What fucking planet are you fuckers fucking from, anyhow?

Or, Performance Improvement, Management-Style

We had a MANDATORY SEMINAR this week on performance improvement. The PI guidelines were written up by management (read: those with little or no patient contact) and presented to us in PowerPoint form (read: we had the handout read to us) or in skit form.

One of the best parts was this: (bear with me...)

A very short, morbidly obese patient had come in for some treatment or other and had had problems with the bed in the room being too high even when it was lowered as far as it would go. He'd also had problems with the toilet seat being too high for him to sit on, as it had a riser. A riser, for those who don't work in hospitals, is a large plastic device used to raise the seat of the toilet high enough so that hip-replacement patients don't have to squat to poop.

These problems had apparently gone unfixed for several days, leading to aggravation and frustration on the part of the patient. I get this, and sympathize, having dealt with it myself in the past. However, management's solutions were to a) take the riser off of the toilet, and b) provide a stool for the patient to stand on so he could get into bed unassisted.

There're only two problems with this approach: a) The toilet risers are permanently installed on toilets in a percentage of rooms and cannot be removed and replaced with a regular seat. Nobody seems to have thought of this and moved the guy to another room. B) Stools for patient use are strictly forbidden under hospital policy. We on the neuro/ortho unit have to sneak them into patients' rooms in order to provide people with extra inches. As far as I know, there is *one* stool in the entire hospital, hidden in our supply room.

The PI skit focused on how to validate the patient's feelings and solve his problems. It was performed by two people who apparently operated in total ignorance of hospital policy and technical reality.

Need I mention that the MANDATORY SEMINAR was held at 0730? For half an hour? And that was the only time of day it was offered? So that day-shift nurses had to leave the floor at the busiest time of day, and night-shifters had to lose an hour of sleep?

So I left my patients in the capable hands of my overworked charge nurse for 30 minutes in order to prove that I was committed to patient care.

Teamwork, by the way, is an essential part of this PI initiative. In order to facilitate teamwork, each floor manager is going to post a list of people who've gotten props from the patients on a monthly basis.

Uh. It doesn't matter if I pray with a patient, talk to her for forty-five minutes, or get many compliments from family members. All of those things, by the by, have happened in the last seven shifts. What matters to management is if those patients fill out a piece of paper. I feel idiotic saying to a woman who's just cried on my shoulder, "Hey, I know you're in a rough spot, but would you mind filling out this questionnaire to let my boss know I'm doing a good job?"

I'm not (and I'm sure this is shocking) good at self-promotion. Guess it's time to go back to work with the attitude of loving the job for its own sake.

In other news

It really sucks when you tell a friend that you have to lose 25 pounds, on doctor's orders, and she doesn't say, "Oh, you look great as you are. That doctor's blowing smoke."

Guess it's time to go do some situps.

Goal: size 8 by April 24th. We'll see how this goes.

Welcome to the other side of the stethoscope.

I now have two chronic health problems.

I am too fat. And my blood pressure is too high.

It's a sure bet that my cholesterol numbers, if my doctor knew them, would cause his eyes to bulge out like Large Marge's from "Peewee's Big Adventure." However, neither he nor I know them, because I haven't had my cholesterol tested in...far too long.

So now I'm on the other side of the stethoscope, with a stern lecture from my doctor on my weight (which is about 25 pounds too much) and my BP (about 15 points too high on both numbers) and my lifestyle (cheeseburgers are a food group, right?) and my stress level (contact dermatitis that worsens whenever I go to work).

It doesn't help that my doctor is normally the non-lecturing type. Some of these guys lecture as a way of life when they're not out climbing Everest or keeping their cholesterol at 133. This doctor doesn't lecture. Instead, he cheerleads.

Not today, though. So here I am, beginning a new phase of my life: close contact with my primary-care physician.

This week I'm not eating anything bigger than I am (cow, pig, sturgeon). Next week I'll cut out animals that pair-bond. I'm sure I have some vegetables somewhere, and I seem to remember a treadmill in the workout room. In a month I'll have a follow-up exam, and by God, he'd better see some results.

Oh, dear.

Grand Rounds!

Are at The Well-Timed Period this week.

Dadratit, I need to add her page to my link list.

Link o' the mornin' to ye!

Dogblog

Rampaging PMS

Controversy Roundup

In which Jo comments on controversial issues in the news.

1. Terry Schiavo: get your power of attorney and living will done, people. That's the lesson to take away from this.

2. The supposed lack of women bloggers, as bemoaned by male bloggers: I'm a woman blogger. We exist. Get over it.

3. Steroids in baseball: Yeah, whatever.

4. Abortion clinic records subpoena'd by legislators in an attempt to research child sexual abuse: Why is anybody buying that argument?

5. Lindsey Lohan's and Paris Hilton's behavior: zzzzzzz*snurk*zzzzzz.

That's a new one on me.

Just when you think you've seen everything, your patient brings a homeless person back to the hospital to share her room.

There are a number of things wrong with that sentence. See if you can list them. I'll give you a few minutes.

In other news, management is apparently still concerned with our customer service skills. In addition to initiating formal charge nurse rounds (not the sort you think, hang on), we have a new script to follow and a new set of guidelines on how to provide good customer service. The new formal charge nurse rounds, rather than being the usual CN rounds, are focused on customer service. Instead of rounding on each patient to make sure the CN knows what's going on and what sorts of issues the patients have, CNs now have to round to make sure that the patients know their nurse's name and that they're happy with their interpersonal interactions with the nurse.

Never mind that we're dealing primarily with people who have pretty massive brain injuries. Only two of my five patients could possibly remember my name; the others think they're either in Paris or being held hostage by the FBI. Or they're faking neurological problems in order to get more drugs and so won't cooperate anyhow. I forsee a number of problems with this new customer service focus.

Okay, pencils down. What's wrong with a patient bringing a homeless person back to her room?

Well, first thing, you really ought not to be leaving the floor right after brain surgery. You ought not to be going outside to smoke, that's for sure. Probably striking up a conversation with a random person in this neighborhood isn't the best idea, nor is bumming a cigarette off of them. You just don't know what you're getting. Finally, bringing said random person back to your room will present problems for both the nurses and (when they get involved) the security staff.

Of course, this was the same patient who tried to fake neurological deficits in order to get both more attention and more hydromorphone (Dilaudid). My morning started like this:

*ring ring ring*

Doctor: "Yes, this is Doctor Unpronounceable."

Jo: "Doc? That patient in 33? She's complaining of new numbness and pain. And speaking like Yoda, she is."

Doctor: *slightly hysterical laughter* "Okay. I'll be up in a sec."

It's amazing how fast those embellished neurological symptoms disappear when you tell the patient that the surgeon is coming up to tap her shunt, after which she'll be going for a long and probably uncomfortable series of tests. I dunno, they're probably going to have to do a lumbar puncture too, so I'd better start about four more IVs.

Yes, this is sadistic and manipulative. However, the sort of behavior that woman exhibited is a prime example of Shit I Don't Have Time For. I have actual, real, live, *sick* people to take care of; don't waste my time because you like your narcotics a little too much. Besides, if you start faking new symptoms, we'll figure it out--you simply don't know that much about neurology. And if we're unsure, we'll take you off the narcotics completely to see if the symptoms resolve.

So there, too. I'm fairly sure my customer service rating will dip on that one.

Oh, my goodness gracious.

My feet hurt.

My ankles won't bend.

My lower back hurts.

So does one little muscle that runs from my lower back to my right buttock.

My hamstrings are stiff.

And my shoulders hurt.

And I have to do it all again tomorrow.

I'm glad somebody is braver than I am.

I ran across a link at Bitch, PhD's site called "Abortion Clinic Days". The stories she tells and the way she tells them took me straight back to the days when I worked at an abortion clinic.

Prior to that I'd been a paraprofessional at a Planned Parenthood clinic that did general and women's health care. When I started school, I needed a part-time job a few days a week; one of the clinic's aftercare people was leaving, so I took that job. And it was an experience.

An overwhelmingly *positive* experience. Let me emphasize that. Aside from the times that protesters tried to follow me home to get my address, or the time that I had to body-block a protester who started to get violent with a post-procedure patient, it was an amazing time. We were all women there, and all of us had had abortions. Two of us had had abortions pre-Roe, and one of them had been botched. I had my own abortion at that same clinic, with the same doc. That was the whole reason I ever considered working there--the women I met were so kind, so supportive, and so positive about what they were doing that I wanted to be a part of it.

Writing about those days makes my palms sweat. At the same time I was working at the clinic, I was also doing post-abortion counselling both online and in real life. But doing post-AB counselling and working at a clinic will bring two very different reactions in public. Neither are something that you'd necessarily want to announce at a cocktail party--or even in a blog--but the first, at least, won't get you harrassed.

The thing I remember most about those years is this: everywhere I went, from grocery stores to restaurants, women approached me to thank me and the people I worked with for the job we did. Once it was a woman in her 50's whose breast cancer had been discovered by a mammogram that PP paid for. Once it was a woman whose 13-year-old daughter I'd counselled about delaying sex. The daughter had quit hanging out with boys and had made the varsity volleyball team that semester. (That story made me cry; it also made me glad I'd refused a subpoena, but that's a different story.) Once it was a woman who just wanted to thank me for speaking openly and honestly about the circumstances surrounding the abortion I'd had.

It strikes me as strange indeed that one in three of us will have had an abortion by the time we hit menopause, yet talking about it is something nobody wants to do. Or, at least, we don't want to start the conversation. Even typing "I had an abortion" brings up the fear of the sort of comments I hate to see being left here. Women don't write them down on their medical histories. They don't tell their doctors or NPs about their abortions. They've even tried, in the past, to lie about why they were getting aftercare at the clinic. (Um...we saw you last week, okay?)

The reasons we don't talk are shame and fear. The fear is real, and protective: I've been followed in public, followed around the store, gotten nasty postcards from people who claim to be praying for me. Nobody wants to let themselves in for that. The shame is equally real, but comes from a different place: the straw-man idea that women who have abortions are automatically bad and wrong.

We might have been stupid at one point, or forgetful, or had some health problem that only cropped up later. But we're not bad and wrong.

And here is this anonymous woman who's writing about an experience that few of us will have. A third of us will have abortions; many fewer of us will ever talk professionally about the decision or help other women weigh it. Most of us who have done it or do it now don't talk about the work we do, except to other people in the same business. I'd bet that only a fraction of us actually come out in any public way and open the discussion ourselves.

Damn, I'm glad somebody is braver than I am. Whoever the hell she is, I wish her the strength not to fear the people outside the clinic, the ability to keep listening, and the stamina to continue her work.

Addendum: I've decided to leave comments enabled on this post.

Political discussions, if they go on too long, will be closed. As will any sort of debating. Flames of any sort will be returned to sender with a heapin' helpin' of rebound kharma attached.

Don't be stupid, friends.

From Izzle Pfaff

Clicky

Sylvia Bath

I have done it again.
One day in every ten
I manage it--

A sort of caulking miracle, my tub.
The sour mildew
Will vanish in a day.

I have suffered the atrocity of toilets.
Munge in the bowl
My brush filaments scrub and burn, a hand of ick.

Now I churn up soapstuffs that fly about the tub.
A film of such indolence
Will accompany my bystanding: I must shriek.

Cleaning
Is an art, like everything else.
I do it not terribly well.

I do it so it does not smell.
I do it so it feels clean.
I guess you could say I bought some gel.

Does not my sponge astound you. And my rag.
All by myself I am a schmutz Godzilla
Scrubbing and powdering and brow-dering, flush on flush.

I think I am cleaning up,
I think I may sanitize--
The motes of green Comet fly, and I, toilet, I

Am a pure ammonia
Virgin
Attended by noses,

By hisses, by effluvium,
By whatever these pink fingers clean.
Dead hands, dead astringents.

There were stains on your white parts
And we tenants never liked you.
We are dancing and showering in you.
We always noticed your goo.
Bathroom, bathroom, you bastard, I'm through.

A week of frustration.

Every nurse has Those Weeks once in a while: you work your three, or four, or five days, and each day has three, or four, or five little frustrations that make you wonder why you're doing this job rather than working at McDonald's.

The uniforms, after all, aren't as cool at McDonald's, but the hours are better.

Speaking of uniforms, two of my scrub jackets have come down with some sort of stain that even soaks in bleach and hot water can't remove. This in itself isn't an unusual occurance--I've had everything from antibiotics to Dead Guy Bile end up on my shirt--but the thing is, I can't remember how on earth something pink got up on my shoulder two days in a row. And scrub jackets are intensely personal. Everybody who wears one has a favorite, a second favorite, and one they wear only when everything else is filthy. These two are two of my favorites and have to be replaced.

Speaking of replacing things, I now need a new stethoscope. I lent mine to a nurse's aide who lost it within 15 minutes of putting her paws on it. We searched the entire floor and couldn't find it. It wasn't a particularly nice one, but it's still irritating.

Speaking of irritating, a tip for future patients: if I discharge you with a list of medications and how to take them, and spend forty-five minutes teaching your family how to administer said medications to control your pain and inflammation, *please* follow my instructions. I'm not doing this for the exercise, after all. If you don't follow my instructions (which come from the doctor and not my fevered brain), please don't get readmitted on the evening of the day you're discharged for a headache. Really and truly, this will not make me disposed to like you. Especially if it turns out that no, you didn't take any of the pills that I so laboriously educated you about.

In short, prayer might make you feel better and speed your healing, but God expects you to take advantage of pharmaceuticals as well. Heaven helps those and all that.

And finally, speaking of Heaven, that's where you might find yourself if you air your Neanderthal views about nurses to me.

This, people, is a biggie. There aren't too many folks around any longer who express surprise that I'm not wearing a cap or a white dress or whatever fantasy of nurse that Playboy has taught them, but there are a few. Most of those folks know enough to keep their mouths shut and not treat nurses like a combination of waitress and stripper, which only makes the person who doesn't keep his or her (yes, there are both sexes involved here) mouth shut that much more surprising.

I have had people try to tip me. I've had serious job offers from rich old ladies who want companions. I've had more offers of young sons and nephews than I can count. I have never, though, had a critique of my scrubs that included the opinion that they're a) too baggy and b) not low-cut enough until last night. Especially not tagged with the word "Darlin'".

"Darlin'" coming from an old cowboy is charming. Coming from a World War II vet covered with tattoos, it's appropriate. Coming from a lecherous man who dates women half his age, it makes me wish for a large-gauge needle.

It's frustrating weeks like this past one that make me wonder if maybe I shouldn't start working in the OR, where everybody's asleep, or in labor and delivery, where everybody's female.

I hear Wendy's is offering nine bucks an hour to start. And their uniforms aren't bad.

"Isn't there somebody who can get it all?"

No. Not when the "it" in question is a glioblastoma that's reached its tentacles into parts of your brain that you actually might need later.

As I told his wife, "there's no getting better with this, but there's often 'staying good'."

Then I went into another patient's room to say goodnight. He and his family ribbed me unmercifully and joked around as they'd done all day, with him leading the pack. All 160 pounds of him, cramped up in an odd position because multiple sclerosis had left his muscles too weak to support his body weight.

Last year he was playing football in high school and cruising with his friends.

And I wonder why I have dreams about missing an algebra test, trying to write an English paper, meeting my boyfriend's parents, and my car breaking down--all at once.

I am the luckiest girl in the world.

And not just because I ate poutine twice in one week and lived to tell the tale, and not just because Sheezlebub has made me Minister of Whacking Stupid People On The Head. I'm the luckiest girl ever because I got to hang out in Montreal with people that I love and whom presumably love me back.

Montreal is, at first glance, all balconies. That's what I remember--balconies on every apartment, and spiral staircases so steep that your head clears the second curve before your feet clear the first. Balconies and windows painted different colors on every building: purple and pink, yellow and green, black and richly stained wood. "Pas de circulaire" signs on all the doors of all the apartments, not color-coordinated with the balconies. That's probably a bit too much to ask.

We went up a horridly steep spiral staircase to Magda's one afternoon and into her long, narrow, utterly beautiful apartment. We consumed bread from the Polish bakery down the street and spinach pastries from the Pakistani restaurant and rabbit pate. I played with her cat, Kropka, who has a tiny spot on her chin (hence the name, which means "little dot" in Polish). All the time we were there, from the first bite of bread to the last bit of coffee and cherry tart, the sun shone through her kitchen windows. I was in the room with three of my favorite people and one person I was beginning to like very much.

Then, Friday, we met up with jhave totally by chance--an email had been misdirected or had gone unread, so he wasn't sure what I was doing or when I was leaving. Thanks to synchronicity and a bad lecture on temporal modalities in art, we got to hang out at the cinq-a-sept for a Chinese artist and talk neurology and productivity and romance. So there was Close Pal Number Four, just dropped into my lap.

Afterwards, we all (save jhave, who had a hot date with his girlfriend) went to Pied de Cochon and ate pork bits. Except for me, who had venison bits. Jacques and Arek and Justina and Joey were in rare form, the waiter teased me about being from Texas and shooting him, and then we went home to bed. Can't do better than that.

Now I've got a pot of spaghetti sauce bubbling on the stove. When I look out the window, I don't see Parc La Fontaine covered with snow; I see boring plain balconies. Spring is coming, the pear trees are trying to bloom.

I can't paint my balcony pink, but I think I'll get some window boxes this week.

In which Jo eats her way across Montreal

The best part of travelling anywhere is the food. It's also the worst part, but we'll get to that in a bit. For the moment, let's concentrate on the positive.

Joey and Arek live in a high-ceilinged old apartment across from Parc La Fontaine. It's got those cool old windows that are five feet high and a foot wide and push out rather than lifting up, though nobody's doing any window-opening when it's twelve below. There is the requisite exposed brick wall on one side, and Joey's painted most of the rest of the place in shades of cream, sage green, and light turquoise. It's a sunny place, filled with African masks and Polish ceramics and Joey's paintings and Arek's books. It's also filled with about forty different kinds of cheeses, so that when you open the refrigerator door, you get whacked across the snout with CHEESE.

Cheese here is made from unpasteurized milk. Pasteurization is a marvelous thing; it keeps various nasty bugs from growing in an otherwise wholesome beverage. Unfortunately, the process of pasteurization (as I understand it) also reduces the number of cultures which can grow in milk to make cheese. So the cheese that you get in the States, even some of the best stuff, is a pale approximation of the wonderful creamy, nutty goodness you can find here.

Junk Food

There's a restaurant just 'round the corner that sells practically nothing but poutine. Poutine, for the uninitiated, is French fries with cheese curds and brown gravy.

I'll just wait over here while y'all recover yourselves.

Anyway, the specialty of this place is poutine, and they're proud of it--for good reason. Poutine is one of those things in which wildly disparate ingredients combine to make something that the angels eat in Heaven. If there's a National Food You Can't Believe You Ever Tried But Now Crave for Quebec, poutine is it. Nothin' like it, friends, when you've downed a couple too many Maudites and now need a sponge for the alcohol. I credit poutine with getting me where I am today, which is mostly vertical and with some basic neural functioning.

Good Food

Another fun thing I tried the other day was tendons. Yep, tendons. See, the pho restaurants at home don't offer tendons (hard or soft, your choice) for good reason: people run screaming from the mention of connective tissue in the US. But the brave folks at Ho Pho or Yo' Pho or Go Pho or wherever it was we ate proudly offer tendons (hard or soft)...and they're pretty damned good. As in, I took a bite expecting to be able to swallow, but not expecting to eat the rest by choice. I ate the rest.

Odd Food

Did I mention the peculiar Quebecois humor of putting small amounts of maple syrup on everything edible? Well, practically. There wasn't any on my poutine, but then, I wouldn't have been shocked to find it there.

I'm spoilt. I've been here, what? three days? and I already have a craving for hash browns and barbecue. And a good burrito. First place I'm stopping when I get off the plane is at some hole-in-the-wall barbecue place with good old vinegar sauce.

In the meantime, more coffee is in order. And maybe a little cheese.

And on the third day, she rested.

Saturday: fly, wait, fly. Land. Customs. Purpose here? Tourist. What do you plan to do? Be a tourist. Customs official looks irritated. Drive to the market. Taste breads and cheeses. Buy flowers and a tart. Home. Bread, cheese, beer, nap. Nuit Blanche. Art museum. Video installation, sculpture, interpretive dance installation. Breakdancing exhibition, but the line was too long. Jazz. Home. Sleep.

Sunday: bread and cheese and coffee. Vieux Montreal. Brunch of jamon et fromage crepes with maple syrup (?!)--odd but good. Lunch tab: $74. A musical piece played on ships' horns and train whistles, still attached to the ships and trains. Tugboat-as-icebreaker. Science museum. Magda's for pate and spinach pastry. Home. Oscars. Did anybody else notice that Pacino seemed drunk as a skunk? Sleep.

General: the silence at the airport, and the walk from the gate to the new terminal. Church bells on Sunday. French of a type I can barely understand, spoken at breakneck speed, and the feeling that I ought to be following it. My own fumbling attempts greeted very politely. A huge amber necklace in a shop. Very strong coffee. Green domes of churches and tall, slender windows. The mountain on Saturday, with the cross on top, and every shaggy-friendly dog in Montreal coming over to pay their doggy respects. The park with ice skaters.

In which Jo contemplates mortality

I hate flying.

Flying in an airplane is the quintessential combination of boredom and terror. Especially on two-hour flights, during which one has just enough time to get bored in between a terrifying takeoff and equally terrifying landing.

Tomorrow I get to do that, not once, but twice.

The situation's not helped by my umpteenth reading of Mary Roach's Stiff, a book about the...er...life of corpses. In it, she recounts an interview with a man whose job it is to determine what happens during and after an airliner crash--from the bodies of the victims. Not good pre-flight reading. Note, too, that this caveat is coming from someone who read Steven King's short story "The Langoliers" on a flight to Denmark.

Everything is packed save my glasses and makeup. The bed has fresh sheets on it, the laundry is done. The Boyfriend has been deputized to take care of The Cat for the week. (Sample from Cat-Care Instructions: "Under no circumstances should you attempt to impress The Cat by throwing gang signs or using such slang as 'Fo' shizzle, mah kizzle!' This will merely irritate The Cat, who will respond by bustin' a cap in yo' ass.") The folks who run this joint understand whom they are to call if the building falls down in my absence. The refrigerator is mostly free of food. I think I might just have it all covered.

Now all I have to do is wait for 4:30 a.m. to come. And dread the flight in the meantime.

Kevorkian scarf...

Link o' the day goes to Ill Will Press, home of Foamy the Squirrel.

clicky

Then click on "Kevorkian Scarf." I swear I have seen that squirrel running through my hospital. "Oooooh sad is the world...."

Also, check out Thinking Nurse. Way more intelligent and focused than I am. Really worth reading.

The downside of nursing.

There is, near as I can tell, only one real downside to nursing as a profession.

I'm not joking, people. The hours are long and the pay can be miserable, but there's always another (possibly better) job out there. Physically, it's hard work--but there's always another (possibly better) job out there. Patients and coworkers do share bugs with you now and again, but you get better. Mostly. Even the caffeine addiction can be broken, with time and careful medical management.

No, friends, the downside of which I speak is Not Being Able To Dress Oneself Any Longer.

I wear scrubs half my life. The other half I'm mostly in pajamas, unless I actually have to go out in public, in which case I'm in jeans. Packing for this trip to Canada has thrown me into a bit of a state; exactly how ugly a sweater can I wear on the streets of Montreal without being arrested for endangering the public? Are corduroys a good idea or a bad one? Should I take a belt? Do I own a belt?

Correspondent Albacore was kind enough to reassure me that Montreal isn't fashionable in the way Atlanta or Dallas is fashionable. She put it like this: it's more important to look different than to look good. Which is comforting because, while my dress is different, it's not good.

Albacore also mentions in the same email that there are great places to snowshoe and cross-country ski in the area. This frightens me. Longtime readers might recall last summer's trip to Banff, during which I was hauled gasping up and down mountains by my fit pals Joey and Magda. I just know that Joey and Magda will now strap me into a pair of snowshoes (or worse, skis) and take me out so that I can watch Joey's grace, Magda and Jhave's impressive fitness, and be instructed, German-Border-Guard-Style, by Joey's boyfriend Arek in how to ski. Or snowshoe. Just like he taught me to play pool.

Right now I'm packed. Down to the long underwear and pajamas. Things may change in the next 72 hours, but for now, it's done.

Be warned, Montreal: the world's worst dresser is headed your way.

Housekeeping

You will notice new links to the right. I encourage you all to click on them all, in series, and marvel at how much better all of those folks are than I am at writing.

Also, comments are now enabled. You know what to do and how to do it.

I am so tired.

I am tired, so very tired, of being sick.

First the flu. Then, just as I thought my immune system would be somehow cranked and ready to deal with any kind of little buggy-wug, a cold. (And yes, as I said to the doctor yesterday, "I *know* the immune system's more specific than that, but I can dream, can't I?")

And the cold turned, as it so often/always does, into a sinus infection.

Which means I called in sick this morning. I really thought I'd be able to make it, but simply sitting upright is taxing. Which makes me feel like a complete wimp/sellout/let-down.

Please reassure me that working sick is not a good thing to do. Please tell me that if I show up drugged and uncomprehending, it's not good for my patients. Please remind me of all the times I worked during a short-staffed shift and how it turned out fine and dandy.

The worst thing, at this point, is not the coughing or the facial pain (though that sucks). It's the guilt for calling in. Working sick is such a normal part of being a nurse that your whole metric for illness changes: "Okay, well, I've only vomited once this morning, so if I eat crackers and Sprite all day I'll be fine." "I only have a fever of 100. That means I can go in." "I can't forget to pick up a mask."

Of course, it's other people working sick that got me into this situation...but I still feel guilty for not going in and helping out.

Funny thing is this: in the other jobs I've had, ones with horrible deadlines (getting 18,000 pounds of books out of a warehouse by Wednesday) or ones where I Was It (the only waitress in the diner), I didn't ever feel guilty if I were well and truly sick. And now that I'm well and truly sick--flourescent mucus, crushing head pain, not having slept in two nights--all I feel is guilt, guilt, guilt.

If I had my way, new nurses would be fitted with a third arm and a pair of eyes in the backs of their heads rather than this Ubiquitous Guilt Chip they apparently stuck into my neck when I graduated.

Holy kamole.

Here's an object lesson for everybody: Before you leave the examining room, ask your doctor what she plans to prescribe for your condition.

I don't like narcotics. They make me sleepy and sick and fuzzy-headed, so I prefer not to take them whenever possible. I have made this clear and asked that it be noted in my chart at every doc I see.

Today I went to the usual place for a sinus infection. While I was there, seeing an MD that I don't normally see, I mentioned that the cough that went with my URI was keeping me up at night. He told me he'd give me something to calm the cough.

He gave me Flutuss HC. I had to Google it, having never heard of it before. It's promethazine (Phenergan) and codeine. Narcotic, yes. Combination of two drugs that will guarantee sleep, no joke. I've had patients on both drugs who came close to not breathing any more. Fuzzy-head-making and quease-inducing? You bet.

It may be time to dig out the Tessalon Perles (it knocks me out, but it's relatively short-acting in my system) and just go with that.

Meanwhile, I have a bottle of stuff I can't use. If I'd just asked a simple question or two, or reconfirmed that I don't like narcotics, I could've saved both my insurance company and myself some dough.

Beautiful.

Harriet McBryde Johnson's piece on disability rights and debating Peter Singer. (Addendum: I have tried eight times now to get that link to work correctly; it won't. try this:

http://community-2.webtv.net/@HH!80!A2!2134BF518044/stigmanet/HarrietMcByrde/

Shout-out to Alas, A Blog for linking to this in the comments section.

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?
brought to you by Quizilla

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.