Why we have protocols.

I've said it before, and I'll say it again: "A policy does not exist to inconvenience you. There is a reason for it."

That was brought home to me last week in a big way.

A patient had come in, had a bad surgical outcome, and had spent the better part of eight weeks bouncing from unit to unit. At one point, some bright person had noticed that the patient was coughing up a lot of junk (sorry for the technical term) and decided to do an acid-fast smear and culture on that junk.

Acid-fast bacteria are a big family. Most of 'em you don't really need to worry about, but one you do: tuberculosis. Our hospital policy says this: if a patient has an acid-fast bacillus positive smear or culture, that person is put into respiratory isolation in a negative-pressure room until it can be determined that they do or do not have TB. It sounds draconian to do that, but it's really quite sensible; the treatment for TB is nasty beyond description and takes a very long time.

So this patient had a negative AFB smear and a positive AFB culture. The micro lab called the floor where the patient was at the time and gave the results to a physician's assistant who had been following the case.

Here's where the system breaks down. The PA, being a Quasi-Important Person with an inflated sense of his own authority, decided that the culture didn't matter, that the patient didn't have TB. How he determined that without psychic abilities escapes me, but the point remains: he didn't notify the infection control folks or put the patient into isolation. In other words, he carefully ignored the protocol that the hospital has put into place for the protection of everyone.

Micro also screwed up. They're supposed to call report, with a read-back, to two people: the resident in charge of the case and the nurse caring for the patient. They didn't. They ignored the protocol that was put into place for the protection of everyone.

So. Fast-forward four weeks. The patient's been on our floor for two weeks. Another bright person, this one from the pulmonology staff, takes a walk through the patient's chart and finds the old AFB positive culture result. The patient is slapped into isolation, where I find them after I come back from a three-day weekend.

I'd taken care of that patient for two weeks solid. Several times I had gotten coughed on and sprayed with mucus (no matter how careful you are, this will sometimes happen). I was told that an AFB-positive culture had *just come back* from micro, hence the sudden isolation.

Which struck me as fine, until I read the chart and noticed that the AFB culture had actually been done back at the end of May. And that it had been positive. And that the patient had been un-isolated and coughing on yours truly, as well as other nurses, techs, support staff, and doctors all that time.

My hair caught fire. I started making phone calls. I found the record of an order for a PPD (purified protein derivative test for tuberculosis), but no record of its having been done on the patient. (Protocol again, this time a failure of a nurse to chart properly.) I wandered into the room and inspected both arms--yep, there's the permanent-marker circle that defines a PPD placement. Okay. It's negative. Back on the phone, I paged the infection control team leader and told her about what had just happened. She paged the PA in question and the chief attending physician of that service. The attending called me, so I had to tell her the same story I'd told everybody from IC to ICU.

The upshot of all of this drama? The patient got some super-duper DNA screening widget test that involves turning urine into gold, or some such, which determined that there was no tuberculosis bacillus present. Period.

(Of course, we'll all have to be tested again in twelve weeks, just to be sure.)

The test costs not-a-little-money. It has to be sent out, and the results in this case were statted, which costs more. The hospital is going to eat that cost. There were also a number of us who'd cared for this patient who'd had to go home and inform our families that we might've been exposed to a particularly icky bacillus. (That was a fun one; Chef Boy was coming down off of having his smoker explode when I told him.)

Yes, TB is hard to catch. Yes, it's treatable. Yes, the chances of my having caught it, even with direct exposure to infective goop, were quite slim.

But the point remains: at least two people in this little drama didn't follow protocol. One didn't follow it because he just knew he was right; the other didn't follow it because they were just plain lazy. As it turns out, everything was fine--and the PA in question really *was* right this time.

Still, it cost us 24 hours of worry and cost me quite a lot of time to clear up.

The worst bit? The PA, since he doesn't work for the hospital itself, can't be written up or otherwise go through our disciplinary--sorry, "counselling"-- process. And the lime pit in my back yard is already full.

Well, that was nice.

I got a very sweet piece of fanmail the other week, from a guy who says that my blog is the "blog by which other nursing blogs should be measured."

Which is a lot like saying that mayonnaise is the condiment by which other condiments should be measured. It gives you a solid median, but there's plenty of room for improvement.

Still. Whether or not I agree, it's nice to get props.

In other news, Kelly (She Who Rocks The Night Shift) is dropping her blog, Time to Lean. I've replaced that link in the list with Shrimplate's blog. No, I'm not a disloyal bitch, just too lazy at the moment to re-figure-out the whole HTML thing. At some point in the future I'll add a list of Gone But Not Forgotten links--blogs that aren't updated any more but which still are worth reading.

Given that it's about to start raining again and that power this week has been spotty at best, I'm going to go eat a bowl of panzanella and hope my refrigerator stays on.

Write an order, dance a jig, beat up your fellow nurses.

"I don't understand why you people are so incompetent."

That's a bad way to begin any conversation. Unless, of course, it's me saying the words, in which case it's perfectly acceptable.

But it's not a good way to begin a conversation with me.

Especially when you're a resident who just started on this unit on the first of the month.

Perhaps especially especially when you're not the sharpest tool in the shed yourself.

Universally Competent and Marvelous Resident (UCMR) was upset that his patient hadn't gotten a number of treatments and medications that UCMR had discussed with one of the nurses. When I say "discussed" I mean *discussed*, as in "Do you think we ought to keep this guy on the high dose pressors he's on, or cut 'em back for a while?" and "Does the wound care service take care of ingrown toenails?" and "What's the procedure for calling a pharm consult for vanc dosing?"

Never mind that these are Very Simple Questions, the answers to which UCMR should've already known. Never mind that the nurse he discussed them with wasn't even the patient's nurse; UCMR had just pulled the poor guy aside during the middle of the night to pepper him with questions.

UCMR lit into me because none of his brilliant ideas had translated into action on anybody else's part.

"You know," I said, trying my best to be gentle, "we can't do anything without an order from you. Just talking about it isn't the same as ordering it, since we don't know exactly what you want."

"Well, you *should*" he protested. "And isn't writing down verbal orders your job anyhow? I don't have time for that shit."

"A verbal order," I replied through my fangs, "should be given as such, not as a series of increasingly idiotic questions. Preferably, it should be given to the nurse caring for the patient. And as for shit, I don't have time for yours. Write your orders and get out of my chair."

Poor UCMR. He really should go into plastics, or some other specialty where people are nicey-nice.

TEAM players

Management has come up with another marvelous idea. This time it's TEAM, a laboring acronym that stands for something like "Teamwork, Enthusiam, Attitude, Managing problems". Here's how it works:

Patients and family members are supposed to fill out little cards the hospital sends 'em a couple weeks after discharge, then mail 'em back, prepaid, with their glowing review of staff members. Each staff member mentioned by name gets a gold star (no, I'm not making this up) next to their name in a file somewhere. When the staff member compiles enough brownie points, they get a nifty T-shirt to wear that proclaims them as a TEAM Player.

Management has its collective crinoline in an uproar. Our unit has gotten the fewest TEAM mentions of any unit since this whole thing started. The assumption on Management's part is that this makes us a bunch of hard-drinkin', dirty-talkin' malcontents without professionalism or caring attitudes.

The reality, of course, is that we have the largest proportion of patients who are totally gorked. Many of 'em either die shortly after they leave us or go to some sort of inpatient rehabilitation. None of those factors make it likely that the patient will suddenly sit up/return from the grave/begin to speak rationally and commend the care he or she got with us. Never mind that the families are dealing with a different set of issues than family members of patients who just had a facelift or breast reduction.

Let's face it, people: Creutzfeld-Jakob disease is not a condition that makes anybody want to fill out a postage-paid postcard six weeks after diagnosis.

So those of us on the Pariah Unit have come up with a plan. We're gonna have white vinyl jackets made up, in the style of 1950's Broadway musical gang members, and have "TEAM PLAYA" embroidered on the backs. We're going to get matching tattoos, set up a wet bar in the nurses' station, and take to dandling Lucky Strikes out of the corners of our mouths. Then we'll mug any nurse we see wearing a TEAM Player T-shirt.

In a few weeks, our reign of terror will be complete. We'll have the hospital under our thumbs. Ice cream sundaes for everybody in OR 7!

Things I do not understand.

1. Why are the French considered cheese-eating surrender monkeys? They mobilized eight million some-odd people for World War I. Over a million of those got killed in combat alone. That's not counting the three-quarters of a million folks dead of disease or badly injured, or the civilian casualties. Yet they were able to contribute another five million bodies for WW II and run a fairly efficient sabotage operation even while being occupied by the Nazis. That doesn't say "run away, run away" to me.

2. How come people in Lexuses (Lexi?) drive so badly? 60 in the fast lane, signalling for MILES without turning and turning abruptly without signalling, cutting people off, playing with their hair. What's up with that? Does owning a Lexus make you stupid?

3. Why won't that guy in 108 get it that I cannot get him a bigger room, no matter how much cash he offers me or how much he cusses? Can I please please please tell him tomorrow that I'm not his nurse because he's so personally unpleasant?

4. What *up* with the pharmacy, dawg? Why can I not get a timed vancomycin dose that only comes every thirty-six hours? Is that not enough lead time for you guys?

5. What's the appeal of those little batter-boogers that seafood fast-food restaurants put under your fried fishlike substances?

6. What *up* with you residents, dawgs? Like, your patient is sick. Do not come to me and tell me that and then stand there like I ought to be able to wave a wand. Write an order. Call a code. Dance a jig; I don't care. Just effing *do* something, okay? Okay.

And that, again, is all.

A Guide to Getting Along With Me, by Nurse Jo.

1. If you are a doctor, please sign the orders you write. What's easier--signing the orders while you write them, or signing them all when I present you with a big stack of incomplete charts and an evil smile, when you're already late for dinner with your wife?

2. If you are a patient with six different diagnoses, all of which must be reached by exclusion, all of which are obscure, and four of which require narcotics to control, you might consider that you're a whackjob.

3. If you're a night nurse, please don't bitch that I "left" you a single piece of not-very-challenging paperwork to fill out during your shift. I had five discharges and six admits today, and your head explodes with one of each, so shut the hell up and fill out the paperwork.

4. If you're a patient's family member, please understand that I don't have the power to get you a "bigger room". There are no "bigger rooms" in the hospital. Yours is as big as it gets. The fact that you're inviting twenty people to witness your being wheeled away for minor surgery is not my problem.

5. If you're a floating nurse on my shift, can the twenty-minute report. We write reports for a reason. You really, really, really don't need to go through every normal system in detail. Hit the high points. We all want to go home.

And home is where I am, with a plate of nachos and a beer.

And I get to do it all again tomorrow.

Well, shit.

Wish I knew whether friend Judy, OB/GYN extraordinaire, is okay.

Damn.

You know you've worked too hard when

You have a dream that Gregory House is leading a tour you're on through Cape Verde, and that you've forgotten your sun hat back at the hotel.

However, I did manage both to avoid dysentery and to earn his praise by figuring out how to manufacture pure oxygen using only a match, a tablespoon of mayonnaise, and a bowl of spinach.

I am *so* done with you.

Just a tip:

If you plan to seize eight times in four hours, please seize at least once during the five hours that you're in the EEG lab. That will save a lot of trouble.

If you're not going to seize in that five hours, please don't seize twice in the five minutes it takes to transport you from the lab to your room.

And, for God's sake, if you do *that*, seize just one goddamned time after I've set up the incredibly complex and nasty portable EEG monitor and glued things to your head. Okay? Okay.

And one more thing, this for another patient:

If I tell you to hold still, it means *hold still*. As in, STOP MOVING. As in stop fucking wriggling around, or this line that's in your artery, or going into your heart, or just in the wrong damn place, will puncture something that I won't be able to put pressure on.

And, while I'm at it, don't tell me how much more money I could be making as a fucking medical equipment sales rep, because that would mean I have to give up this incredibly rewarding and satisfying job, holding you down so you don't kill your own money-grubbing, shallow, awful self.

Um.

Anybody wanna buy a DynaMap?

Quick housekeeping

No, I don't know why Netscape is inconsistent with Blogger's commenting. I can't even fix my own HTML without a handful of Xanax and somebody standing over my shoulder.

Sorry if I haven't replied to your email. It's been rather busy here. Don't take my lack of response for a lack of interest, unless you're calling me a baby-killer or a bad woman, in which case you may. Everybody else, I've got two days starting tomorrow and will run through the inbox then.

General advice: It is a bad idea to eat half a Virginia ham by yourself, no matter how lovingly prepared and wonderful it is. You'll be up all night slugging water.

I'll be back tonight or tomorrow. Salut!

Unusually political post....

Fuck you, so-called "liberals".

Let me lay two things out for all of you right here and now.

1. Abortion is not a "devisive" or "minority" issue. It is a normative fact of women's lives. Forty percent of women under the age of 45 have had abortions. It is *routine* for women in this country to terminate pregnancies. It is a basic part of women's health care.

Whether or not you agree with whether a woman has an abortion is not the issue. This is the issue: Would you support criminalizing, in what's likely to be 21 or 22 states, a procedure that many women have during their lifetimes? Would you be willing to accept the morbidity and mortality that would certainly result from women too poor or too desperate to travel to a different state for a legal procedure?

Which brings me to the second point:

2. Criminalizing abortion criminalizes all aspects of pregnancy loss. If a woman in a non-choice state has a late miscarriage, chances are she will be quizzed prior to or during the delivery of services to determine whether or not she had help in ending the pregnancy. Those people who wish to help women terminate pregnancies safely will be prosecuted, and will likely lose whatever licenses they have. Those who don't care--the kitchen-table idiots--don't have anything to lose.

Consider for a moment what your life would be like if you, or your partner or wife, had a miscarriage and needed medical help. Would you be willing to have that pregnancy loss investigated as a possible crime?

Think it can't happen? One of the women I worked with at PP got into women's health after watching her first patient ever die. Of tetanus. From an illegal abortion. In 1980. She lived in a place where abortion services weren't available.

After the institution of parental consent laws in my home state several years ago, I saw two young women during my emergency department rotations, a year apart, who had both tried to self-abort. One is now sterile. Both were afraid to tell their parents.

I met a woman who, in 1968 in Texas, was denied emergency care during a hemorrhagic miscarriage until she provided the name of her abortionist. The fact that she hadn't *had* an abortion didn't matter to the cops. Her hematocrit got to 15 before a doctor intervened and saved her life. She ended up in the septic ward anyhow, and lost a kidney.

Probably things won't be as bad now as they were from the 1930's onward, when women had to go to literal back alleys to terminate pregnancies. The advent of cheap airfare and better medical technology, along with a generation of medical providers who grew up with legal abortion, will probably prevent too many horror stories. Probably there will be a new Jane Collective, dedicated to helping women get safe illegal abortions. Probably we won't see the return of septic wards, thanks to better antibiotics and better practice.

But I am not willing to rely on probably.

Edited to add this addendum, which I only just remembered:

Several years ago, I was cleaning out the cabinets at our local Planned Parenthood. I came across a file box full of index cards that had come from the women's health clinic that PP had taken over. On one of those cards was the name and phone number of a doctor who performed illegal and safe abortions in the town's only hospital prior to 1973. The police apparently gave him a pass, given that this is a liberal college city.

The doc was my mom's obstetrician. He would've delivered me back in 1970, but he was going under for an emergency root canal at the time. I asked Mom if she knew then that her doctor did illegal abortions. She said she knew. I asked why she chose him.

"Because I knew my life would be important to him, just as my pregnancy was important to him."

My right hand really hurts.

It's stiff, too.

That's because I spent twenty minutes with a hell of a lot of weight on it, leaning into that nice man's groin last night, trying to keep him from either bleeding to death or getting the world's nastiest bruise after that post-A-gram bleed.

That's the bad news. The good news is that, not only did he not bleed, he doesn't even have a hematoma there today. Nurse Jo with the magic fist!

It's not often that you can come home from work and pat yourself on the back for something you did really, really right. So I'm wearing out my other arm, patting away. It didn't hurt that the poor post-surgical nurse is brand new and so stood there gaping like a trout, thus making me look good. She was scared to death, poor thing, having done mother-and-baby for the past fifteen years.

In other news, it poured rain today for umpteen hours (actually about two) just at the time I was at the farmer's market. I stood in the rain and talked organic gardening with the thin, intense guy with tomatoes, okra and peppers with the old fat farmer guy, and blackberries with the blackberry guys.

Then I came home, napped, and made this:

Stuffed Zucchini, Jo-Style

Get you two "Eight-Ball" zucchinis. No, these are not zucchinis that have been mulched with heroin; they're round and about the size of baseballs.

Cut off the tops and scrape out the insides with a spoon, leaving about a half-inch border of flesh on the inside.

Chop that scooped-out zucchini gut stuff up.

Chop up about three tablespoons of onion and a handful of small mushrooms, too, while you're at it.

Heat a pat of butter in a non-stick skillet. Add a handful of chopped pecans and saute them until they start to smell really good. Then dump in the rest of the vegetables. Salt and pepper them once they turn soft, then add a tiny bit of dried thyme or oregano. Garlic is optional.

Just when you think the veggies might be done, when they're looking mushy and slightly browned and marvelous, add a chopped-up Roma tomato or two that you got from the organic gardening guy. Heat the whole kit and caboodle through, then take it off the heat.

When it's cooled a bit, stuff the zucchinis with the veggie and pecan mixture.

Put 'em in a pan, add an inch or so of water to keep 'em from burning, and bake 'em at, oh, about 350 until the sides of the zucchini wonderfulness cups can be pierced easily with a knife. Parmesan cheese, grated over the top during the last few minutes of baking, is really good.

Serve to general applause.

Now, can anybody give me some really good recipes for the umpteen gazillion crookneck yellow squash that Thin Intense Organic Gardening Guy gave me as a bonus?

So I had planned to

Come home today and lift weights. After all, if Georgia can live on 1200 calories a day and exercise like a madwoman, so can I. Right? Right.

But instead, after an alligator-to-the-eyeballs day with an arterial bleed at 1830, I went and had two beers and a grilled portabello mushroom.

With cheese.

NCLEX question: How much blood can one lose from a femoral artery bleed following an arteriogram?

Answer: Not as much as you'd expect, but God it looks like a fucking lot when it's spread around.

Sudden moment of self-doubt: am I still cool?

Hate Coldplay.

Bored by Tom and what's-her-name. (Speaking of which, recent research has shown that certain "important" faces might be stored in a few brain cells devoted exclusively to that purpose in our brains. Thus, we have a few brain cells devoted to Halle Berry, a few devoted to Robert Gould, and so on. Which depresses me. Any number of brain cells devoted to celebrities is too many.)

Love political discussions.

Two vintage painted Mexican tourist skirts in closet.

Hair sticks up all over head without my trying.

Two holes, one in each ear, no tattoos. (Wimpy, wimpy, wimpy.)

Screamingly liberal, still.

Thinking of taking back old part-time job as family planning counsellor at Planned Parenthood.

Can quote lines of poetry.

Make kick-ass mac & chee.

Share that recipe with the world.

Thirty pounds overweight...
...but boobs not yet hitting waistband of jeans.

Excellent intuitive diagnostician, paranoid nurse.

Consumes gallons of Scotch. Neat.

Just commented on 18-year-old's blog. For the record, she writes *hilarious* stuff. Much funnier than my best efforts.

Yeah. I'm still cool.

Whoring and hobbying.

Food whoring and hospital hobbying, that is.

Remember the corn I got? I got more from the farmer's market and mixed it up with black beans and diced tomatoes and some broth from the Dead Chicken of the other night (this was older corn that could be treated this way) and made SOUP. Mmmm. Soup. (There, Kit, is your Corn Whoring.)

As for the hospital hobbyist, here's the story. It's instructive to note that all the time the residents and attending were writing orders, we the nurses were the ones that had to deal with this patient.

Every once in a blue moon, you meet a person with an incredible tolerance for pain medication. For those of you who aren't nurses, the Painkiller Of Choice for a lot of people with a high tolerance or a big addiction is something called Dilaudid.

Whereas morphine and Demerol are dosed in milligrams, Dilaudid is dosed in tenths of milligrams. It's not only whoppingly effective, but it's whoppingly concentrated. Keep this in mind: a patient-controlled pain pump filled with morphine is dosed one milligram of drug to one milliliter of fluid. Dilaudid is dosed 0.2 milligrams of drug to milliliter of fluid.

With addiction (I'm not going to use the word "tolerance" here, since it's not appropriate) comes other problems, most of them psychological. Sometimes it's bad enough that our very-pampered MDs will skip seeing a patient daily, just so as not to have to deal with their weirdness.

Which brings me to the Champion Hospital Hobbyist: a person who spent six weeks in our facility with a wound infection, who was on a Dilaudid pain pump with a setting I had to read twice to believe, who got additional narcotic painkillers and Dilaudid boluses every hour, and who still was able to get up, go down seven stories, walk out to the parking lot, and smoke.

(For the nurses, the pump setting was 0.4 basal, 0.6 q 6 minutes, 30 mg q 4 hour lockout, boluses q1 prn. Which was increased every few days as boredom set in. Along with fifty of Phenergan q2 and the occasional Lortab.)

This patient was crazy enough that the attending had left it to the residents and nurses to handle things for six weeks. We were all wondering if Said Patient was simply going to move in, since there didn't seem to be anything wrong that we had to deal with, when I finally asked Attending the burning question on everyones' minds:

"So...this person's been here a month and a half, and we haven't really done anything. How many nudie pictures of you *do* they have at home? 'Cause that's the only reason I can imagine that we're keepin' 'em."

Champeen Hospital Hobbyist was gone the next day.

Boy, I wish I had a dog.

Four a.m., I've been up for an hour, and today will not suck.

I woke up an hour ago to the sound of drunken shouting and the screeching of tires in the parking lot. Where I used to live, this would not be an issue; in fact, it was a normal part of daily life. A car landed in our front yard about once every two months, propelled by somebody who'd already had too much to drink and who was looking to beat closing time at the closest liquor store.

But here it's odd to hear yelling at 3 o'clock in the morning. Or any time, for that matter. So I was wide awake, listening for running footsteps or gunshots or screams, when the Great Dane next door started to bark.

Woof. Woof. Woof.

Nothing frantic, nothing hysterical. Just the thoughtful, measured "woof" of a dog that outweighs the people it lives with.

It struck me simultaneously that not only would a Very Large Dog be a good thing to have, but that anybody who keeps a Very Large Dog in a thousand-square-foot, third-story walkup apartment is dedicated in a way I can't even imagine.

Anyway, having the big guy next door makes me feel safer. Knowing that he's going to produce a subsonic "woof" at a disturbance dozens of yards away makes me feel better about somebody trying to get in here.

Why today will not suck

As any nurse will attest, there are some weeks when you lose track of time completely. It's a sad day when you have to depend on your patients to reorient you to date and time, but it happens. I had the sudden, horrible conviction that I actually had to work today, and had to go check my calendar to see if I was right. Nope. No working today. Which means farmer's market and natural food store and nap.

Speaking of which, I found something remarkable at the grocery store yesterday. Corn was two bucks for five ears, so I bought five, intending to prepare it somehow for dinner last night. When I shucked the first ear, I discovered that what I'd bought was perfectly ripe white corn with tiny, sweet kernels. So I cut it off the cob, steamed it in the microwave for three minutes, and dressed it with butter and salt and pepper. Yum.

Enough foodwhoring. Kelly wants to hear the story of the hospital hobbyist who spent six weeks without seeing a doctor, so maybe I'll tell that one later. Right now it's time for leftover dressing and gravy and another cup of joe.

Dinner.

Roast chicken. Stuffing with pecans, mushrooms, and onions. Corn off the cob (not sure if I'll steam it or cream it). Carrots. Potatoes, maybe scalloped. Cherry pie.

Who wants to come for dinner?

No, Speed Racer, no.

His legs were already over the bedrails by the time I got to him.

"You'll have to wait a minute to get up until I get your walker" I said.

He tried to get up anyhow. He's not demented or confused, just convinced that his seventy-eight-year-old, six-foot-eight, three-hundred-pound body works as well now after back surgery as it did before. The two-foot-long incision might give the lie to that.

He got to the chair, let go of the walker, and plopped into the chair with one buttock on the chair arm.

We had a little discussion after that. He'd fallen the night before--sitting down hard on his ass after getting out of bed despite raised siderails and a bed alarm.

"Look," I said, "you *have* to wait until I get in here to get up. And you *have* to use the walker correctly, or else you will fall again and have another surgery. If you fall, I'm not even going to try to catch you. I'll just get out of the way."

"You won't try to catch me?" he asked, disbelieving.

I looked up at him--he's still taller than I am, even when he's sitting and I'm standing, and said, "Uh...no."

Tell me where these people come from so I can shut the gates.

A happy customer service story

So I ordered some clogs from The Clog Shop. Dansko Sport clogs are the only type I can wear; the Professional line has too narrow a heel, and I fall over a lot.

Today I got a call from a very nice man at the store. Seems the clogs I'd ordered were only available in white, not black. They'd gone to the trouble of tracking down one of the only remaining pairs of another style that's practically identical. The store sending that pair to *them* wanted to get a C.O.D and charge them $20 in shipping.

The Clog Shop guys offered to eat half the shipping and charge me the other half. Since their shipping is already free, I said "Hell, yeah!" I now have two pairs of Dansko Sport clogs on their way, thanks to the smart people in Great Neck.

I believe strongly in shopping Mom & Pop places rather than El Giganto Box Stores, and this is why.

You know how "they" say

Never to eat shellfish in a month with no "R" in it?

Well, they're right.

The shellfish-induced nightmare I had last night might've had more to do with the fact that the shellfish came from the seafood equivalent of the Little Guy With The Cart With Bells On It Who Sells Tamales. Eugh. Still, I'm not chancing it again.

Normally I'm not a huge fan of Filipino food. The dried fish is good, though rich, and the eggplant has its place, but I just can't get behind the little cakes that might be sweet or might not be. The mussels, though. Mmmm, the mussels.

From the mussels came the dream I had: I was catering a wedding in Chef Boy's absence, but I was doing it *in the hospital*, and nobody had ordered food that week. Which meant I had to deputize someone to handle washing all the dishes and someone else to go for groceries while I watched fourteen patients who all had odd rhythms and ectopy on their monitors.

Never again. I get enough of that stuff when I'm awake. No need to do it when I'm asleep as well.

Quick shout-out to Em

Who rocks my world for explaining how to make my sidebar look ept once again. Its ineptness had been bugging me.

Little did I know that she's also a student nurse and a writer, and a good one at that. So go check out "Where's My Towel?" over thar.

For my nice pal from Digitalstakeholders-dot-org...

I cannot fathom the rationale for a so-called "critical nursing shortage" in light of your postings.

God love him or her; s/he's brought out my soapbox.

I paint a really rosy picture of being a nurse. Most of the nurse bloggers I know do; it's because we have the time and energy to blog because we work in good facilities. But there *is* a critical nursing shortage--and don't let the word "critical" make you think that everything that follows it is hyperbole. It's not.

The facility where I work is private. It's famous all over the South for the work that its surgeons do. It's one of those places where you meet doctors from all over the world who've competed hard to gain fellowships. We recruit nurses from all over the country, from some of the finest nursing schools around (both two- and four-year; we're not snobby that way).

As much as I bitch about the administration, there are certain things that are unique--and wonderful--about the place where I work. The attending physicians have nicknames. Nobody is verbally or physically abusive. The patient-to-nurse ratio is quite low. The pay is good, the support staff is smart and competent, and teamwork is emphasized.

I've heard stories from non-nurse friends that chill me. One woman told me about going to visit her mother in the hospital and seeing a nurse punched by another patient's family member. I've been told about doctors screaming obscenities at nurses in a patient's room. And I've heard one story from a pal about the hospital her father was in--the place was so badly controlled that he was beaten up by his roommate.

The stories from nurses are even worse. One woman I precepted as a student nurse accepted a job with a fairly prestigious hospital and got a three-week orientation (ours is twelve). On her first day as a brand-new nurse, she got nine patients. Nine. With no practical nurse to work with, no patient care aide, nobody. I hear stories from colleagues of sixteen or more hours of mandatory overtime a week, or worse, of being so overwhelmed that your charting isn't done until three hours after your shift ends.

No wonder there's a nursing shortage. You know the shortage is bad when Our Beloved Governator, Arnold, calls nurses a "special interest group" because the unions had the temerity to fight for safe nurse-to-patient ratios.

We're at about a ten percent vacancy rate across the country right now when it comes to floor nurses. Critical care and specialty vacancy rates are even higher. (Don't even ask about rural and deep-urban shortages.) We just aren't graduating or keeping enough nurses to staff the hospitals we've got; at the same time, we're having to build new hospitals to keep up with demand.

Part of the problem is in nursing schools. Teaching positions pay shit, compared to working on the floor, and the hours are even longer than those of floor RNs. There aren't enough teachers to go 'round, so there aren't enough spaces in nursing schools. My class started with thirty (out of 228 applicants) and ended with 21--not a bad attrition rate, if you think about it, but a horrible acceptance rate.

Part of the problem is with nursing curriculum. Especially in two-year programs, the workload is insane and the competition horrendous. Medical residents go through an eight-year weeding process to cut out the dead wood; we get two years. A couple of my colleagues graduated with less than a third of the classmates they started with. This is one of those necessary evils: if you're not quick enough, smart enough, and strong enough to handle the schooling, you're not going to be able to handle nursing.

But the main problem--the thing that is solvable but unsolved--is the fact that hospital administrations see nurses as a homogenous group of masochistic machines who'll do anything for a three-thousand dollar signing bonus. Money rarely gets put aside for continuing education, cost-of-living increases, or special awards. Nurses are unrecognized, on the whole, and expected to take on ever-more-critical patients with ever-less-available resources.

And hospital CEO's, like CEOs all over the country, make gazillions of bucks. Consultants get hired to tell hospitals how to improve customer service (ignoring the best way to have happy patients--have happy nurses). New hospitals get built with all the latest bells and whistles, then offer only 80% of market rate, thinking that nurses will be happy to get taken for a ride, as long as they get all the greatest technology.

So yeah, beloved DSH, there is a rationale there. And the shortage is critical *right now*--maybe not across the entire country, but it's certainly dangerous in spots. (One of our sister hospitals has *two* nighttime RNs for its orthopedic unit.)

Now I'm going to put the soapbox away, thank heaven for my job, and go get some coffee.

HTML Nurse...

Okay. I've added to and rearranged links on the sidebar, a task that leaves me shaking and sweaty.

For you Safari users, Ivo's blog sponsorship is probably still taking up way too much space--sorry. I've gotten ahold of Ivo's tech guy but have heard nothing back yet. (Hey, BEN!! I'm callin' you out in public, man!!)

No, I don't know why there are big spaces between headers and the first links under "Nurses" and "Docs". I also don't know why things changed color. I am an Aitch-Tee-Em-Ell Idiot. Anybody want to help me out, email me privately. I'll take good care of you if you ever end up in the hospital.

Things I like

In honor of having three days off in a row

Making up new lyrics to Pussycat Dolls music: "Don't you wish your girlfriend was as brilliant as I am?/Don't you wish your girlfriend was as smart as me?/Don't you wish your girlfriend was a specialist RN?/Don't you wish your girlfriend had a PhD?"

Having three days off in a row.

Cheese fries and a leetle nightcap at the restaurant I favor, when everyone else is done. Bartenders are interesting people.

Running/trotting three miles at once and not dying.

Clean sheets.

Clean scrubs, all at once.

My cat, just in general. She's insane (Janet The Writer heard me cuss at her more than once on the phone, poor woman) and cranky, but I love her.

Speaking bad French to people from Louisiana who speak good French.

Air conditioning. That should probably go up at the top of the list, given what the weather's been like lately.

Big giant dogs. As in 180 pound Great Danes and big ol' English Mastiff puppies that weigh almost as much as I do even though they're only nine months old. I'm crazy about big dogs, much like Audrey was crazy about Tiffany's.

Vacation plans. Practical jokes. Waiting in the airport for my flight to take off. Silver pins. Polish stoneware. Blonde jokes. The first scene of Episode Three. Going to bed early.

And so, Goodnight.

Swear to God, I'm gonna kill somebody one of these days.

Not in the medical-malpractice sense, either.

One of the weird things about nursing is how dichotomous it is. One week, you'll get patients who will actually use their incentive spirometer (a fancy name for a widget one breathes into to keep the lungs healthy), walk when they're supposed to, and generally work at getting out of the hospital. Their families will be understanding and kind, and the doctors will respond to pages.

The next week you'll get people like I got this week.

Papa is in his mid-seventies with a new diagnosis of Parkinson's and dementia. Papa don't walk so good, as evidenced by Mama's dislocated shoulder. He fell, she tried to catch him, and they ended up in a pile on the floor with Mama underneath. It's amazing neither of them broke a hip, but then, stupid people tend to bounce instead of shattering.

Papa is a max assist, three people, and stands well over six feet tall. I am short. I mean, *short*. As in I put everything on the bottom shelves of my kitchen cabinets because I can't reach the second shelf short. Which, as you might imagine, puts me at a small disadvantage, leverage-wise, when moving folks like Papa onto and off of a bedside commode.

So why did Mama stand so close to me as I was helping two other people move Papa? Why did I have to tell her twice to back off (nicely, of course), and then actually almost knock her down when Papa sagged? Why? Why don't these people listen to me? I do, after all, do this every day.

Or the nice man with the crazy family. "He's a hard stick. The last hospital, they had to have five people try to get an IV in. You might want to call somebody...older, you know? Like, are you able to do this? I mean, do you know how to start an IV?"

By which time I'd gotten a nice big peripheral line, one stick, in a place it wouldn't bother him or be painful. I do, after all, do this every day.

Or the nice woman with the crazy family. "She's got thrush on her tongue. She needs Nystatin. I mean, that thrush is nasty. Look at how it rubs off when you swab her tongue."

Thrush doesn't rub off. The patient is also on long-course Diflucan therapy for yeast in other places, so thrush is a remote possibility. I suggested to the patient that she actually *brush her teeth* (without mentioning that her breath could knock over a horse), thus decreasing the problem.

Did I mention that I do this on a daily basis?

*sigh*

The one bright spot in the crowd of psycho patients' families and obnoxious doctors was the guy who owns one of the best Italian restaurants around. His wife kindly brought me a sampling of food for dinner--three takeout boxes' worth--which I ate with relish for lunch the next day.

If this is "ER", I want my makeup artist.

We had one of those Sundays that happens only on medical dramas: nurses chugging down the hall at a dead run, stethoscopes flying, scissors bouncing out of pockets, yelling things like "I need OXYGEN!" and "TWO MILLIGRAMS ATIVAN! STAT!" We sent three people to CT for emergent scans--one person twice--which led me to point out to the neurosurgery resident on call that, with two more scans, we'd get a free eggroll.

Therefore, I present

What I Cook On My Day Off

A really great layered sandwich:

Chop up a bottle of pitted kalamata olives. Mix these little guys, all chopped up, with enough mayonnaise to make a semi-creamy glop. Then add some good mustard and a clove of crushed garlic.

Slice the top off of and yank the innards out of a round loaf of bread. Spread the olive mixture on the bottom and up the sides. Schmear some more on the cut side of the top.

Layer salami, prosciutto, and pastrami into the cavity in the bread, alternating with chopped seeded tomato and provelone and fresh mozzerella cheese. If you're feeling adventurous, toss a few chopped-up basil leaves in there occasionally. Red pepper or thinly sliced red onion is good, too.

Keep layering and packing the sandwich goodies in there tightly until you've reached the top. Now slap the top of the loaf on, squash it all down, and bake for forty-five minutes or so, wrapped in foil, at about 400 degrees.

Yank it out and slice into wedges. Serve with salad or potato salad or strawberries with cream.

Just now my hands are stained yellow-green and smell strongly of dill. In Mom and Dad's neighborhood, dill grows wild in vacant lots. Here I have to buy it in plastic packages at the store, then toss it in the blender with black pepper and yogurt. I still serve it over cucumbers or with chicken breast, though.

More than two hundred days

Ali was making coffee, the thick black cardomom-scented stuff that Kuwatis drink by the gallon, when I mentioned to Mahmoud that I was reading "A Hundred and One Days", a book by a Norwegian journalist about the second Iraqi war and the occupation of Baghdad.

I wonder, I said half to myself, what it would be like to live in a country that's occupied.

Not easy, said Mahmoud. Ali had his back to us, still swirling the coffee in the tiny silver pot, but I could hear him muttering to himself in the Kuwaiti dialect they speak.

Mahmoud is my age. In 1991, when Saddam occupied Mahmoud's country, I was in college. When the American bombs started to fall, I was in Scandanavia. Ali was in California with his family.

Mahmoud was in Kuwait for all of it, the sole support for eight other people, all too pregnant or sick or old to leave.

We had no water, he told me. Every day I would go out and get cans of water from wherever I could, sometimes from the ditches by the side of the road. My brothers and sisters and my parents had left for Jordan and I stayed behind. Someone had to take care of my grandfather and my aunts and the babies.

We would line up for hours for bread, he continued. Sometimes in the bread lines the Iraqi soldiers would come and take some people away. We never knew why or where they went. I walked everywhere, passing through Iraqi checkpoints several times a day.

All you could do was keep your head down. Some of them, you could make them laugh, and that was all right. Others thought we were trash.

Ali poured coffee into tiny glasses. Iraqi soldiers, he said conversationally, are like the Chinese. Dirty. Not all of them, but most of them. Dirty.

Mahmoud and Ali broke into something faced-paced and gutteral I couldn't follow, my Arabic being so far limited to compliments, thank-yous, and requests for basic food items and water.

It was not easy, Mahmoud repeated. After the war I felt I had to do something for my country, so I volunteered at the hospital where they sent people who had been frightened by the shelling. All I had to do was sit and listen to them talk, the men, but after three days I could not go back. The men frightened me too much. The stories were too frightening. I could not do more for my country than I had done. I had helped keep my family alive until the end of the occupation.

Then he looked at me, full on, for the first time since he'd started speaking. Don't tell anyone, he said. Not even David. I don't want anyone to know what I did.

Why not? I asked.

Because they will ask me questions, he answered.

Star Wars: A Guide For The Newbie.

Yesterday I met two people who'd never seen a single "Star Wars" movie. Tragic. Having just seen Ep.3, I hereby present my own capsule versions of the movie, to bring other Tragic Teens up to speed.

Episode Four: A New Hope...for about ten minutes.

Despite its name, the first in the series. Whiny kid plugging womp rats hooks up with mysterious monk-type, wild-and-crazy spaceman and his giant ape companion, and cute princess. Mayhem in the form of cantina scenes and space war ensues. (Note: Pay attention to the cantina scene. At the time, it was the best special effect bit most of us had ever seen.) Happy ending complete with medals and Wookie hollering.

Episode Five: What the Hell Am I Doing On This Swamp-Planet?

Whiny kid, now no longer a kid, gets frozen. Then he thaws out on a swamp planet with a wise monk-type Muppet. Meanwhile, crazy space-cowboy turns into HanSicle, much to Princess's distress. Wookies. Pseudo-Oriental philosophy. A large sluglike creature. Space wars.

Episode Six: In Which Billy Dee Proves He Has No Rhythm

Carrie Fisher in scary hair extensions! Luke, I am your father! Dead Yoda! Happy Han and Leia! Ewoks, most of whom sadly survive! Chases on rocket sleds through Northern California! Bad ending with Billy Dee Williams clapping off-beat!

Okay. We've gotten through the first three. Now for the prequels....

Episode One: In Which We Encounter Anakin, Savior of the World

Small child with incredible powers. Two monk-types, one of whom is much younger than the last time we saw him. A guy in scary face paint and horns. Chariot races. Space wars. Yoda, but younger. We meet the Princess, mother of the Later Princess.

Episode Two: The One I Don't Remember Very Well

Er....lessee. Princess falls in love with Whiny Teenaged Anakin. Politics. Clones. Politics. Space wars. Er...Politics. Something about a secret marriage. A REALLY REALLY IRRITATING GUY WITH LONG EARS.

Episode Three: In Which All Is Revealed

Pregnant Princess. Pushy Palpatine. Arrogant Anakin. Observant Obi-Wan. More Wookies. Better bad guys. Tragic ending with half-burnt half-corpse on the bank of a lava river. The best opening sequence since the first movie. Samuel L. Jackson looking oddly out of place. Yoda, kicking ass.

And now the cat (my very own quadripedal Sith Lord) is drinking out of my water glass, a signal that it's time for bed.

What not to do.

Don't, when you're standing in a group of people including nurses, nurses' aides, transport people, flight nurses, unit secretaries, and one attending physician, respond to the physician's snarky comment with the words, "Oh, gosh! Dr. House, it's so nice to finally meet you in person!!"

Everyone but the attending will laugh.

*sigh*

Nice things other nurses have done for me lately

Listen up: If you're in nursing school or a new-new nurse, you're going to learn a lot of really, really cool stuff and have a lot of folks doing you favors. At least, you will if you live in *my* universe, where nurses don't eat their young.

And if you're a not-so-new nurse (I refuse to call myself a New Nurse after three years, thanks), you'll still be learning/on the receiving end of nifty stuff. To wit:

1. A while ago, I had a patient come in through our triage center who the nurse downstairs thought might could use a blood transfusion (given that his hematocrit was something like 20, I could see that). So the nurse, in addition to starting an IV for me and hooking the patient up to normal saline, *hung that fluid with blood tubing* to save me a little time. Bless his head.

2. If you've got a person who's a really, really hard stick and you manage to get an IV on 'em, you can usually draw blood from that peripheral IV if you slap a tourniquet on the arm above it. I learned that just two days ago. For some reason, I'd never thought of the tourniquet.

3. Clearing feeding tubes is a constant bugaboo. If flat Coke doesn't work (and don't waste your time with other sodas; they're not acidic enough), magnesium citrate will. Strangely, this saline laxative, given time to dwell in a clogged feeding tube, will dissolve almost anything. Of course, you then have to deal with having fed your patient a laxative, but it's better than replacing a tube.

4. Chlorhexadine will get iodine stains out of clothing if the stains are fresh.

5. If you have a triple- or double-lumen central line with one lumen clotted off, it'll take you only thirty minutes with TPA to unclot it. If you wait until the whole thing's verklempt, you'll spend an hour mucking with TPA and saline. A stitch in time saves nine, you know.

6. Another nice thing somebody did for me: a workaholic patient came in with suspected meningitis. By the time he came up from admitting, his cell phone and Blackberry were already in Security, locked up away from him. (Meningitis patients do better with very little stimulation and stress in the early days.) Bless the admitting nurse who saved me the stress of getting his technology away from him.

7. If you're having a hard time starting a Foley on a woman, make your last pass with your iodine swab *up*. The urethral meatus in most women has a down-facing lip, and you can usually tell where the meatus is if you wipe up with iodine--it opens up a bit. Likewise, if you hit the vagina on your first try, *leave the catheter in there as a landmark* while you start the next one.

8. And finally, if your female patient has a very full bladder and you're trying to start a Foley, in-and-out catheterize her first with a tiny little catheter. For some reason I don't understand, that'll loosen things up enough that you can get a larger-bore Foley in there easily. I found that one out by accident, in desperation, and it's worked every time since.

Now that all the medical folks are nodding their heads, half are saying "She didn't know *that*??" and the non-medical folks have all crossed their legs and said "Oooooooooooo", I'm going off to iron.

Link o' the mornin' to ye!

I love this one:

Food Whore

Why, yes, I *do* live in a novel.

The Flailing Patient had just cold-cocked me in the kidney during a fit of frustration. I was getting a bit tired of a person who lashed out--physically and verbally--without the slightest qualm, so I took myself into another room where there was an alarm sounding.

I fixed the alarming pump and glanced at the patient in the bed. Something about him seemed familliar. Then I glanced at his armband: "Schlomo Fishnugget."

Schlomo Fishnugget???

"Uh, sir?" I ventured, "Are you the same Schlomo Fishnugget that invented the Ding-Dang Freakywidget and postulated the Creakynut Energy Conversion Theory?"

"Why, yes, I am" he replied, with a boyish grin.

"The same Fishnugget who won the Nobel Prize for applications of the Ding-Dang Freakywidget?"

"Yep."

I was standing in the presence of one of my heroes. It was as though Bucky Fuller had knocked on the door and offered to sell me some Girl Scout Cookies (now with less waste!).

I gaped. I've taken care of politicians, minor members of royal families from all over the globe, heads of small states, rodeo clowns, circus performers, musicians of all stripes, investors, and interesting normal people, but here was Schlomo Fishnugget. And I was clearing an alarm on his IV pump.

So, after the requisite I'm-Your-Biggest-Fan business, we talked about dogs. And how to make the perfect potroast.

On the record, off the leash

I spent a pleasant hour yesterday chatting with a very nice woman named Janet Wells, who's doing an article on nursing blogs for Nurseweek magazine. Why on earth *I* seemed like a candidate for an interview I don't know; there are plenty of other nursing blogs both more sane and more nursey than mine.

There was only one point at which I had to say, "Wait! Wait! No! Don't write that down! That's off the record!" Given that I was simultaneously talking to her, knocking cobwebs off the ceiling with a broom, trying to unpack two boxes of books, keep the cat from going completely schizoid, and drink a beer, I'd be surprised if what she prints is comprehensible. The quotes from Jo will probably end up looking like this: "Urgh. Dammit. Ow! Silly cat! Nursing. OW!!"

That's me, the only undiagnosed Touretter ADD nursing blogger out there.

I guess I really ought to subscribe now, or at least find a copy, so I can tell if I translate well to print.

Oh, for those who were wondering (like anybody was), there will be no picture. I haven't got a digital camera, so Janet is on her own looking for a representation of a Typical Blogger.

Cooking and those who don't.

I can bring home the bacon and fuckin' fry it up, man.

Today, before one o'clock, I had made two chicken pot pies (the real sort, with mushrooms and carrots and peas and cream sauce and biscuit dough) and a brisket and put together my crazy Kuwaiti friend Mahmoud's desk.

Mahmoud bought, on a whim, one of those melamine desks with forty umpteen holes and numerous little odd screw-things that are supposed to attach the various bits together. He had no clue how to start with the thing, so I went over to his place and had it together in fifty minutes.

Let me tell you how to reduce a crazy gay Muslim to rapture: bring a chicken pot pie into his house. I'd fed him once before on the stuff and he kept asking, "Is this something Americans eat all the time? Or do you keep it for special occasions?" Every once in a while he'd mention it with a sigh and a woeful look. So I thought I'd take him a pan. He ate half of it while I put his desk together.

Then, as I was leaving the house to get gas, I ran into a neighbor. She doesn't cook either.

(A quick aside: When I say "doesn't cook", I mean *DOESN'T COOK*. Mahmoud keeps Tupperware in his oven. Stephanie occasionally heats things in the microwave.)

Anyway, she's doing spring cleaning at the moment and wanted to give me three pans: all Calphalon. One's a medium-sized skillet, the twin of which I already have, but there are two true finds: a very small omelette pan, just perfect for one person, and a straight sided skillet that I've been looking for in thrift shops for years. Neither of them is made any longer and haven't been for some time.

So I came back and made her a cake. Chocolate, with chocolate frosting, because she likes that sort of thing.

The top looked a little rough-and-ready, so I grated some white chocolate over it. Then I noticed that the middle of the top was sagging a bit (it was still warm), so I just piled on some of the tiny sweet strawberries I got earlier today at the store.

I just took it downstairs. Stephanie looked like I'd handed her an Oscar. She got very flustered, round-eyed and stammering, and finally put it on the counter and stood staring at it for a few moments.

This is what I love about people who don't cook. What for me is a fun hobby and for Chef-Boy is a way of making money is some sort of arcane alchemy to them. The simplest things, like making stock from scratch, fill them with awe and appreciation. Tell people who don't cook "Sure, come on over, I'm just about to pull the bread out of the oven" and you'll hear sonic booms preceeding their entry into the driveway.

Therefore, in honor of those who don't cook, I present the best recipe ever for those who do or don't.

Kick-Ass Mac and Chee

Melt four tablespoons of butter in a very big saucepan. Use medium heat; you don't want to burn the butter.

Add five tablespoons of flour. Whisk the butter and flour together until it's marginally smooth.

Pour in four cups of milk. Whisk like a madman until all the lumps are gone. If you can't get 'em all out, don't sweat it.

Add a teaspoon each of dry mustard and garlic powder, along with a couple of shakes of cayenne pepper. Keep heating the milk mixture, stirring, until it thickens up a bit.

Now add eight ounces of grated or chopped-up sharp cheddar, five ounces of mild cheddar, and five ounces of mozzarella cheese. Don't add 'em all at once; let the previous cheese melt a bit before you add the next.

Let it melt all together, stirring constantly, until it's creamy.

Pour over twelve ounces of cooked pasta. Devour.

Things about which I do not care, Sunday, 5:53 am edition:

1. Michael Jackson.

2. Any of the celebrities who slept in Michael Jackson's bed.

3. Ultra-super-duper long-lived mice with healthier hearts.

4. The men's rights movement.

5. Anything much going on in Kansas. I promise I'll care about that later.
(Apropos of which, I met somebody the other day, about my age, who actually believes the world is only 4,000-some years old. Given that almost nobody believed that idea *when it was postulated*, I think we should put her in a glass case. Amazing.)

6. Cholesterol. It's just too damn early.

7. Florida.

8. What David Beckham is doing these days.

9. Laura Bush's comedy routine.

10. Merck Pharmaceuticals.

Why am I up this morning this early? On a day off, no less? Because Beloved Chef-Boy has to cook a Mother's Day brunch (plated, limited menu, special selections) and so has to be at work at 7 am. This is early for a chef, especially when he worked dinner the night before.

Wish your mom a happy Mom's Day. And reserve a few good wishes for those long-suffering members of kitchen crews who were up late last night and will be up early this morning.

Listen up, Fashionistas.

Sonic Nurse (love that title) complains that scrubs for guys suck. Most scrubs for women suck, too, but I have a solution to that little problem.

It's called Ladybutton Fabrics.

Yes, yes, I know. The fabrics there are nine-fiddy a yard. You'd have to find somebody to make you the tops once you do have the fabric. But honestly, come on: where else you gonna find scrub toppable fabric with sushi on it? "Futurella" pinup girls? Women who love their appliances? Beloved sister had a sushi scrub top made for me two years ago that looks fantastic still and gets many compliments. Soon I will have *more* crazy scrubs, since it looks like LBF just got some new stuff in.

There's no excuse for being boring in your nursey suit. If your facility allows you choice in scrubs, join me. Rainbow-colored poison dart frogs are only the beginning.

Not-smart things to do

For a pretty smart chick, I sometimes do some pretty dumb stuff. Managed it again last night, when I went to a local dive with some friends. Now, no matter how good and greasy dive-bar food is, no matter how nice it is to sit next to a biker named Skillet and his dog Nanook, sometimes you need to exercise a little restraint when it comes to adventurous eating and drinking.

Those words are shocking my friends, who remember me saying things like, "Oh, look! A guy selling tamales out of his car! Let's get some!" Or stopping at every boudin shack within a hundred-mile radius. Or eating way-undercooked turkey legs proferred by toothless inbreds at VW Fests. Whatever. I'm learning slowly, in part due to Skunked Beer.

I do not know, nor do I want to know, what makes beer skunked. All I know is that I got one last night, had enough of it to realize that it was off somehow, and then thirty minutes later came down with the second- or third-worst headache I'd ever had. It's an odd sensation, sort of like having the stomach flu but without any stomach symptoms.

I'm better today thanks to liberal applications of water and ibuprofen, but I'm still feeling a little peaked.

Which leads me to a book review.

I'm reading Bill Bryson's A Short History of Nearly Everything and making slow progress, not because he's a bad writer (near as I can tell he writes on every conceivable subject and makes it all understandable and fun), but because the book is so damned dense.

Still, it rates a Highly Recommended on the Nurse Jo Nonfiction Scale. He makes string theory comprehensible. I can't wait to see what he does with quasars.

Well, that was interesting.

It's crunch time at the hospital. Every patient in the ICU is on a vent--no kidding--so we're getting a lot of really...er...marginal patients up on the floor and into our ICU overflow. Makes for an interesting day, as we discharge everybody that is ready for discharge, move people hither and yon to open up rooms, and then wonder what fresh hell is coming up from downstairs.

One of my guys this week was in after a major stroke to one of the big arteries in his brain (posterior basilar, if you're interested. Also, writing the word "basilar" over and over makes you wonder if you've spelled it right). He's lost all function except for voluntary eye movement, and that with a fairly significant delay. Ask him to open his eyes wide and he will, but only with what seems a lot of work and after a couple of seconds.

The report I got gave a diagnosis of "locked-in syndrome", a nightmarish situation in which a brain injury or other problem robs a person of all voluntary movement except those of the eyes. Given that that diagnosis was postulated by a pulmonology resident and not a neuroscience resident, I was a little weirded out. Anyhow, my poor patient had all the prerequisites for a rotten diagnosis: fulfilling life, happy family, loving friends, beautiful kids. At this rate, I'll live forever.

Another patient (beautiful children, loving family, loyal friends) came up to us after two weeks in a phenobarbital coma for status epilepticus.

In English, that means this:

You know when you have an epileptic seizure, and the electrical activity in your brain goes completely haywire? Imagine that without end. Status epilepticus equals completely wacked-out electrical signals. A phenobarbital coma is a fun little medical tool we use to calm peoples' brains and bodies down long enough to give them a rest and us some breathing room to figure out what the hell to do next. (By the way, we still have no clue as to what caused the problem, so please don't ask me.)

This poor patient had been in an almost-constant seizure state for *three weeks*. The seizures had calmed down to the point that facial twitching was her only symptom (well, probably also because she really couldn't move anything else, given the amount of damage she'd had), so they handed her off to me.

Nobody told me that the seizures would occasionally stop for a few minutes at a time, leaving my trached/g-tubed/paralyzed patient aware of what was going on. Unable to speak or move, but aware.

At which point she would sob silently, tears flooding down her cheeks.

Then, maybe mercifully, she'd start to seize again and would become unaware.

Makes you long for a tumor. At least those, you can get out of the hospital in a week or two.

In which Jo meets Satan and Satan wins

You know it's going to be bad when one of your patients is complaining about another patient he met in the emergency room.

You know it's going to be worse when you can hear the complaining patient all the way down the hall, being wheeled up in a stretcher, bitching about how, Goddammit, he pays fourteen hundred dollars a month for insurance and ought to be in a private room.

You know it's going to be unbelievably horrible when you try to explain to the patient that the reason he's in a semi-private room is that this is ICU overflow and he's got an expanding hematoma, and all he does is say, "That's a good line, cunt" and then ask you if your hair is *really* red.

Of course, he came in positive for benzodiazapenes, cocaine, cannabinoids, alcohol (BAC 1.2), and opiates. He's morbidly obese, has diabetes, has had five heart catheterizations, multiple gut surgeries, and is hypertensive. He's noncompliant with all of his medications, but still complained about the food and the pills I had to give him.

The black eye he had from getting drunk and falling over improved neither his appearance nor his mood. His family doctor, who showed up and humored him, didn't improve my mood.

You can talk all you want to about being assertive, setting boundaries with your patients, and laying down the law. Sometimes it just doesn't work. Sometimes you have to get out of the room before you either say something unforgivable or actually hurt the person in a red fog of rage.

But we showed him. Yesterday we assigned him a nurse who'd been the charge nurse of a busy county emergency room. By ten o'clock he was behaving.

Call me a wuss, but I really hope I never have a patient like him again. If I do, I hope I have a good supply of morphine and a ball gag.

No comment needed

Why is my job not like this?

This is what's good: or, What I cook on my day off

Onions (red) and mustard seed (black), a handful of each. Cumin seeds, a lesser handful. Fried in olive oil until the mustard seed starts to commit pop-kari and hop all over the stove. Then, add a bag of baby spinach that's been rinsed and shaken out. Let the spinach wilt.

Serve with basmati rice. Bitter, sweet, spicy, crunchy, chewy, all at once.

Zucchini: tiny baby zucchini, the size of your thumb. Cut 'em in half or thirds. Saute in REAL thank you butter, just a bit, until they're vaguely golden brown on the cut side. Eat. Spring in a frypan.

Asparagus: roasted dry so all the sugars carmelize, then drizzled with a tiny bit of olive oil and salt and lots of fresh black pepper.

Broccoli is good any way you make it. If anybody has any idea how to make a garlic-and-broccoli aspic (solid uniform light green, not clear) like I had at L'Express in Montreal, please do tell. Mmmmmm. Not at all what I expected, not edible-looking, delicious.

Eeeen-tee-ninesy strawberries from the pick-yer-own patch, sliced and served with really, really good balsamic vinegar and a dash of fresh ground black pepper. Trust me on this.

Right now I'm hunting for a blackberry patch. My secret old half-acre tangle of blackberries got bulldozed, dammit, for overpriced McMansions, so I'm scouting the fields and back roads. When the blackberries ripen, I will pick them and eat them immediately, then turn the rest into jam. Recipe to come then.

Ooooooh. And blackberries with cream. And blackberry shortcake. Mmmm.

"Do you practice what you write?"

Just saw that comment on another medical blog, one written by a doctor.

It got me thinking: do I practice what I write?

Most of the time, the answer to that should be "God, I sure hope not." If ever I did, there would be nastiness flying that would make Dr. House look like a kinder, gentler Florence Nightingale. (Not that that would be hard, you understand. Ol' Flossie was a bit pushy, then a bit weird. But you get my meaning.) If I had one day to say what I *really* thought...goodness. The building, with its overfed administrators and clueless management, would likely burn down. Hopefully with the aforementioned people still inside it.

So most of the time, no, I don't practice what I write. I don't often write about how difficult it is to find something to say to the wife of a young man with a highly aggressive and atypical glioma. I don't write about how often I have to tell people that they will *not* get any better, that where they are is as good as they're going to get.

I don't write about the times I don't say anything. Those times are the most important, in the larger scheme of things, and you never know they're coming until they're on you. Sometimes the most therapeutic (I'm making bunny-ears in the air to signify quotes around that word) thing you can do is shut the hell up and let the other person vent. Sometimes that happens at the very most inconvenient time possible, like at the end of the shift when you're exhausted, because that person decides to trust you when your hand's on the door.

A lot of this job has to do with reminding yourself nearly-constantly that it is not about you. People will bitch, moan, complain of being abused by the physical therapists, and be insulting to you...but they'd do that to any willing ear that came in. They'll compare you to other nurses. (Nota bene: Other nurses are always better than you in retrospect.) They'll be nasty.

Then, all of a sudden, it really *is* all about you. For some weird reason, this person has decided that you, with all your faults and pettiness, are the person that they want to express their fears to. And you have to be ready for that, and not make any huge blunders.

Then it stops being about you again, if you do your job right.

So...no. I don't practice what I write. What I write casts me as Super Nurse, with the big S on my chest and the cool boots. (No capes.) I wish I could write what I practice, but there's a delicacy to the interactions that I just can't do justice to.

Eventually, maybe, I'll get there. In the meantime, though, what I do is this: imagine my day, before I even get out of bed, as though everything is going perfectly smoothly. I think of the ideal responses, the ideal emotions. I store those away. And then, for the next twelve hours or so, I try--not to live up to the ideal--but not to kill anybody or dope-slap anyone out of frustration.

Yesterday I read four books.

I got home to find three books in my mailbox and a fourth waiting for me at the office. Hooray for Amazon's used book service! Hooray for ALibris!

I walked into the apartment and said to the cat, "Kitty, we're rich! Wealthy beyond our wildest imaginings! We have BOOKS!!" She mumbled something about tuna and went back to sleep.

So, without delay, reviews:

1 and 2. Life on the Border and Bordertown, both edited by Terri Windling:

I'm a big fan of the book Finder and a lesser fan of the book Nevernever. Both of those are part of the "Borderland" series conceived by Terri Windling, who apparently has nothing better to do with her life than convince other people to write fantasy novels. She's also responsible for Tam Lin, a modern (1970's) retelling of the Scottish ballad by Pamela Dean. I got sucked into all this, by the way, when my sister sent me a copy of War For The Oaks, a very funny and fast-paced first book by Emma Bull.

LotB and Btown are basically interchangeable as books go. They're both collections of short stories that deal with what happens when Elfland shows up with a bang after millenia of not being around. Elves and humans start to mix in large cities, portions of New York and San Franciso disappear, dogs and cats run wild in the streets, and I'm sure at some point there're some sheeted dead gibbering there too. Nice concept, brutal execution in spots.

Or maybe I'm just not in the fiction-reading habit. Or maybe I got spoiled by reading Sayers and Edmund Crispin over the last weekend. Who knows? Point being, there are some gems in both books, but the titles and plots of the gems escape me. There are also lots of folks with pointed ears, and a surprising number of in-jokes, mostly having to do with Minneapolis. Charles de Lint continues to suck dead rat. Emma Bull and Will Shetterly retell bits of stories I'd read previously, but from a different point of view.

Bottom line: worth it for serious Bordertown fans, which I'm not sure I am. If anybody wants to read 'em, don't spend $20 at ALibris. I'll let you borrow 'em.

3. Gullible's Travels, by Cash Peters:

Love Cash Peters's commentaries on NPR. Love 'em.

Too bad this isn't like those. He's essentially put together a tale of all the bizarre places he's visited as NPR's Bad Taste Tourist, mixed in with healthy doses of not-too-subtle sarcasm and a touch of misanthropy, and put it on paper. *sigh*

4. Neither Here Nor There, by Bill Bryson:

Now *this* is a travel book. Bill Bryson retraces his steps through Europe, seventeen years or so after his first trek. It's funny, it's informative, it has hilarious moments, like when he tries to go down a staircase in an Italian hotel only to find the door at the bottom locked. He gets drunk in Nyhavn, cold in Oslo, frustrated in Naples, and enraged with the Visa travelers' check office in Geneva. His experience in Denmark mirrored mine--I realized at the end of the book that we'd been there at roughly the same time--and his retelling of spraining his ankle in Split had me gasping for air.

Bottom line: I'm planning to read everything else travel-related that he's written, having already exhausted his books on language.

Next up: Elizabeth's London by Liza Picard, and Inside the Victorian Home by Judith Flanders. I have another Bordertown book coming as well, one I'd forgotten I'd ordered. Also an out-of-print Gerald Durrell and a book on ravens, which I'm really looking forward to. Amazon tells me that their estimated ship date is Not Soon Enough and the delivery date is Long Enough Away To Make You Scream.

Now I'm off to take some aspirin for this over-reading headache I've got.

IF I'M SPEAKING A LITTLE TOO LOUDLY, FORGIVE ME.

IV pumps beep when there's a problem. Sometimes that problem is a kink in the line, or air in the line, or you've run out of fluid. Be that as it may, they beep.

Some IV pumps set up an outraged, high-decibel, high-pitched screaming fest when they run out of batteries. One of them did yesterday as I was settling in a patient, a fresh post-rotator cuff repair. I jabbed futilely at buttons for a few seconds, then dragged the thing outside the room. It continued to wail. It was *off* at that point, but that didn't seem to make a difference. The Evil One had gotten into that IV pump and wasn't letting go. It was the Amityville IMED.

Result? I couldn't hear very well for the next couple of hours, being's as I had my head down near the damn thing when it went off.

That, as it turned out, was a good introduction to the day.

I started with five patients, had a total of seven all day, and only kept one patient for the full twelve hours. You can do the math on discharges and admits on that one.

We ran out of IV needles, urinals, toilet paper, and patient belonging bags at about 1500. Since I'd already had to tap into my stash of dressing change supplies and soap, this did not make me happy.

My charge nurse seems to have lost his mind and decided I'm the go-to girl for unexpected admits and discharges. That post-op patient I had? I got less than thirty seconds' warning that she was coming. While this might be normal, it does not make for a relaxed Jo. "Oh, by the way, that's your patient" is not what you want to hear from your charge as a bed rolls down the hall.

One of my patients didn't like her Jell-O and threw it at me. Another didn't like the world and decided to delay asking for a shower until 1645. A third had two negative ultrasounds for DVT and a positive VQ scan for pulmonary emboli.

And they were out of chocolate cake in the cafeteria. Daaaaaamn, what a day.

Would you like fries with that new nurse?

Guess it's time I addressed the "nurses eat their young" thing, as I got three--count 'em--emails on the subject yesterday. (Shout out to Yolanda, holdin' it down in her commhealth clinicals!)

Yes, there are some really nasty, disgruntled, embittered nurses out there. There are also some really nasty, disgruntled, embittered bookstore employees, gas station attendants, soldiers, airline pilots, fashion models, and so on. Nurses are not the only folks who eat their young. Reparatory theater actors, for instance, are *much* worse.

But the public has this outmoded idea that nurses are angels of mercy who are always sweet, patient, kind, and dressed in white. They don't realize that we're highly trained, exhaustively educated people who are taking care of sick people and don't have time for B.S.

If you are a student and attempt to bullshit us, we will cut you off at the knees. Not only is bullshitting a waste of my time, and unprofessional, but it's irritating. If you don't know the normal values of potassium and sodium or what Lopressor is for, and you're a last-term student, you *bet* we'll bite your head off. Your job is to have some idea of what's going on. If you don't, you're not safe and you won't work with me.

If you're preternaturally stupid, we'll deal with you with patience and tact until management can get you transferred somewhere less challenging or to another hospital. And yes, that has happened with a new nurse I worked with--she didn't check vitals once during a twelve-hour shift and recorded *every* patient as having the same neuro exam.

However. If you're a new student who's showing some enthusiasm for what's happening, even if you're clumsy and ignorant, we will make sure you get the best possible clinical opportunities we can muster. Same with a new nurse: if you're a decent human being and willing to work hard, we don't care what you know or what you don't.

Same with residents. Same with new techs. We're a pretty forgiving group, provided you don't either ask us out during the shift (as an eighteen-year-old nursing student did with me once) or act like a jerk.

Of course, I work in a really good environment. If you're unlucky enough to be stuck in a hospital where people are ground down and unhappy, *everybody*, from the unit secretaries to the attendings, will be taking bites out of one another. That's called "a bad work environment", not "nurses eat their young."

Funny point: the people most willing to promulgate NETY as a truth are nursing instructors. Who usually haven't worked on a floor in years. Who have limited contact with clinical nurses. I had twelve instructors over the course of my schooling. Ten of them, when I asked 'em, said they'd gone into teaching because they hated floor nursing. Two of 'em said they loved teaching--and those two still worked weekends and off-days in the NICU or PICU or on the floor.

The ten who hated floor nursing were the ones who told us that nurses eat their young. The two who loved nursing and teaching, both, were not coincidentally the best instructors I've had in *any* course I've taken.

It's not hard to do the math, here. Point being, don't be afraid of nurses. You might be soft on the outside, crunchy on the inside, and taste good with ketchup, but that's not an automatic guarantee that Dragon Lady will eat you alive on your first day as an RN. Fall back on what you've learned in school and in your previous jobs and keep your eyes open. Be willing to learn from everybody. And, just to be on the safe side, do not bring large bottles of seasoned salt with you to work. It's just too much of a temptation.

What I do on my day off

"Sweet creeping zombie Elvis" Karen said as I walked into the bar, "Don't you own any sandals?"

I had put on a black short-sleeved sweater, jeans, and red pointy-toed cowboy boots. Karen's reaction caught me off guard until she explained that it's *spring*, dammit, and I ought to be showing off my toes.

"As a matter of fact," she continued, "I don't think you own anything that isn't a T-shirt."

She had a point.

Next thing I knew, she was pulling out her Palm Widget and making plans for us to go shopping. In a few days, I'll be heading out with a woman who is well over six feet tall and who holds a BA in fashion merchandising.

I forestalled her, though. Today I went shopping. Heh.

I bought two--*two*-- pairs of sandals. One is brown and low-heeled, with complex straps across the top of the foot; the other is black with one big strap across the toes and a pair of D-rings for decoration. The black pair has higher heels. Don't ask me why the D-rings; I assume it's Fashion.

Also a nice handbag. "Don't you own another purse?" Karen asked, eyeing my Peruvian woven shoulder-bag distastefully. The new one is black leather, shaped like a doctor's bag, and has muted white stitching and silver hardware. It's softer than the nicest pair of shoes I own and the handles fall over perfectly when you set it down.

And a linen suit. Nota bene: check out Target's new spring suits. And a pair of black cropped pants. And a blue linen man's shirt.

And three V-neck Hanes T-shirts. Hey, a girl's gotta be true to her inner Fashion Maven.

Simple definitions from life

We occasionally use the phrase "jacked up" at work. This is somewhere between "on vulture precautions" and "train wreck", and is a source of confusion for those people not versed in the cynical and bitter humor of a neuroscience unit. Therefore, I present examples of "jacked up" and "not jacked up" for your perusal. It is to be hoped that they will clarify the issue.

Migas: not jacked up.
Migas with store-bought pico de gallo: jacked up.

Hole in your belly I could put my head through: not jacked up.
Hole in your belly secondary to an abcess that's been cooking for twenty years, ever since you had gastric stapling: jacked up.

Hemiparetic after a stroke: most definitely not jacked up.
Hemiparetic and in respiratory distress: potentially severely jacked.

Spontaneous Creutzfeld-Jakob disease: jacked up. No question.

Asshole third-year resident: not jacked up, as there is still hope.
Asshole third-year resident in peer review: irretrievably jacked up.

Twinkies: total jacked-uppery.
Deep fried Twinkies with Hershey's syrup: not jacked up.

Fractured pelvis and dislocated hip: only semi-jacked-up.
Fractured pelvis, dislocated hip, history of polio: jacked. Up.

Nurse on day one of a three-day week: not jacked up.
Nurse on day three of a three-day week: jacked up.

Having a kneecap kicked off by a horse: jacked up.
Getting inadvertently stepped on by a one-ton bull: not jacked up.

Brain tumor: depends. If it's a meningioma: not jacked up. Glioblastoma multiforme? Jacked.

I hope that's a little clearer now.

A place I never imagined I'd be.

So I'm sitting on the couch, reading the local nurses' news magazine (they're very unhappy about unions, but more of that in a later rant) and wondering how much Zappo's is charging for Danskos these days, when I realized:

I'm a nurse.

As in, an actual nurse. Jo, RN. I can sign my name with those initials, and sometimes do, by mistake, on checks. I ache all over after a busy shift, I eat things for breakfast that would make most normal people cringe, I speak a language that only a few people really understand. I'm a nurse.

Back in the day, fresh out of school with a BA in music performance and sociology, I had no clue what my life would be like. I'd had an interest in health and health-care for years, but I couldn't see combining that with the music degree that Dad had his heart set on my getting. I spent ten years working in bookstores, recording voice-mail mazes, and singing commercials before I got a job at Planned Parenthood and realized that I was really good at this odd thing. For some reason, people relaxed when I walked in the room; they told me secrets and embarrassing things without a qualm.

So I gave in and fell in love with my job. Rabid advocate? That was me. Trying to empower people to ask questions and take control of their care? Sometimes it worked, sometimes it didn't. Wanting to know more, to learn more, to have more input? Yep. And so it was off to chemistry, and a harrowing microbiology class, and several semesters of maths, both basic and advanced, and finally, Nursing School.

I've been a nurse now for just about three years--a "new nurse" in a lot of people's eyes, still. I remember my second semester of clinicals, wondering what it was about nursing that made these women I worked with tough, impatient, and unwilling to say something more than once. It got to the point that I could pick out a nurse, even if she or he was in civvies at the grocery store, just by the way they looked.

Now I'm one of them. My sense of humor hasn't tanked completely, and I'm not willing to fake a kidney stone attack to get out of working with students, but I'm a nurse. Jo, RN. Looking through catalogs, wondering exactly who it is that buys avacado green scrubs. Wondering if the liver function profiles on that undiagnosed patient ever came back. Setting my alarm for four-twenty in the morning, then explaining things once to everyone I meet and expecting them to get it.

If you'd told me when I was 21 that I would be doing this, I wouldn't have laughed. I would've gazed at you in utter disbelief, wondering what planet you hailed from. At 31, I wondered if I would survive nursing school (yes), if my marriage would survive nursing school (no), and if I would ever get to the point that "Nurse" became a part of my personality.

I did. It did. And here I am.

Two of my fondest memories from my career so far: Hearing a patient say, "Thank you, Nurse" as I left the room, a raw fresh-grad preceptee, and having another patient tell me that I reminded him of a nurse he'd had during World War II.

It's a fortunate person who falls into what they were born to do. If I'd continued singing commercials and saying "To speak with an operator, press zero", I would've been good at it. I could've been good at any number of things, without thinking about it much. This is a challenge and a joy and a source of pride. The fact that I'm good at it, the fact that I feel like I was born to do *this thing*, is an extra benefit. I'm a lucky girl. A lucky Jo, RN.

Various random notes

First and foremost, Grand Rounds is up at Grunt Doc's place.

***

"He looked so well-cared-for last week!"

The patient's wife was obviously distressed. Her husband was partly uncovered, in restraints, and unshaven. She was upset with me mostly about the "unshaven" part, and couldn't understand why I hadn't managed to get four days' worth of beard off his face. She was also upset (but less so) about the soft restraints on his wrists.

He had constant myoclonic jerking--uncontrollable, spastic movements of all his extremities and his head--and facial grimaces. Last week he could walk, with two people helping him. This week we'd had to restrain him to keep him from gouging out his own eyes accidentally. There was no chance we could've shaved him; his head kept bobbing up and down of its own accord, and I didn't want to cut his nose off. The jerking of his legs had thrown his covers down around his ankles.

"He just looks so much worse this week than last week."

I had to find a kind way to tell her that yes, he did look worse, but that with CJD, he would continue to look worse every week until he died.

***

A note to all nursing students who read this blog: Please Bathe.

Especially if you are a tall nursing student. My nose will be right at armpit level every time I work with you, so I will notice if you haven't bathed that day. Or for several days.

This is Nursing 101, folks. I know you're in a well-regarded, prestigious four-year program, on your way to getting your BSN. But frankly, not bathing daily would not have made it in my podunk two-year program.

If your nails are not clean and short, if you smell of pit-funk, if you have the remnants of last night's makeup on your face or a three-day growth of beard, I will not precept you. If you show up in wrinkled scrubs, with dirty shoes, I will not precept you. Period. End of story. I will send you back to your teacher with instructions to keep you out of the public eye for the day.

Frankly, you don't have enough knowledge yet to dress like Dr. House. None of us do. Looking professional--and smelling professional, for Christ's sake--inspires confidence in your patients.

So fucking BATHE, already.

***

Do not bring your long-haired chihuahua into your room at the hospital and expect me to keep it a secret. Especially if you're in reverse isolation because of a compromised immune system.

***

That is all.

It seemed like a good idea at the time.

He couldn't bend over easily, due to a combination of spinal arthritis and a frontal-lobe glioblastoma multiforme that had made it harder for him to coordinate what he was hearing with what he wanted to do. Unfortunately, bending over, or rolling up into a ball, or sitting slumped forward was exactly what we needed him to do, since we had to get a cerebrospinal fluid sample to figure out why he'd suddenly gotten so weak.

So I balanced him on the edge of the bed with his toes barely touching the floor. If his feet touched completely, he would try to stand up. Then I braced his knees against mine and wrapped my arms around his shoulders, pulling his upper body against my shoulder. Then I went into a half-crouch and supported 150 pounds of dead weight as the neurosurgeon tried to get the spinal tap needle into his back.

I stayed in that position for twenty minutes. By the end of it, I was alternately cursing my idiocy and thanking God that I'd been taking the stairs for six weeks. This morning my butt and legs are tight, my shoulders hurt, and my abdominals feel like I've done an hour of Pilates. But the patient didn't fall, we got the lumbar puncture done, collected the CSF, and everybody is happy. Especially the neurosurgeon. She thanked me repeatedly, then said, "I had no idea that you were that strong."

Neither did I, frankly. I did *not* take the stairs up to my car yesterday evening.

In other news, I had another Hospital Hobbyist yesterday for eight hours. She decided around noon that she didn't like her nurse, given that he wouldn't shoot her full of Dilaudid as often as she would've liked. She's been on our floor for a month, getting four milligrams of Dilaudid (a very strong painkiller, highly addictive) every hour. That's a bolus on top of her patient-controlled anesthesia pump, which delivers a milligram of Dilaudid every ten minutes. We're not sure what's wrong with her; general consensus is that she must have nudie pictures of the neurosurgery team stashed somewhere to stay as long as she has. Of course, since she hasn't worked in fifteen years (on "disability", probably because of her Dilaudid preference), she has plenty of time to spend in the hospital.

Your tax dollars at work, people.

On the other side of the coin, I got to tell a marvelous man that no, he'd have to go to the Veterans' Administration hospital to get the medicine he so desperately needed, since there are no community programs in place to help him. He has insurance. He even has prescription drug coverage. Unfortunately, the job he's had for ten years pays so little that, after taking out what he needs to support three other people, he can't afford the deductible or co-pay for his prescriptions.

He's just had brain surgery, is newly-diagnosed as hypertensive, and has bad blood sugar control.

I won't bother to point out the contrast between my two patients.

Total Fluff.

Say what you want about Charles and Camilla. I think they looked happy as clams and were just cute as could be. I really hope the Queen had some of those cream-and-silver napkins printed up--the sort with the wedding bells and doves and "Chuck and Millie: April 9, 2005" below.

Paging Doctor Orac!

Paging Doctor Orac! Doctor Orac to Head Nurse's station, please.

My folks just got back from the Oregon Vortex. Mom claims it cured her arthritis for two days.

What's a skeptic to do?

Did I mention that the turkey was bad?

Those turkey legs. Love 'em. The smoker crew couldn't keep up with demand. I think they were a little chintzy with the thermometer.

Today my general misery has declined, only to be replaced by a general itch.

Ugh.

What I do on my day off

I exhibit all the signs of being an incomparable genius, that's what I do.

The Beau and I went to a semi-local VW Fest yesterday. This is the state where good VWs go when they die, to be reborn as either all-stock show cars, all-stock daily drivers, or some combination of dropped and street racer and wildly painted wacko machine. Ever seen a VW Bus drag-racing? Neither had I, before yesterday.

Anyway, we went to the VW Fest. Got there about 11, left about three. Spent those four hours in the gorgeous sunshine--not a cloud in the sky, about 70 degrees--looking for NOS (new old stock) parts and refurbishable things for the 1967 Beetle David just bought. I found, by the way, a window crank from 1967 and felt quite proud of myself. He found the other. Then I found an NOS gearshift head and giggled. Then he found a turn signal relay and started acting like Gollum. Then we got some sausage and a turkey leg.

Then I noticed that I had forgotten sunscreen.

I am the odd redhead that doesn't generally sunburn. Yesterday, though, I sunburned. So badly, in fact, that I had to call in today because I can't wear clothing. My normally buttermilk-colored arms are a shocking shade of dark pink, and my neck is a study in ow yow yeesh augh ouch. Let's not even talk about my nose.

I don't *think* I'll blister. It's been 16 hours and no sign of it yet. I'm living covered in aloe vera gel and cold wet rags. I did not sleep last night; turning over was a lesson in what it means to be truly stupid.

If ever I get badly burned in a fire (probably when some VW or another goes up in my face), please either unplug me immediately or feed me lots of morphine along with my Parkland-formula fluids. Thank you.

What he said:

"You're way too smart to be a nurse."

What I did not say:

"You want somebody stupid at the bedside?"

"What would you rather I do: teach students, or teach you?"

"Are you saying that nurses are dumb?"

"How many hours of microbiology and chemistry do you think we all have to pass?"

"Should I be a doctor instead? Do you have to be smarter than a nurse to be a doctor?"

What he said:

"You should get your PhD or something."

What I said in return:

"What I love doing is this. I love being here at the bedside, helping people heal. I like working with very intelligent, dedicated people. I have a good time, and I don't want anything different."

I once, more than half my life ago, took a stage movement and modern dance class at Carnegie-Mellon University, as part of a summer theater program. At one point during the semester we were joined by the local high-school football team. A couple dozen teenaged boys (we were all teenagers) came in snickering about how "faggy" it was that they had to take a dance class with all these theater geeks.

Not a one of them made it to the first break. What they thought was easy and low-status and faggy actually took a combination of incredible strength, concentration, and stamina.

This is how I feel about people who say "You're way too smart to be a nurse." They have no idea.

You can't educate people like that. You can't change their perceptions in the twelve hours you have with them. The best you can do is remind yourself that murder is still a capital crime, then put all the pillows out of reach.

Sheesh.