or flack about wearing short skirts and a cap. (Say "I'm in neurology" to even the most uncivilized bar patron and they back off.)

But still. Why is it *my* responsibility to educate/lecture/come down on like the crack of Doom somebody who just doesn't get it? If I have the time and the inclination, I will. Otherwise, watch out: if you're an attending physician who hasn't learned to be a decent human being by this time, I am not going to educate you. I'm gonna push back as hard as you push instead.

A group of interns made a video in our nurses' station about how to deal with sexual harassment. It wasn't focused on how to handle the nosy patient if you're a young female doctor, or how to deal with the predatory professor that occasionally crops up. It was on how to deal with a (female) predatory nurse if you're a (male) doctor.

When we (female) nurses all stopped laughing and wiped our eyes, we got into a serious discussion with the instructor of the group. Why, we asked, were the students not being taught lessons that would serve them in good stead? Sexual harassment is covered in our medical school. Being professional and working on a team is not. How not to yell at somebody simply because they're following the rules is not. I'm not implying here that sexual harassment is a chimera or overstated; it's not. What I'm saying is that the curriculum at our facility pays far too much attention to the one problem--often to the exclusion of the other.

I'm a feminist and childfree and a nurse; raising consciousness is not unfamiliar to me. What's unfamiliar is the unwillingness of other professionals with whom I work to police their own. It's left entirely to us to educate/train/police the people who technically are our superiors. At the same time, we're expected to provide good care for sick people and their families, act as gatekeepers and coordinators of care, and keep a smile on.

I once had to report a resident to his attending for being a jerk. I heard the tail end of the lecture the attending gave the resident. Just before Attending turned Resident loose to go back to work, he said, "...and don't let their hysteria get to you, okay? Most of them just aren't that tough." (Enter Crack of Doom Nurse hard on the heels of that statement.) Point being that I'm expected to Educate and Enlighten this person, but his boss will undermine me, then blame nurses for the lack of respect that his students show them.

Honestly, I have no solution for this particular problem. All I can do is keep practicing as professionally as I know how and deal with trouble when it happens. I just hope I'm not completely burned out by the time I retire.

Okay, okay, it's done.

Bidness

Whew. I got a number of new links up. My original idea was to parcel them all out nicely so that Gentle Readers would have some idea of what they were getting into (Medical? Humor? Other?), but not only do my HTML skills suck, I figured at the end of the day that I don't know what I'm getting into at any given moment; why should you?

Update the First

Coworker's Brother has had the last of four surgeries. The docs found the bleed that was giving him trouble, so he'll be medevac'ed to Europe in the next few days.

Update the Second

Troublesome Coworker is rapidly weaving rope.

Update the Third

Hemicorporectomy Guy (and don't feel bad if you've been humming "Eric the Half-A-Bee"; we all have) is doing fine.

End of Updates.

Any nurse can tell you that a number of folks will ask, when told that you're a nurse, how to improve their health, well-being, and general mood. In an attempt to head off those folks at Christmas parties this year, I present:

Nurse Jo's Tips On How To Live A Happy, Healthy Life

1. Don't be mean. That's number one for a reason. If you're mean, you make everyone around you miserable. You'll be lonely and sick and people will think you deserve it. So don't do it. Smile, smile, smile.

Or if you can't, at least fake it.

2. Shut your piehole and move. No great mystery here. The average person eats too much and moves too little. Get or borrow a dog and take it on runs. Play with your kids. Turn off the TV, or at least do crunches during the commercials.

3. Vegetables: the green things at one end of the grocery store. Vegetables are fun. Really. They're interesting. You should eat them occasionally.

4. Relax. There's nothing worth getting *that* upset over.

5. Drink if you like, smoke if you must. Just don't be a self-righteous twerp. See Point Number One. Self-righteous twerpiness goes right along with meanness in shortening your life. I don't care what you do as long as you're a reasonable human being. If your choices are smoke crack or be a twerp, let me get you a lighter.

6. Water. Your body is 70% water, not 70% Diet Coke.

7. Find what you like to do, then do it. This relates both to work and non-work situations. If you passion is basket-weaving, then by all means, weave baskets. The point is to have at least one thing in which you can lose yourself on a weekly if not daily basis. Which brings me to:

8. Get out of your own head. It ain't all about you, so find something that helps you remember that.

9. Act. Whatever gods are running the Universe don't care what you *think*, they care what you *do*.

10. Recognize that life really *is* that funny and ridiculous.

I have hinty bazillion links to put up

And will do it on Wednesday or Thursday, I promise.

Too close to home

A coworker's brother was shot halfway to hell in Fallujah today. (Yesterday? I don't know the time difference.)

His squad was marching down the street when a car bomb was detonated next to them. The guy behind him died, but in doing so, sprayed my coworker's brother with bullets. He (the brother) also has some nasty shrapnel wounds.

Thanks be to the Army medics who got there first. They're still working on him in a field hospital in Iraq, trying to find the internal bleeding that's keeping him in critical condition. After they do, he'll be airlifted to Europe for further surgery.

When the Red Cross called her as she was on her way to work, all the person could tell her was that her brother'd been shot. They had no details. Wouldn't you hate to have that job?

Any prayers on her behalf, on behalf of her brother, and on behalf of her two siblings--also in the Army, also near or in Fallujah--would be gratefully accepted.

Any political emails will be tossed back to the senders so hard that the electrons bounce. I'm too upset by her upset-ness to be rational.

Odds and Ends and Drama

From Correspondent Tim, somewhere out there in the Worldwideinternetwebland, comes this very funny list of do's and don'ts for patients. Tim says "all of these would've come in handy had I known to tell my patients beforehand."

Some generalized advice for patients

Dos
1) ...ask if the large puddle of blood pooling under your disconnected IV is normal.
2) ...ask for help reinserting foley catheters if you pull them out.
3) ...use short chairs instead of tall barstools if you drink too much and have osteoporosis.
4) ...ask for help if you wish to amputate a body part BEFORE you start cutting.

Don'ts
1) ... tell the hospital policeman that you need to go get your gun.
2) ... steal the laptop computer I use to sign out your medications.
3) ... slam the Pleurevac in the door of the cab as you leave AMA.
4) ... barf on the nurse. (the biggie)

*snork*

It finally happened

"It" being Nurse Jo coming down on another nurse like the crack of doom. "Goddammit" was probably an ill-advised thing to say. "Fuck" was certainly unprofessional. The screaming will surely be discussed and embellished in rumor for weeks to come...but the only thing I feel bad about is the fact that I'll have a whopping big meeting with the floor manager on Thursday.

There's something about being a nurse that makes other people think they can yell at you. I got yelled at yesterday seven times before noon--that's more than once an hour if you're keeping track, which I certainly was after Yell Number Three. The reason I was getting yelled at and complained to was the attitude and shoddy people skills of the nurse whose patients I got yesterday morning.

A very nice paraplegic guy was upset because he wasn't given enough in-and-out catheters to use all night. Given that he gets dysreflexic if there's more than about 200 ccs of urine in his bladder, catheters are important. He also didn't get antispasmodic medication (very important for spinal-cord-injury patients; the limbs don't just lie there, they spasm) or pain medication for most of the night. There were other problems too minor to go into here...but they add up.

Another patient's husband was upset about the lack of communication on the nurse's part vis a vis what was happening with his wife. The doctor on the case was upset by her lack of help. The doctors on the consulting team were unhappy that the patient had gotten a large enough dose of sedative to leave her obtunded for hours and still zonked the next afternoon.

And all this came down on me. I ran around for several hours making nice, trying to wake my patient up, and generally picking up the pieces. The nurse who left me with this basket of rabid weasels is a technically excellent nurse. She's the shit when it comes to starting IVs and doing paperwork, but her attitude toward any patient who doesn't sleep peacefully all night sucks.

I'd finally had it. After she'd started complaining once again about how big a pain in her ass the obtunded patient had been, I went into Screaming Harpy Mode and yelled. For about ten seconds, at which time I realized it was pointless. Any nurse who responds to the suggestion that she might've oversedated a patient just a *leeeetle* bit with the words "I have to give what the doctor orders, that's my job" is a nincompoop.

I should've used the word "nincompoop" rather than "idiot". I should've moderated my tone and spoken to her in a calm, professional manner outside of the tension of the report room. I should've taken into account what had happened to her that night to make her personality even more wretched than usual.

I should've ripped her arm off and beaten her to death with it there on the spot.

Addendum: I came home to find a message on my machine from this same nurse, asking me to call her so she could clarify something with me. "If you can't, it's no big deal" she said. So I didn't. It's three a.m. If anybody says word uno to me about my not calling back, I'll point out that I too have been dragged into the 20th century and own a cell phone. Call me on that.

Ooooooohhhh, I am *so* not looking forward to Thursday.

Blog O' The Mornin' To Ye!

I love this woman. She writes and thinks the way I want to.

Mouse Words

All I want for Christmas

The tree is up, the frost is on the goose, the pumpkin is getting fat.

Or something like that. The tree (a nice Fraser fir) is indeed up, all six feet of Seuss-inspired silliness of it. I went to a local Walgetmartorama to look at artificial trees and came away unutterably depressed, so I broke all the apartment complex's rules today with my Fresh Cut Tree! Hooray!

The cat is disturbed by the presence of a tree in the living room, but she'll live.

What I want for Christmas, the non-commercial version:

1. To be listed under "Nursing Staff" on Cut to Cure.

2. To get a submission accepted for Grand Rounds. Note that I haven't actually submitted anything yet, primarily because the people who are listed are, like, geniuses. And I feel like an idiot. A neurologically-focused idiot, but a moe-ron nonetheless.

3. Three or four days off in a row with nobody calling me to see if I want an extra shift, or if I'd be willing to be on call. Everybody's been sick lately, what with induced labors and broken backs and the flu.

4. A comic strip that is as unironic and simply beautiful as the old "Peanuts" was.

5. Six more residents like Dario, Mia, Christos, and Jay. Another attending like Kevin: "I went to the Kellogg School of Management so I could manage cornflakes more effectively." Another surgeon like Duke or Bruce.

6. Failing that, no more like Dr. Chucklehead.

Wired, tired, and done, oh my.

I am finished wrapping Christmas presents. That is, I'm done wrapping the ones I have to mail to my family. I'm not done wrapping the ones I bought for The Boy, nor have I even finished assembling the present for a Secret Pal I have through an online forum. But the majority of Christmas present-wrapping is done, which gives me great pride. Even more than that, none of the presents look as though they've been wrapped by a mentally-deficient orangutan with Tourette's. This is unusual for me.

Yesterday was one of those days that every nurse dreads. Nobody coded; nobody had intractable pain...but nothing happened all day.

Nothing, that is, until about an hour and a half before the shift ended, at which point we got eight admissions. That sort of day will make you crazy: You start out well, get into your groove of planning and assessing and running around, then hit a wall. You sit for eight hours with absolutely nada to do, and then all hell breaks loose in the middle of your nap.

I got home so wired I didn't get to bed until after midnight. That's twenty hours out of twenty-four that I was up. It's no surprise I took a two-hour nap today.

Following is an opinion I sent to a pal via email today, included because I'm too damned lazy to think of anything new to write:


I have a BA in music and sociology (double major) and an ADN myself.
Unless you want to teach, research, or be an NP, don't get an MSN. MSNs
are highly specialized and focus on management (ugh) or specific areas
of practice like oncology or family practice or women's health etc.
MSNs are a waste of time for the average floor nurse (which is what I
am) and not a great idea for anybody who wants to stop at, say,
midlevel management. Even for upper-level management in a hospital or
community health setting, an MBA would be a better choice.

BSNs are fine and dandy, but I think they're overrated by the nursing
establishment. The amount of clinical experience you get with a BSN
compared with an ADN is about the same; the major difference is (again)
in the focus on management and decision-making skills. What the
proponents of BSN over ADN fail to recognize in my experience, though,
is that the majority of people getting ADNs are doing so because
they've either already got a degree or three in something else or
because they're 45 and changing careers. Both of those things reduce
the need for extra courses on prioritization, law, and management. We
been there, done that.

My advice, which costs what it's worth, is this: get the ADN. It'll
come near to killing you if you pick a good program, but you'll get
more knowledge in less time than you would if you did it any other way.
After that, work in a clinical setting of some sort for a year or two.
(Everybody says that and I've become a believer myself; there's just
something about knowing what works in real life versus what the books
say.) After *that*, make a decision on what to do with the rest of your
brain. You might decide that eine kleine floor nurse is what you want
to be, or you might have found some specialty that sparks a need to go
further in school.

A word about specialties: everybody ("everybody" being nursing
professors, nursing consultants, and others who haven't worked in the
field for years) says to work med-surg for a couple of years to "build
your skills" before you specialize. Bullshit, in a word. People coming
into hospitals are so sick now, and have so much going on in terms of
different systemic involvements, that even a specialty is broad enough
in practice to learn things. I deal every day with cardiac involvement,
diabetes, arthritis, women of reproductive age...you name it. And I
work in an environment that I lot of people would consider progressive
care rather than an acute care floor.

That, in long, is my sermon to anybody considering starting a nursing career after doing something else.

Can't Do Better Than This 'Un...

Courtesy of Geena.

Rock/Suck

The occasional Rock/Suck list returns.

Rock:

1. Hamilton-Beach's version of an electric grilling machine. I just made no-added-fat salmon with garlic and pepper in under eight minutes. And mushrooms. And asparagus. Next up, portabello mushrooms. Plus, you can flatten the darned thing out and put on flat grill plates and make pancakes for your sweetie!

2. Glad Corn. For the love of Mike, stay away from this stuff. It's salty, crunchy, a cross between Corn-Nuts and popcorn, and I think they dust it with crack. The cat even ate some while my back was turned. You can find it at any good organic food store, right under the sign that says "I'd Turn Back If I Were You."

3. Land's End flannel sheets. I have a set that Beloved Sister sent after she was done with them, and they're still the softest, warmest things I own. No frays, either, on the hems.

Suck:

1. Garnier Fructis Revitalizing Shampoo. I'm sure it's wonderful for some folks, and gee it smells terrific, but it turns my hair brown. My hair is red.

2. Any generic brand "guacamole-style" dip. Just...don't.

3. Dropping a Christmas present on your feet. Especially if it's a Christmas present your folks sent you. Especially if it's a 19-kilogram (41 lb) folding butcher-block table with a stainless steel frame. Again, just...don't.

What I do when I'm not working.

Truly kickass pasta salad

Normally I hate pasta salad. I don't hate this one. Warning: it will make all vampires in your neighborhood very scarce.

Boil 1/2 pound of pasta, preferably something twisty or round-y or ridged.

While the pasta is cooking to the al dente stage, combine:

3/4 cup olive oil
1/4 cup red balsamic vinegar
2 tablespoons capers
about a teaspoon of anchovy paste
about a teaspoon of black pepper
5 big cloves of garlic

In a blender and whirrrrrr until it's all unlumpy and creamy.

Drain cooked pasta and dump in bowl. Follow with enough of the dressing to coat--you may not need all of it. Let it cool down a bit.

Add:

*1 cucumber, peeled, seeded, and diced
*1 diced red pepper
*2 cans quartered artichoke hearts, torn up with your hands while you giggle
*1 pint of quartered or halved cherry tomatoes--the really sweet sort you have to stop snacking on as you cook
*enough black olives to make you hum under your breath. Kalamatas are good.
*some cheese, cubed. Mozzerella is yummy, though I'm partial to a nice mild Muenster.

You want something that's mostly veggies, with pasta as a filler. Sometimes I add tiny whole broiled mushrooms or chunks of cooked chicken. Sometimes I add bits of ham or salami. Sometimes I don't add anything extra and simply sit on the floor, eating the salad out of the bowl with my big wooden mixing spoon.

Back in the saddle again...

A couple of folks have mentioned that my blog isn't the Laff Riot lately that they're accustomed to. I therefore present...

Tips for Folks.

1. If grandma is frail, confused, and 90 years old, put her bedroom on the *first* floor. That way she won't fall down the stairs and break all sorts of things.

2. Turn on the fucking light before you go to the damned bathroom. You won't break an ankle in 14 places.

3. I am the new sheriff, here to clean up the town. Deal with it.

4. You *will* get up. Doctor's orders are *orders*, not suggestions.

Don't make me tell you this again, people.

Have I mentioned lately how crazy I am about my boyfriend? I got to meet his sister in law, a woman with whom I'd love to have a couple of cups of coffee, over Thanksgiving weekend. It's rare that I approach somebody with the catlike caution that means I might make a friend, but I did her.

Also, his brother rocks my world. He mentioned casually during the evening that, as far as he was concerned, I was his new sister-in-law. Brother was rewarded with seeing me gape like a goldfish for a good five seconds.

But best of all is the way the day suddenly improves when he calls.

Enough mush. Off to the fridge for a beer; Nurse Jo is done for the day.

This one is for John.

I've been corresponding off-and-on with a nursing student in Arizona named John. He's married with kids and works full-time in addition to going to nursing school. That makes my jaw drop: anybody who's done nursing school, especially an accelerated program, knows that it invades your sleep, your dinner table conversation, and your showers. Working while you do it is crazy. Raising a family is nearly impossible.

So I asked him how he's managed it. In return, he sent an explanation that included a mention of his recent surgery.

John weighed 500 pounds last year. He had gastric bypass surgery three months ago, in an effort to live long enough to see his kids grow up.

People, 500 pounds is no laughing matter. At that size, as John points out, breathing is hard work. You can be smothered, literally, by your own weight as you sleep--for that reason, many really obese folks have little machines that push air into their lungs as they snooze. Walking is difficult. Your knees, hips, and back start to give out. You live with chronic pain and skin infections, as the skin folds you've got trap bacteria and fungi. Going out to a movie is out of the question, as is sitting comfortably--or at all--on the average toilet seat. Furniture breaks, beds sag, cars need struts far more often than those driven by those of us who are a measly 30 pounds overweight.

Imagine for a moment being so large that you can't have laparascopic surgery--the instruments aren't long enough. Imagine being told that for the rest of your life, a half-cup of food at a time will be a lot. Imagine having to pay more attention to food--now an unattainable addiction--than you've ever had to before in your life...and not being able to eat until you're full without vomiting immediately.

Now put all that in context with working for a living, going to nursing school, raising three kids, and trying to be a decent husband.

John, man, I salute you. You've taken on one of the toughest challenges a person can face: one that'll change your life, hopefully for the better, but that'll take time. It'll necessitate your changing your long-held beliefs and your perspectives, it'll require that you develop emotional reserves you didn't think you could.

And I'm not talking about the surgery. To do what you've done is brave and impressive and I'm sitting here, admiring the hell out of you for it.

What would you do?

We were discussing (not on my regular floor) the Hemicorporectomy Guy yesterday. One of the nurses asked if he had a family and kids and grandkids and so on, because she "couldn't imagine living like that if I didn't have something else to live for."

Wow.

I replied that I hoped I'd never have to make the choice, but that there was still an awful lot I wanted to do and see and learn, and that maybe I could manage with half a body.

"But you'd only be half a person" she protested.

Double wow. And this from a rehabilitation nurse. Who works with amputees and paras and quads all the time.

There's a difference between being half a person and being a whole person in half a body. Obviously. As far as I can recall, I've never met a half-person. I mean, I've never met anybody so stunted or handicapped emotionally or mentally that they weren't able to appreciate, at least on some level, the same things that the rest of us do. People who are persistently vegetative or profoundly mentally handicapped respond well to touch and music and other sorts of stimulation; just because they can't talk politics doesn't make them a half a person.

Likewise, losing the bottom half of your body doesn't make you a half a person. You still have a brain, a mind, and the technology to get around physically. You can still roll around the middle of Seattle or Paris or wherever you'd like. You can still type, write the Great American Novel, or compose music. It would take determination and imagination and a hell of a lot of help, but you're not half a person without your legs.

Living only for your kids and grandkids in that sort of situation strikes me as unfair, both for them and for you. Maybe your kids and grandkids would feel terribly guilty, knowing that you didn't want to be alive, really, except for them. And what sort of barriers are you setting up to your own growth if you say, "The only reason I'm alive today is for you"?

Hell of a burden to bind on anybody else's shoulders, I say.

In other news

You'll notice a new link on this page. The link goes to Ivo Drury's medical blog, which is part of his physician career consulting site. I'd mentioned some weeks ago that I was considering taking advertising here, and this is it. I feel okay about imploring readers to click his links because I click them myself. Ivo is a concise, entertaining writer. He expresses the humanity necessary in medicine in ways that anyone can understand. He's not afraid to expose his own vulnerabilities or talk about his own mistakes.

So click the damned link, already.

Nota bene: I am being paid for hosting his ad, yes. The monies that come in from that are going to charity: half to pay for an annual exam at Planned Parenthood for some person with no money and half to pay for shots and a check-up for some puppy or kitty-cat with no dough at my vet's office. So not only are you helping out Ivo by reading his stuff, but you're helping the poor and downtrodden mammals of my town.

Suddenly/I'm not half the man I used to be...

There is a man, currently on a different floor of the hospital, who will be coming to us after his next surgery. His previous surgeries have been to debride decubitus ulcers (pressure or bed sores) and to create an ileostomy and urinary diversion in his abdomen.

His next surgery will be a hemicorporectomy.

Think about that word. "Ectomy" is a suffix meaning "to remove." "Hemi" means "half," while "corpo-" means "body."

This man will have half his body removed, a la the magician's trick of sawing the lovely assistant in half. Only for him, it'll be real. And dangerous; there's a strong chance that he won't survive the surgery. Even a high amputation of one leg is tricky; taking a person's lower half off is bound to be a stinker.

He was sent home to die by several other hospitals. He has chronic infected bedsores (he's paraplegic), has become septic, and was seen as a non-starter by surgeons. He's also in his early forties and is intact save that his legs don't work and have turned against him with gangrene. So he decided to take the chance of dying during surgery for the opportunity to live a whole life in half a body.

If I sound lighthearted, it's because the thought of this surgery scares the bejeezus out of me. Imagine waking up after surgery with your lower spine, your buttocks and genetalia, your legs...gone. On purpose. It sounds like something out of a bad horror movie, doesn't it? But it's an option that this man discovered on his own, researched, and then convinced one of our doctors to consider. She did, and now he's scheduled to be sawed in half (in a measured, careful way) so that he doesn't die of various infections.

After which he'll come to our floor for recovery, then move on to rehabilitation. Most nurses might see one or two hemipelvectomies (those are amputations that remove a leg and half the pelvis, usually for cancer) in a lifetime; the chances of seeing somebody with a hemicorporectomy are quite slim. For that reason we've all been researching and reading articles and discussing this case for the last two days. It's a way to prepare; the nursing care is sure to be challenging.

So will the emotional aspects, and not just for the patient. When you see somebody who's shy an arm or two or a leg or two, you don't automatically assume that that person is thereby less of a person. The idea of losing so much of your body, though, makes you question whether or not the person's person-ness will be adversely affected. It also makes me face my fears of traumatic amputation (or planned amputation, for that matter) and the fears I have of something so uncontrollable, so horrible happening that I would consider such a thing.

On to lighter topics

My Culinary Institute of America-trained, three-star chef boyfriend asked me today how to roast a turkey. "Bake at 325 or so until the thigh registers 180 on a meat thermometer...wait. You don't know how to roast a turkey? You've never roasted a turkey??" Turns out he doesn't like turkey and never bothered to learn how to roast one. If he gets any compliments on the turkey at La Schwankienne Restaurante today, I'm taking credit.

Which might just balance out the fact that the rolls I made for his family dinner tonight, to his instructions and with his recipe, suck. Maybe they're supposed to be that way. All I know is that if he'd've let me make my own damn rolls, we'd be chomping our way through mounds of doughy goodness tonight rather than breaking teeth on hockey pucks the way Grandma used to bake 'em.

Speaking of, I have just over an hour to shower and dress for The Big Family Dinner. Yes, Mom, I am bringing a hostess gift. Hope everybody has a happy Thanksgiving, no matter what bits of you may or may not still be attached.

*sigh*

Employee reviews were yesterday. Everyone on the floor was rated a 3 on a scale of 1 to 5, three being "meets expectations". Ones are apparently reserved for nurses who, you know, actually kill patients, while fives are reserved for the Holy Ghost Incarnate types who work immense amounts of overtime, spend hundreds of hours each year on clinical ladder work, and generally overachieve.

For what it's worth, I got two fives--one for "talks to her patients as though they're human beings" and "takes time to explain the niggly shit that nobody else does".

Still, there are things that bother me about this. Why, for instance, would a manager simply mark everybody at "meets expectations"? There are a couple of folks on the floor who most decidedly do *not* meet expectations. I was always under the impression that reviews were supposed to give you something to work on as well as kudos. And why would a manager who spends most days on a different unit bother to rate our practice at all? Why not leave that to the sub-managers, the people who actually see us practice? Why not give us something useful rather than simply playing it safe?

It's an interesting sidelight to this that the manager has specific goals for all of the nurses on the floor: Everybody Has To Do Everything. We have three "special" programs on the floor: clinical ladder, preceptoring, and COU.

The close observation unit is something I've written about before, so I won't go over that again. Preceptoring is, basically, taking on a new nurse or a new-to-us nurse and training them in the procedures and patients that they're likely to run into on a neuro floor.

Preceptoring takes a person with a lot of patience and a well-organized mind. I have a well-organized mind but a shitty memory and zero patience with students. Realizing that, I told Manager yesterday that I will not precept. Period. "But you're good with the nursing students" Manager protested. Yeah, for five minutes at a stretch. Give me the same person for six or eight weeks and I'll turn into a snappish martinet. There's no need to traumatize a new nurse in order to prove that I'm not good at teaching; I've done it before and know my limitations.

The other bugaboo is Clinical Ladder. This is a hospital-wide program designed to make nurses more competent in their specialty, as well as to introduce them to the wide world of volunteer work and training other nurses. We do get paid more if we complete the clinical ladder program, so there are compensations besides being a Champeen Form-Filler-Outer.

At the end of the day, all CL proves is that somebody is willing to copy articles, post them, and cram for a cert. exam once a year. There's no standard formula that tests whether a nurse on the ladder is actually becoming more competent. Those who invest the time in CL are generally those who 1. live in the city and don't have to commute, 2. work three-quarter time or only on weekends, or 3. are generally recognized as being such strange people that it's inconceivable that they'd have a life. Petty but true, that last one.

I'm pretty damned competent, as are most of my colleagues. We see no reason why, as a group, we should be expected to conform to a standard set apparently at random by someone who isn't competent in our field (Manager is a cardiac nurse, not a neuro nurse) and who doesn't live in our unit.

I guess what bothers me about this whole culture of standardization is this: We work with patients who have weird brain things going on. Every patient is different, as is every nurse. Yes, there are some similarities among people who have subarachnoid hemorrhages, as there are among people who specialize in neurology...but you can't expect total uniformity inside either group.

If you hired me because I'm unique, then let me *be* unique. Don't pressure me to do things that I'm just plain not good at, like preceptoring, or expect me to produce the outward flourishes that signify competence instead of demonstrating competence. If you want good nurses, let us be good nurses. Let us spend time with our patients rather than pressuring us to copy yet another article from JAMA.

I probably have more esoteric crap stuffed into my brain than almost anyone else in the unit. I read compulsively and widely. My talent is Translating Medicalese Into English For The Benefit of Civilians. I'm good at what I do. I'm as intelligent as almost anybody else and more so than a number of people...but the current standard, as it's been put into place by Manager, doesn't allow me to demonstrate that.

Nor does it allow other nurses with different talents to demonstrate those talents. It's the standardization that bugs me. We're a tight group of loose cannons. We demonstrate our strengths every day. Watch us instead of asking us to fill out yet more forms. You might learn something.

Channelling Andy Rooney

Grump, grump, grump.

There's nothing like being awakened three times during the night by someone else's child, then treated to the sound and sight of repeated temper tantrums at 0630 in the morning on your day off. This is why I do not have children. This is also why I left The Boyfriend's house this morning without coffee or a shower.

Please explain to me why people can drive like bats out of Hades when it's raining and pissing and visibility is what you'd see in, say, the middle of a tar pit, yet slow down in the same construction zones on perfectly clear nights. There are two construction zones--the sort with no shoulder, where three lanes of traffic zoom between concrete barriers--between me and work. Every clear, lovely night people slow down and we crawl through at 25 miles an hour. On nights like Saturday night, when it's raining cats and dogs, they blast through the flooded areas going 80. Riddle me that.

If you tell me that you're friends with the hospital board president, it will not make me treat you any better. Especially if you're obnoxious. Let's face it: unless Mister Bigshot is in the room with you, holding your hand, you're just another patient.

My hospital hobbyist is now in isolation. Unfortunately that means little or nothing to HH's spouse, who insists upon heating up dinner in the communal microwave and removing equipment from the room. Given that these are the same people who think that empty rooms are good for taking naps or entertaining the kids, I'm not surprised...

Goodness. In my current mood, the only thing to do is scrub the shower. That'll make me feel less grouchy, and I'll end with a sparkly clean bathtub.

Never, ever, evereverever....

Drink with a fireman.

Especially a fireman who's just gotten off his 24 hours. An English fireman (that is, an Englishman who's here fighting fires) at that. Perhaps especially, never ever drink with an English fireman from Islington, a place that apparently endows its children with heart of oak and liver of stainless steel.

If you do decide to drink with a fireman, do not trade stories about work. If you do decide to trade stories about work, do it somewhere other than a quiet pub. Otherwise, people might start to look at you funny.

At least I know that my job, whatever its adventures, is not so bad. "What's the hardest thing you've done lately? Trauma?" I asked. "Oh, no" he replied. "Trauma is easy. CPR on a 400 pound corpse is hard." "How corpsey?" "Very, very corpsey."

In other news

We have four ICU overflow beds on our floor. That is, when the intensive care unit is tippy-top full, the Powers That Be send the extra neuro ICU folks to us. I worked a shift this weekend in the overflow unit, with--thank you, God--only one patient, and her with only one drip.

Having ICU overflow beds on a regular floor is a bad idea. The number and type of monitors, drips, and tubes your neuro ICU person has wired into his head or heart requires that the room be set up differently and that it be out of the way, in a place surrounded by signs warning of the Dangers of Cellphone Use. That means that the only practical place to put overflow patients on our floor is in a suite of rooms off in the boonies where nobody can hear you scream.

More importantly, we are not ICU nurses. Hand me a patient with a nicardipine drip (used to control blood pressure) and I can handle it without too much trouble...but I don't like it. I'm not in practice for it. Telemetry, while not a completely closed book, is not something I do every day. I can bumble along, true--but bumbling along is not something you want for a person who's sick enough for the ICU.

It was lucky for everyone involved that my patient was stable.

How to be an addict

If you're poor, you'll have to get your hits from the street or a series of ERs. If you're rich, you can milk a few months out of various hospitals with a series of ever-more-complex problems that require Demerol and Phenergan to treat. If you're rich and well-connected, you can find a doctor who will diagnose you with a rare disorder, one that requires diagnosis by exclusion, and you can run with the Dilaudid for years on end.

One of our pet Hospital Hobbyists came in three weeks ago and is still with us. This patient is still getting various fun narcotics to control pain that's caused by a rare disorder--one that allows a significant amount of activity in the hospital but apparently renders one inable to go home to perform the same activities. Dilaudid every two hours, nausea medications every four, and a tea-time dose of some sort of tranquilizer is helping the Hospital Hobbyist get through the day, see friends and relatives, and take a little vacation from real life.

I had another of the Hobbyists a few months ago, with the same attending physician, and got into an argument with said physician over my unwillingness to push 50 milligrams of Phenergan and 8 milligrams of Dilaudid every two hours. For those non-nurses in the audience, these are drugs at doses that would knock down a small hippopotamus for several hours. Yet the Hobbyist in question was still happy and conversant, completely sane, and relieved that the withdrawal symptoms had stopped for a bit. Not that any Hobbyist would ever admit that, of course. Nor would a Hobbyist appreciate the observation that their hospitalizations tend to come over holidays and other high-stress times in their lives.

Don't ask me why people do this. Don't ask me to speculate on how they get this way or why their physicians allow the behavior to continue. I swear that when my liver decides to cut out the middleman and hop out of my body to find a bar on its own, it won't have to go past hospital security to do it.

Finally, a political post.

This gentleman is the reason I'm a liberal.

"Comfort women." Nice. Just...well, I'll be honest with you. I understand that a blog's a blog; that people can be just as sweet or as nasty or as purposefully inflammatory as they want, and that a lot of folks are inflammatory for fun. We'll take that as read; I'm not naive enough to believe that everything written in the NetWorldBlogOSphere is meant to be taken seriously.

But "comfort women"? Uh...do the thousands of Korean women who were tagged with that name originally not mean anything to you?

Curb stomping and comfort women. Amazing. Makes me wonder if somebody like Joe Lieberman is, in this guy's eyes, a Comfort Heeb. You know, not too bright, but good with the deli meats and bagels.

Holy shit. This is the reason I'm not moving to Canada. Specifically, the likes of Ann Coulter and William Bennet are the reason I'm not moving to Canada. *Somebody* intelligent has to stay and enunciate the other side's views.

For the record, the above link came from Pinko Feminist Hellcat's blog.

Ethical noodlings, or, Friends Don't Let Friends Treat Friends. Or Family.

Geena at Code Blog has a story that every nurse can echo: the conundrum of the patient whose doctor is unwilling to let him die the way he'd like. When something like what she describes starts to go down, everyone around gets involved--the family, the nurses, the residents. Sometimes it works out. Sometimes it doesn't. Here, from my own experience, two stories that came swimming back to the top of my head after I read Geena's post. Note that these are even more heavily fictionalized than usual.

Case #1: Bill W.

Bill W. was a high-powered executive with a large national company based in our town. He was well-liked, considered by friends and coworkers to be a highly ethical, stand-up kind of man. He had a large supportive family. He was diagnosed with lung cancer at 45 and, with extensive treatment, went into remission.

His remission lasted twelve years, at which point he ended up with brain, liver, and spinal metastases. The prognosis was quite poor; you rarely end up beating back a disease as aggressive as lung cancer more than once. He ended up in my care on the medical floor. The first day he was communicative but disoriented. The second day he was responding to touch but not making any sense. The third day he stopped responding at all.

He and his family agreed that he should be no-coded (ie, a "DNR," or "do not resuscitate") and that treatment should be palliative. His doctor, on the other hand, was unwilling to let his patient die. On the third day I had Bill in my care, his doctor wrote orders for IV fluids at 125 ccs per hour (about half a cup; much more than is necessary for palliative care), every-six-hour fingersticks for blood glucose, insulin injections, and three different IV antibiotics.

The man was comatose. His kidneys had failed; he was producing about three tablespoons of urine in an hour. What his kidneys couldn't get rid of had settled in his legs, his scrotum, and his lungs. His hands and arms were swollen and bruised from repeated IV sticks and lab draws. His breathing was harsh and slow, with long periods of apnea.

The resident and I got into a very polite shouting match about his treatment. I told her that it went against my grain to go against his and his family's wishes for his death; she told me that her boss (his attending physician) felt he had to "try everything" for the man and the family he'd known since childhood.

Eventually, the family's and my viewpoint carried the day and Bill was put on an IV morphine drip. Palliative care was all we gave; we stopped the insulin injections and the antibiotics. He died the next afternoon with his family in the room with him; I bathed his body and walked it to the morgue.

Who was right? Who knows? Who can say that a person at the edge of death, unable to talk or make his wishes known, might not experience a change of heart and want others to do whatever's necessary to bring him back? Is it cruel to run IV fluids and antibiotics and stick somebody with needles when they most likely can't feel it, or at least can't translate the pain into anything meaningful? And would the person in the bed want to go through all that, if it meant that his wife and kids could sleep better at night?

Case #2: Kelly G.

Kelly was involved in a one-car accident that left her in a persistent vegetative state. The trauma of her accident had led to one of her arms being amputated below the elbow and one leg being amputated above the knee. She had a tube going into her stomach for feedings, a trach to breathe through, and a tube coming out of her belly just above her pubic bone to drain urine. She came to our floor without purposeful response to anything including pain, with only basic brainstem reflexes, and with very sluggish pupillary reflexes.

She also, because of the sort of trauma she'd had, had seizures. In order to relax her rigid muscles and prevent the seizures, she was on a number of medications, all of them sedating.

By the time I saw her the first time, she'd been like this for four years. She'd endured seven bouts of pneumonia, uncountable urinary tract infections, bedsores, and her limbs were contracted from lack of use. Her parents had bankrupted themselves to care for her. They were convinced that she would someday wake up and begin to respond to them in a meaningful way.

Shortly after her last hospitalization with us, her parents began to wean her off of all sedating medications, including the ones that were preventing her seizures. Their theory was that the medications were delaying or derailing any chance she had of getting better. Within six months she'd had six tonic-clonic ("grand mal") seizures. One had lasted three and a half minutes, a long time for a seizure. Her spasticity had gotten worse, and she'd begun to vomit tube feeding and inhale it, thus setting herself up for more bouts of pneumonia.

But her parents persisted, thinking that at some point she would, in the words of one of my more blunt colleagues, "Sit up and ask for a Pepsi."

Again, who's right? I can't imagine what her parents went through, having a bright and talented 16-year-old who came so close to dying and returned to them far from intact. Was it cruelty to keep her alive on life support in the first place? What about each successive case of pneumonia? Should one of them have gone untreated? And is it ethical to subject a person, no matter how unable to think or feel or respond, to repeated seizures in an attempt to bring them out of the shell that brain injury creates?

And the question comes up again: would the patient have wanted to go through this in order to spare her family the late-night what-ifs?

At the end of the day, I guess it's just not up to us, as caregivers, to have the definitive answers to those questions. The best you can do is to have some sense of when things are crossing the line for you, personally, and when you have to get somebody else to provide care. Sometimes it's hard like this; most of the time things are easier. Thank God.