No, I didn't fall through the bathroom floor.

She Came In Through The Bathroom Window

I'm moved in. I have one house, one cat, one dog (more on that in a minute), and one almost-bathroom. It needs to be grouted, but it looks *sharp*. It'll be totally usable tomorrow, after everything dries.

The moving guys who took care of the heavy stuff came in a trio. Their combined ages couldn't have been more than 65. All of them were cheerful, stringy, rangy guys who could pick up a fully-loaded cedar chest alone and haul it down three flights of stairs. I'm proud to say that five years of nursing and a year of heavy training left me able to keep up with them. I also let them punch holes in a wall (it's got to come down anyhow), much to their great delight.

Getting back to work was weird. You know how the strange people and strange cases seem to cluster? Well, we've had a couple of clustering weeks; I came back on the tail-end of the weirdness time. The census reads like the table of contents from a particularly nightmarish pathology book: worms in the brain? Got 'em. Basal cell carcinoma that ate into a sinus so that sinus and orbit had to be removed and replaced with a free muscle flap? Yep. Bizarre ventriculitis caused by God only knows what virus? Uh-huh. Autonomic dysreflexia, septic shock, dehydration, dementia, and meningitis? All in one bed, buddy.

In short, I was reminded that "Found down at the Kwik-E-Mart" is not an encouraging beginning to a history.

The Curious Incident of The Dog

Eons ago when I was still married, my then-husband found a dog in a vacant lot near our house. He (the dog, that is) looked determined to lay down and die, being nearly starved and looking like he'd been on the road a while. That, of course, is never gonna happen in *my* neighborhood, so off to the vet I went, with an 80-lb stranger in the back seat of my Civic.

Several months later, after he'd been fed well and exercised regularly, somebody at the vet's office mentioned that they thought he might be an Anatolian Shepherd mix. Anatolians, aka Kangals, are enormous livestock guard dogs native to Turkey. They're popular here and in Oklahoma because of their toughness and intelligence. I shrugged, figuring that Max wasn't big enough or furry enough to qualify.

Fast-forward four years. Ex-husband is moving, and needs somebody to take the doggo. I couldn't originally, because a large dog doesn't belong in a small apartment with somebody who works 16 hours a day. However, now I could, because I have the house and the yard and all. So I went last night to pick up Maximum Maxhound.

He must've been a half-grown puppy when we found him, is all I can say.

I now have a 115-lb monster taking up most of the kitchen floor.

The cat beat him up last night. She was unhappy with his being here and so attacked him in the living room, giving no quarter, and chased him through to the kitchen, where she cornered him by the back door and went to work on his hindquarters. He's now understandably nervous about coming back inside, so I wander out every few minutes to the yard to scratch his ears and tell him he's the best, sweetest boy ever.

And he is.

(Note: the picture above is not Max. It does, however, give you a good idea of his size.)

Warning: agraphia ahead.

Agraphia ahoy!

I'm moving on Thursday, so posting will be nonexistent until I get moved in and the bathroom finished.

Ah, yes. The bathroom.

It is not going well.

In fact, it's a hole. There are joists and studs and bare pipes and nothing else. You can fall into the crawlspace quite easily, something I almost did the other day. I was saved by a complicated and entirely instinctive movement reminiscent of something out of the Matrix series, if the Matrix series had been populated by flailing, screeching people holding prybars.

The good news is that everything else is pretty much done. I have to paint the woodwork in what will be my bedroom, but that's pretty minor. I scrubbed the kitchen down today, yuck, and am already moving things in.

Brother Bruce's Bargain Brain Barn is its usual exciting and gratifying self. Word from the carpeted areas is that charges for insurance will go up somewhere in the neighborhood of twelve percent starting in September. This is a no-big-deal thing for those of us without spouses or children, but a very big deal for those with, as their insurance actually costs them money. Us bitter, barren, lonely extras at the dinner table have everything covered. That's one benefit to being bitter and barren, I guess.

The dude with the huge glioma in his left temporal lobe? Turned out not to have a huge glioma, which is good. He instead has some wacky viral infection there, which is bad, but not as bad as a glioma. After a couple of weeks on some IV antiviral I'd never heard of and can't remember the name of now, he bounced right back and is fine and dandy.

Also, the young kid with the exploding AVM is talking, walking, and generally getting on people's nerves. That's a plus, since she was doing the staring, drooling thing last time I saw her, which was three weeks ago.

Speaking of getting on people's nerves, or maybe of staring and drooling, I may have to have A Chat with one of our resident brain cowboys.

He stares. At the nurses. Not in a smouldering, McDreamy way (as if; have you ever seen a bunch of real-life neurosurgeons?), nor in an intimidating, you-oughta-be-in-a-hajib-mindset way, but in a vaguely clinical, oddly disturbing way, as if he's wondering the best way to get to our hypothalami. He stares mostly at me, which is beginning to bug me. And will likely get him an entirely new digestive system if, after I point it out to him, he continues to do it.

He is, like all neurosurgery residents, totally socially inept. And he stares.

If you'd like something new to stare at, check out this week's Change of Shift. It's over at Nurse Ratched's. It's a Western theme, which is pretty darn cute.

I'll see you guys in ten days or so.

Noodling.

Goodness gracious. I just checked out Blogdorf Goodman for the first time and am amazed. One of the bloggers there did a whole series on makeup brushes. A series. On makeup brushes. With photos and a discussion on natural versus synthetic bristles.

I wonder if a series on catheters would grab as much attention.

In Work News, it's Christmas in August. Seems like every third person is opening his or her stocking and finding a wonderful gift: a glioblastoma! On your left temporal lobe! A meningioma! In your occipital lobe! Oh, boy! Lookit this, Mom! It's my very own spinal tumor!

Temporal lobe tumors are generally a bitch because, as you know if you're a disciple of the brain, they can cause seizures. Depending on which side they're on, they can also rob you of speech and understanding, memory, and the ability to make change.

One of my patients this week had the memory-loss and seizure problem. The memory loss is harder on us than it is on him; he keeps forgetting that what he has is a cancer that is going to kill him, nastily, so he keeps asking. And his family has to keep telling him. The seizures he has are manifested in a really weird way--sudden bursts of uncontrollable anxiety. Panic attacks, basically. I'd never seen that before, though I knew theoretically that it could happen. We put him on Keppra (a kinder, gentler anti-seizure drug) and problem solved, but still.

In House News, the bathroom walls are down. And oh my Frog, what a mess it is.

When the bathtub enclosure was built lo these many years ago, the builders installed a cabinet above the tub. Keep in mind that showers weren't standard equipment in the late 1940's, so it made sense. Need a towel? It's right there. Genius!

Except that somebody installed a shower. And did it badly. So badly, in fact, that I have a hard time believing that the thing actually worked for as long as it did.

See, when you install plumbing, it's important to make sure everything matches up. If you have cast-iron supply pipes, as I do, it's a good idea to get the proper connectors to extend piping up a wall (say) rather than jimmying something together with PVC, copper connectors, glue, caulk, and a prayer. What'll happen if you jimmy and pooky everything together is that the created joint will split and leak and take out the backside of the wall it's running up.

This was brought home to Chef Boy and me when I tapped on the wall with a pry bar (okay, banged on the wall) and the wall came down. Except for the bit surrounding the fixtures, which were glued/sweated/caulked on to the supply lines and thus have to be cut off with a hacksaw. I now have a lovely space just above the bathtub that communicates with one of the kitchen cabinets. Chef Boy suggested that we leave it as is and pass crystal decanters of bourbon and Scotch through the hole so that we can drink while bathing. For a minute, that seemed like a really, really good idea.

Today Chef Boy will install cutoffs on the sink supply lines and we'll take out the toilet, and then I'll go to work on the last wall (and probably the floor as well) with the marvelous pry bar. Later on in the week the cement board and tile will go on. The Evil Secrets of Bad Plumbing will be walled up again.

Maybe the bathroom won't smell so strongly of mouse and mold when it's done.

House Blog, Part 2

Oh, my.

I'm sure the people who lived in the house before me were marvelous folks. I'm sure they were kind to animals, fine parents, socially conscious, and committed recyclers. I'm sure they were all those things and more.

However, they lived like pigs.

I cleaned the bigger bedroom the other day; it took me fifteen gallons of cleaning solution just to do the lower half of the walls. One wall alone took nine gallons of solution. It was...an experience.

Let's not even talk about the kitchen. Suffice to say that I am looking at new stoves rather than clean the one that's in the house. I don't think it'd be possible to get it into usable condition. Thank God they didn't leave the fridge.

So today, when the numbers on the clock are bigger, I'm heading over there with more gloves, more sponges, and more cleaning solution. Today I'll clean, period, and worry about painting tomorrow.

Work

In other news, a simple tip for the family members of patients: The way to get noticed and get your questions answered is not to assault a nurse. You'll get noticed if you do, of course, but it's not the kind of notice you're likely to want to attract. Let's face it: If you kick a nurse, or take a swing at him, you're going to face security guards from countries where genocide is a way of life. They know many, many more dirty tricks than you do.

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

I finally quantified what it is about my nursing style that makes the crazies love me.

When we say "crazies" at work, we don't mean people who believe that aliens live among us or that Star Jones really lost all that weight with diet and exercise. We mean people who are so stressed, or so anxious, or so overwhelmed that the conventional modes of behavior fly out the window.

Everybody who's worked in any kind of health care knows that there are some folks whose behavior becomes unacceptable, impolite, and sometimes downright dangerous in stressful situations. When every other nurse has been fired by a patient or a patient's family, when security's been called, when the doctors refuse to go in to the room, they assign me that patient.

And invariably--I say this not to boast, but in amazement--those patients end up asking for me again the next time I work. And we get along.

I've had several patients in that situation over the last couple of weeks. In most cases, the patients themselves have a handle on what's going on; it's their family members who have lost it. What every situation had in common was this:

I explained what was going on, in English, from start to finish, and didn't assume that the patient or the husband/wife/sister/whatever knew what had been happening prior to that day. If it took re-explaining three or four times during the course of the day, or going back to Page One and going straight through to the end, that's what happened.

It's not that our docs and nurses and therapy folks don't tell people what's going on: they do. In terms of communication and keeping people in the loop, we do very well as a team. I think the assumption is, though, that people in a stressful situation are going to remember the conversation you had with them last night. This is hardly ever true; they have so much going on internally that they often forget to, you know, eat. We do this every day; they've done this exactly zero times before, and so the stress level is huge.

All of this seems really obvious now that I look at it logically. Still, it's the only commonality I can come up with over the course of several years of being the Nut Wrangler. Explain, explain, explain. Warn, reassure, explain.

And, if all else fails, Xanax works wonders.

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

Trivia Treat: Turns out one of our surgeons (not in our department, sadly, but still) used to fight in cage matches to make extra money.

How cool is that? "Twoooo goooo iiiinnnn....ONE coooommmmes ooouuut!" (/announcer voice)

Which explains a lot about this particular surgeon.

Product Reviews: Lovely Lady Lumps Edition

Here it is again! Reviews of products you might could use, wish you didn't have to, and ones you would rather avoid!

1. Title Nine "Because She Said So" sports bra:

I got sick of wrapping my boobs in two or three compression bras, so I bought two of these. They make me resemble a lingerie model from the late 1950's, but that's okay: I don't bounce. At all. Ever. Even at a dead run, or hopping on and off of a step during some new torture routine Attilla the Trainer has devised. The nice thing about looking like I'm All Boob, All The Time is that there's not as much squish to the side, so I can still do things like bench presses without running into the sides of my own breasts.

Verdict: I will only trade these in when I find another Title Nine bra I like better. I bought mine a cup size smaller, just FYI.

2. Rimmel "Volume Flash" mascara in brown:

Due to the fact that I had to give up a pile o' cash for home renovations, I'm not shopping at Sephora for things like Christian Dior mascara any more. Instead, I prowl the aisles at the local Target. And I came up with this mascara, which (dare I say it) works better, stays on longer, and clumps less than even my beloved Dior. Plus, it has one of those really skinny, ineffective-looking brushes that lets you get to every single lash.

The brown is a nice light brown, suitable for somebody with very fair skin and lashes. The only downside is that it's a bit difficult to remove: I find that my usual face-wash stuff put on without water takes it off. Any dilution results in my looking like a football player or a boxer, post-eight-rounds.

Verdict: Rocks my socks, and for only $7.99!

3. Joe's Frozen Chitterlings, pre-cleaned:

No, I did not buy these. I mention them only because I stood before the freezer case in my neighborhood grocer's, amazed that there was such a thing as frozen chitterlings. And that "chitterlings" was spelled the proper (rather than the more charming phonetic) way. "Chitterlings", for you who've never eaten them, is pronounced "chitlins" and are intestines.

Anyway, they're available frozen in some parts of the country.

Verdict: I'm not eating *anything* in the way of pre-cleaned, pre-packaged soul food unless it's Glory Greens and I'm in a hurry.

Speaking of food:

4. Balance 100-calorie Caramel-Vanilla snack bars; Soy Joy Almond-Raisin snack bars:

I mention these together because, together and separately, they are nearly the nastiest things I've ever eaten. I got 'em because they're both small enough to fit in the breast pocket of my scrub jacket. They taste horrible. The Balance bar is 100 calories of oversweetened, cardboard-like stickiness; the Soy Joy bar tastes like almond extract gone bad with an undertone of sawdust. I'd rather drink retsina than eat another one of these ever again.

Verdict: Yeah, they're expensive, big, and calorie-laden, but cut a couple of Odwalla Banana-Nut bars in half, and they fit in your pocket. They actually taste good, too.

Verdictal postscript: I'm trying to think of anything nastier than Soy Joy that I've eaten more than once, and I really can't. I tried the second Soy Joy in the conviction that nothing could taste that bad; that I must've been imagining things. I wasn't. Avoid.

5. Med-Prime suture removal kits:

I hate these fucking things with the burning hatred of a thousand suns going supernova. Med-Prime, my ass. Try Cheap-Shit Medical Supplies That Will Drive You to Drink. The "iris scissors" included in the suture "removal" kit are loose-joined, dull things that simultaneously pierce your patient's skin and refuse to gnaw through the suture in question. Some dickweed bought these for the hospital. In response, we're all hoarding the decent suture clippers; the sort that look a bit like bypass pruners in miniature.

Verdict: Anyone who orders these for hospital use should be condemned to having one thousand #2 silk sutures removed from some ticklish part of his anatomy with the scissors. God, I loathe them.

6. Dansko "Calla" clogs:

The winner, and still, after two years, champeen of the clog wars. Mine are wearing out only now. I plan to buy two more pairs with my next paycheck, because, at $115 a pop, they are Not Cheap. However, they hold up well. You can roll a bed over your foot in 'em and your toes won't break. And, unlike other Dansko clogs, the heels are nice and wide so you won't fall off of 'em.

Verdict: Trade in the Professionals, if you're the clumsy sort, and try these.

7. Target Boxed Wine:

Of all the damn things. Target actually carries wine! (Well, mine does. Along with those cute Pommey POP champagne bottles that come with a package of straws and are bottled by the same people who make Veuve Cliquot, so it's actually pretty good, but anyway.) Target boxed wine comes in White: Pinot Grigiot, White: Chardonnay, Red: Merlot, and Red: Something Else. They're drinkable, but not outstanding.

Verdict: Good for a big party, where nobody's going to be discriminating. Plus, the technology is kind of cool. Plus, at $11 for the equivalent of four bottles, how can you lose?

8. Jezebel dot com:

A great website for celebrity gossip, makeup tips, and girly things in general. Unfortunately, going to the website caused my computer to be infected with Brave Sentry, a malware program of a particularly nasty sort. In fact, now that I've upgraded my firewall, installed malware detection software, and regained access to my computer's registry, I can see that I get an average of 128 attempted downloads *each time* I visit Jezebel. Try Too Fat For Fashion or Faking Good Breeding instead.

Verdict: Unless you want to spend four hours fixing your computer, avoid.

House Blog.

They say that some things sound the same in any language. I can attest to "Shake it, don't break it" and "Hey, baby, give me a piece of that" sounding the same in gutter French or Swedish. It seems that "What the hell are you doing?" and "Stop, dammit!" sound the same in Spanish as they do in English.

The Foundation Fairies* are at work on the New House.

I could swear that I heard a guy say (translated badly from gutter Spanish), "You call that level? My *grandmother* could level better than that! Where are your eyes??"

I also heard, quite clearly, one of the Foundation Minions tell another, "That crazy (female) gringo doesn't know shit. Go turn the power on, willya?"

Things have progressed markedly since the days of hammering on the floor with one's fist and shouting. Now the Foundation Guys have laser levels that beep repeatedly when "level" has been reached. There's a limited amount of shouting and insulting that the Head Foundation Guy can do, but this HFG puts his all into it. There was an interesting call-and-response pattern I heard this morning as I was painting, all of it in Spanish; most of it I couldn't understand unless I concentrated.

"Hey!"
(from under the floor) "Hey!"
"Bring this up two more!"
(under floor) "Bring it up two more?"
"Two more! Two more!"
(under floor) "Like this?"
"Like that!"
(under floor) "Like this?"
"Just a little! Just a little!"
(under floor) "Like this?"
(A flood of descriptive and abusive Spanish that, while interesting, lost me about a third of the way through.)

It was all done in the most gorgeous (and here I'm dropping all snark) sing-song, with a sort of heave-ho mentality issuing from the depths of the foundation.

These guys work *hard*. As I told my Sainted Father that one time, it's the Illegal Immigrant Work Ethic that has made this country great.

The electricity is done, thank Frogs, and the work was passed by the city inspector. I kinda wonder who the Electrical Fairies bribed, since I didn't have the smoke-detectoring up to snuff. The living room is totally painted, and Penny The Lotion Slut's guestroom is painted the most gorgeous color of pale sunset peachy-pink you can imagine. I would've done the rest of the painting today, but I got the feeling I was really in the way of the Foundation Brownies.

In a few days I will start, with Chef Boy, on the Great Bathroom Remodeling. We'll see how many wine boxes from Target it takes for me to retain my sanity during that process.

*I call them "Fairies" not because they're fabulous (oh, snap!) but because they come after I leave and are gone before I come back, accomplishing immense amounts of work out of my sight.

*** *** ***

In other news, I once told the story of a patient who'd had five (five!!) spinal cord AVM embolizations. I am pleased to report that that patient, who was paralyzed from the chest down the last time I saw them, walked back up to the floor on Wednesday to say hi.

Occasionally this job has benefits.

New Change of Shift is up!

Right here.

My cat is aloof. What's it mean when she curls up with me?

Here.

The Weirdness of Id

How much must this suck?

You're walking around fine and dandy one day when suddenly your brain bleeds. Intraventricular hemorrhage, subarachnoid hemorrhage, whatever: suddenly, you've lost your inhibitions, your ability to form coherent sentences, and your will to do anything. You are, in short, a perfect candidate for employment on our unit.

The one thing that's better than it was before is your brain's ability to get into a groove. That would be okay if your brain were focused on ponies and butterflies, but it's usually not. In fact, I've only met one person in five years who grooved on positive things. The rest of the brain-bleed population lives nightmares over and over and over.

One patient, born in America of Iranian parents, was stuck in Paris on September 11th, trying to get home. Over and over. Another was in the middle of divorcing her abusive husband and on the run, something that had happened forty years ago. A third was trying to get the ambulance for her horribly injured youngest child. Over and over.

Mostly, people who groove on nightmares are quiet. Anxious and confused, but quiet. They can't be reoriented (sometimes trying just makes it worse) but usually they can be calmed. And, eventually, the brain heals itself to the point that they can break out of that nightmare box. Until then, they talk constantly about the nightmare they're in.

Sometimes, though, Horrible is happening in somebody's brain and there's no telling what it is. We had a patient like that last week: perfectly fine one minute, he'd suddenly sit bolt upright in bed, eyes wide and face pale, and scream.

Something was coming after him, that's for damn sure. And whatever it was, neither he nor I wanted to see it again. I had a choice. He didn't.

I had no clue what he was seeing. He couldn't articulate it. I got the feeling from watching him, though, that it wasn't as simple as watching a buddy step on a land mine planted by the Viet Cong, or seeing his house destroyed by fire with his family inside. Whatever it was that came out of the walls at him came from his own mind. I don't scare easy, but seeing his face as Horrible came at him, just before he screamed, made it hard for me to sleep for a couple of nights.

I feel like a sicko. I saw "Harry Potter" tonight...

...and in one of the first scenes, Daniel Radcliffe is in a T-shirt.

A *snug* T-shirt.

My first thought?

"Damn. Look at that vein in his bicep. I could slide an 18-gauge in that, easy."

Today

I picked seven cherry tomatoes, two bell peppers, and one cucumber.

The cantaloupe I inherited with the new house and garden is coming along well. Please send anti-bug and anti-bird vibes its way so it will actually get a chance to ripen. Thank you.

Everybody's doin' it...

Dr. Sid is doin' it. Dr. Rob is doin' it. And now I'm hopping in, with my own simple rules and few for you physicians out there who want your patients to end up in my ample lap.

How To Have Things End Up As You Would Like Them To: A guide for physicians in our hospital

1. Please be aware that, as you've been told since your first day as a resident, nurses cannot call for consults. If you write an order for a consult, you're the one who has to call the doc. Wandering vaguely away from the chart rack will not accomplish your consult; neither will being mad at me for not calling. No matter how much you yell, this will not change.

2. If you are sending a patient from your office for a consult, please note that our surgeons have office hours. You, as the referring doc, can't just send a person up to the hospital floor with no warning and expect them a) to be admitted, or b) to be seen in a timely fashion. The doc you wanted is probably up to her elbows in somebody's brain and won't be available for at least six more hours.

3. Don't lie to me. Don't call me with the news that you've got a critically ill patient on his way via ambulance for immediate admission. Not only can I not *do* anything about that (you really should call the bed-board people for admissions), but I will be supremely pissed at you when, after a two-hour scramble to get an acute-care room opened up, your critically ill patient shows up walking under his own power, having driven himself to the hospital.

4. Understand that certain things are not our specialty. Let's say that you have a patient who's post-heart/lung transplant and who is having problems. I will do my best to send them to our sister facility, Holy Kamole, because *they* took over all the heart/lung transplants four years ago. It really doesn't matter how much you want them to be at La Schwankienne; we do neuroscience. We don't know a damned thing about transplants. It's not a personal slight; you don't have to holler. It's about the best care for the patient.

5. Having the admitting physician write a consult request for a particular specialist is, I guess, okay. It's not okay when it was your idea, when you're the one who'll be consulted, and when the patient is your mother.

6. And finally--listen up, guys--when you write a consult for an inpatient, be aware that the patient will be seen first by the resident or fellow, and later by the attending (once the attending finishes office hours or surgery or whatever she's doing). This is how it works in *your very own service*. Do not--I repeat, do *not*--get snippy with the charge nurse when the senior resident or a second-year fellow is the first to have contact with your patient. (You know who you are.) I have nothing to do with it; I can't help you; perhaps you should think back over your last ten years here and see if it's ever been different.

Thank you. You may all return to your regularly scheduled rounds. Please do not rack charts with new orders. Thank you. Thank you.

Head Nurse: The Lazar-House Edition

Take One Tablet Daily. May Cause Dizziness.

It's been wet here lately.

Wet and warm. And things are blooming. And beginning to mildew and mold.

Things are, in fact, so bad that condensation is beginning to form on the air-conditioner ducts in the ceilings of the hospital. That condensation drips on to the ceiling tiles and makes everybody panic, thinking there's an undiscovered leak somewhere. Which is a possibility, as bits of the hospital roof keep getting blown off or washed away by storms.

The immediate effect of all of this is that everyone is sick. We're used to living in a desert this time of year, so the effect of a decent climate sends us all for a collective loop. As you walk down the hallway in our unit, you can hear burbling coughs, the honking of noses being blown, and the sound of the percussion devices that Respiratory uses for pneumonia patients.

And that's just the nurses.

The patients, poor things, are in even worse shape. Bad enough you should have a meningioma or a herniated disk that needs repair--imagine having a condition like that in combination with a chesty cold or a zinging sinus infection. One poor woman came in with such a bad case of sinusitis that we just kept her on a morphine PCA for a week. ENT was finally able to drain her posterior sinuses after she'd healed sufficiently from her meningioma removal.

All we need is for the lights to go out for a while so we can get some nice pitch torches. That and a few rags and a couple of clappers to knock together would set us all up as a group for crying "Unclean! Unclean!"

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

Extreme Whateverover

In Head Nurse House News, do you have any idea how much it costs to rewire a relatively small house?

A lot, that's how much. As in, somewhere north of a good pair of Manolos, yet south of a drawer full of mink. However, it has to be done, given that the electrician suggested I sleep with a fire extinguisher if I didn't want to replace the breaker box.

I've got the dining room mostly painted (this was before I was felled by the same Creeping Crud that's infected my coworkers) in a pleasant pinkish white above the chair rail and an extremely estrogenic rose color below. I'm now having pleasant dreams that involve inveigling good-natured friends into painting the woodwork while I scrub other walls. When it's done, I'll hang bottle-green velvet curtains over the window with a net curtain underneath. This will be, when it's done, a dining room that Lily Allen would be happy to eat in, foofy skirts and all.

The Foundation Guy is supposed to call me on Monday to set up a time to get under the foundation and add joists, replace joists, build new piers, and generally get things back to plumb as much as possible. I'm on call for the Plumbing Elves so that they can run new piping into what used to be a garage for the washer and dryer. With any luck they'll all show up at the same time, and my new refrigerator will be delivered, so I'll find a nicely rewired, replumbed, releveled house with the fridge already set up and plugged in.

And then Lily Allen will come to dinner.

About a hundred posts per year.

This week is the fifth anniversary of my passing the NCLEX and being a newly minted, official RN.

If I had to break things down, I'd say this: the last four years have been the absolute best of my life. The fifth year, the first year I was a nurse, was tough--but still good.

When you're brand-new, you're still in that headspace from school--the one that makes you not want to make a mistake, ever. Ever. It's the mindset that tells you that no learning curve is too steep, no responsibility too big for you--you just have to get in there and do it. It's the same mindset that led me to be certain that I couldn't cut it as a nurse, that I'd surely kill somebody before the shift was out, that sent me (the dubious agnostic) into the chapel every morning before my shift to pray please God please, if you're up there, let me do well today.

After that first year (listen up, new nurses!) things don't exactly get easier, but you develop a routine and a flow. Bobbles that might throw you off for an hour or two get easier to handle. You develop a sixth sense for IV bags, so you can change them before they're empty. You develop the same feeling for fevers, so you can tell when somebody's actually sick or when they just haven't been walking as much as they should. You make up your own shortcuts--and I don't mean that in a bad way--that work better than formalized routines.

After the first year, your feet hurt less, because you've discovered good shoes. You know that going without lunch won't kill you. You've figured out how to manage a fluid rotation (peeing and drinking water) in thirty seconds or less.

During the second year, you find that other nurses will sometimes ask you questions. Certain things get to be routine, like starting IVs or managing minor crises. Bad things bother you less. You redefine "good outcome".

During the third year, you hit your stride in other areas. People calling you "nurse" no longer feels weird. The crazies don't seem to seek you out like they used to. You can see problems developing a long way away, and you finally have the wherewithal to avert crises. Care plans, those things you struggled with in school, finally make sense. More than that, you're making them up in your own head without any problem.

During the fourth year, things really seem to start coming together. You've got your routine down to where it feels natural. Your reports are short, sweet, and hit the high points. You know the guys in Radiology by name. You're finally good at making a bed with a person in it. You can see a patient in a holistic way, rather than as a bunch of problems and potential problems in isolation. You know which size of filter mask fits you. You know what size sterile gloves all your residents wear.

Now I'm in my fifth year. I find that people call me for tough IV starts (zut alors!) and for tough catheter and NG tube insertions. (Everybody has a schtick; mine is catheters and NGs.) Newer nurses ask me for advice. Older nurses bounce ideas and problems off of me. I've learned that leaning on other people and asking questions is a good and honorable thing. The residents and attendings respect me, and I've learned not to be afraid of them.

I've learned the value of teamwork and of occasionally staying late. I know how to fix, jimmy, or jury-rig almost every piece of equipment on the floor. I know where we keep the molasses, and I know where the bodies are buried.

A whole bunch of people I cared for are dead now, most of 'em from what they came in for, some of 'em from other things. More are still alive and doing well. Some have come back to visit. A few people I've worked with are dead for various reasons. Most are fine. We've been short-staffed, overstaffed, bizarrely staffed, staffed with floaters, agencies, and nurses so old they walk around with oxygen backpacks on. We've won awards as a floor. I've won a couple on my own merits, a fact which still baffles me.

I am five years older. I have grey hair now. I'm thirty pounds heavier. My feet hurt sometimes, and I've developed some odd varicosities in my ankles. I used to be intimidated and awed by those no-bullshit nurses who would get straight to the point and tell you something *once*; now I'm one of them. I can change a dressing, calm a fever, stop bleeding, resucitate a dying person. My sleep habits have completely changed. I can and will eat food from vending machines without complaint or adverse effects.

And after five years, when the nice man from the mortgage company asked me what I did for a living, I said, "I'm a nurse." And grinned.

Several days late, uncountable dollars short...

Here's the latest Change of Shirt.

Drove my Chevy to the levy...

For the first time in five years, I got recalled the other night. We'd had ten inches of rain in about four hours, atop already-saturated ground, and the hospital was short staffed. There were folks who simply couldn't make it to the building.

So the night supervisor started calling people from the day shift to see if they'd want to come in and work all night, then be off the next day. The recall, thankfully, was optional for people who'd already worked that day, as I had.

It had taken me an hour and a half to get home. The streets around the hospital were flooded. The major arteries in the city were flooded. They were pulling people out of their cars in high water near the party section of town. The frigging *highway* was flooded. As in, all the way home, a drive of about thirty-eight miles, I wondered if I would make it or end up flooded out like the countless cars I saw awash on the shoulder.

I did not go back in.

In other news, a patient I had cared for a couple of years ago walked in early last week to say hi. This was news because, the last time I saw her, she was going somewhere else for experimental treatment of some bizarre cancer I'd never heard of before and haven't seen since. After two years of chemo and radiation and removal and replacement of various bits of her spine, she's in remission and doing well.

The last time I saw her, I was loading her on to an ambulance stretcher from a Roto-Bed. (That's a bed that moves horizontally and vertically on its axis to keep a person who can't move from getting bedsores.) She was completely unable to move, barely able to breathe. The only thing alive about her were her eyes and her masses of gorgeous black hair.

The hair's gone, thanks to the treatment, but her eyes are the same. And she was able to hug me, tightly, when before she couldn't move her arms.

I don't normally cry at work. I *certainly* don't cry at work where other people can see me. I broke those rules when I recognized her.

Finally, I close on The House today. In about an hour and forty minutes. No, make that an hour and thirty-eight minutes. Thirty-seven. Not like I'm nervy about it, or anything. The entire process has been remarkably pain-free; I was expecting something like the soul-crushing, life-eating experience Chef Boy had in buying his first house.

The only screwup so far has been minor, and will result in me being a little late to my own closing. Like a bride who's late to her own funeral, I'm not concerned--I figure they can't start without me, so why worry?

This blog will be changing after I take posession of the house. I'll be so obsessed with wiring, insulation, paint colors, mortar, and wall tile that I'll have to abandon my usual set of metaphors and go to a new set--one that describes patients' conditions in terms of building materials.

Thrashing

Just an FYI: Blogger is losing comments, or not publishing the ones I approve, and occasionally the blog just disappears. There's no bug bulletin up about these issues, but I'm not the only one with 'em.

So have patience. Perhaps your comments will show up; perhaps they won't. Everything except spam is getting approved, but some of the approved ones are getting lost in the ether (sorry, SHZ!). Maybe the blog will be here when you want to read it, maybe it won't.

Dratit.

Oh, so *that's* why I was so tired.

It wasn't a cold. It was bronchitis. The bacterial sort, rather than the viral sort. The cold I had led to a bacterial superinfection that is now getting its butt kicked with Spectracef (note: Spectracef is one nasty drug).

I slept all day today. *All* day. As in, I got up at six to pee, drink a cup of coffee, and eat some toast, then went back to bed. Got up at one to do the same thing, then went back to bed. Got up at six-thirty this evening and am waiting on toast right now.

So if I'm not around much in the coming days, that's why. The good news is that I feel considerably better. The bad news is that now everybody else at work has this, too. *sigh*

Happy Birthday!

It's the first anniversary of Change of Shift!

Here.

Don't pick.

It all started with a zit.

It was a typical zit, close to his hairline. You know the sort: it grows and grows and gets painful, and finally you notice that it's got a head on it, so you pop it. The thing goes away for a while, but then it comes back. So you pop it again. Lather, rinse....

Six months later, it became obvious that something was wrong. There was that odd red mark where the zit had been, and he wasn't feeling well. Off he went to one doctor, then another, finally culminating with one of our gals for a CT and an MRI and a this and a that.

The various tests revealed various things: that his body was fighting off an infection, that he was losing his balance and having some trouble finding words, that he had been plagued by a constant headache for months. The scans showed an abscess just behind and above where the zit had been.

The abcess had eaten through his skull and into his brain. Lovely. You know it's bad when somebody's skull looks like Swiss cheese in one spot, with bits of dura poking out of the bone because of the pressure inside.

To the OR, then, and the bone comes out. The abcess gets drained. He's returned to the floor with powerful IV antibiotics...and then, quite suddenly, nothing seems to be working. Fever of 41 C (that's 106 F), heart rate in the 160's, big rash all over. We spring into action with cooling blankets, cultures of blood, sputum, and urine, chest X-rays, and fungal cultures of damn near everything else.

Further scans revealed that things had gotten nasty under his skull, so back he went for more draining and washouts. Right now he's in the unit with a tube going into his brain for further instillations of antibiotics and pressure reduction.

People, don't pick yer zits. I don't know how many times I have to say it.

Still, I guess it's better than that one gal who ended up with meningitis from brushing her teeth too enthusiastically.

Rant. Rave.

Gracious, colds take a long time to get over. My two remaining brain cells are huddled in the back of my skull, wrapped in blankets, drinking tea. I'm no longer *quite* as snotty as I was, but goshdarn I'm tired.

Rants:

1. I do not wanna hear you apologizing for "bothering" a doctor when you page her. The correct phrase, when you answer the phone, is "thank you for returning my page." You are not bothering her. You are her eyes and ears and hands when she's not there, so it's reasonable for you to page her with changes or questions. Got it?

2. Lose the acrylic nails. For cryin' out loud, acrylic nails have been implicated in hinty-gazillion reports about the transmission of Nasty Bacteria. Thank you.

3. I should not (and I cannot believe I am saying this again) be able to see either your sacral tattoo or your thong string above your scrubs. Please.

4. Residents: Bathe. That is all.

5. Patients: If you refuse your insulin, refuse to stay on bedrest, refuse tests and procedures and lab draws, don't be shocked when we tell you there's not a lot we can do and send you home.

Raves: Ode To Underappreciated Things

1. Mucus. Who doesn't love mucus? I mean, really. It traps bacteria, viruses, pollen, and small animals; it keeps your stomach from digesting itself; it lubricates your intestines. Sure, sometimes there's too much of it, but on the whole, we don't give mucus the love it deserves. I'm going to start agitating for a National Mucus Appreciation Day.

2. Avril Lavigne: Sure, she's sold out. Yeah, the edgy rebel with the bad attitude got married in Chanel and bought a seven-million-dollar house, but come on. She's got a song out now with the line "She's like, so whatever" and Toni Basil-style handclaps. She's consciously moved from Avril Lavigne the Artist to Avril Lavigne the Parody, and I love her for that.

3. Ramen: Highly processed and full of fat, yes, but what better medicine for a cold do you know? (I don't like chicken soup.) Ramen is patient, ramen is kind to unhappy stomachs, ramen never fails. It, like Twinkies and TV Guide, will be able to survive a nuclear holocaust with no problem. Plus, it never goes stale, even if the package has a hole in it.

4. Vietnamese instant coffee: when you just can't stomach the regular stuff, this magical powder will not only settle your insides but provide you with a buzz that would shame a beehive. Plus, it leaves a weird residue on the inside of your cup, and I think it's full of trans fats. Perfect with ramen.

5. Cheesy fashion magazines. Constantly pilloried for promoting an unhealthily thin body type and conspicuous consumption, fashion magazines are actually the opiate of the cold-infected. Two hours of Vogue or Elle will put your brain into such a comfortable alpha-wave state that it'll feel like you've slept for a week.

Thus endeth the rant/rave for this week. I'm off to get more ramen.

Doped to the gills on Sudafed and wine.

I am coming down with another bedamned cold. My right ear has been clogged for three weeks now; Sudafed offers temporary relief. Today, when the 70-mph winds blew in with their four inches of rain, my chest started hurting. Now I'm grumphing and blowing like an old man with emphysema.

But I made an offer on a house. And it has been accepted. Verbally only, so hold your applause. Keep your digits crossed that the contract gets signed, the inspection reveals no past craziness with termites, and that I can afford to RamJack the house up level. Provided all that happens, my 1948 end-of-year Sunbeam mixer will finally have a kitchen that matches it.

Living with expansive clay soils means that everything, from a 1200-square foot Home For Heroes to the Capitol building, shifts. Sometimes there's subsidence; sometimes the whole damn thing slides down a hill. Luckily for me and my bank account, the subsidence is more of a problem than sliding downhill, since the land is flat.

Living with enormous thunderstorms means you need storm windows, which this house does not have. Likewise, you need gutters, ditto. Likewise, you need a cistern, especially if you intend to keep the St. Augustine grass in the yard, which requires a weekly dose of an inch of water, more in 100 degree heat.

Living with a pecan tree (the state nut, did you know?) in the back yard means that every time a 70-mph wind blows through town, you fret and agonize over the possibility of pecan limbs landing on Your New House's roof. The first rule of camping in Texas is this: Don't lay your bedroll under a pee-can tree; them's the trees that drop branches fer no reason. Bigguns.

Of course, living with pecan trees and healthy shrubs and plenty of rain (this year, at least) means that when you open the lid to the breaker box, the real estate agent you've hired will stumble backwards with a choked scream as a six-inch-long pink gecko leaves its hiding place. And that a large toad will SCREEE at you when you almost step on it, backwards from the house steps.

The basics: It's a post-WWII (Dad is saying "Dubya dubya eye-eye" in his head) Home for Heroes with two bedrooms and a small bathroom that needs work. It's about 1200 square feet, give or take, sitting on a quarter acre. That's big enough for two large dogs who get along well. Or five greyhounds off the track. The original windows, six-over-six with wood dividers between the glass panes, are still there, as are the original fluted glass doorknobs. The kitchen has a built-in hutch with glass doors, perfect for storing Fiestaware (Beloved Sis is foaming at the mouth just now).

There's a room for working out. There's space for washer and dryer connections. The yard, despite something like seven feet of rain in the last three weeks, is not soggy. The foundation, while sagging, seems sound. The roof is halfway through its expected life. The floors are gorgeous. The cabinetry is all original, the doors all solid-core.

The neighborhood is neither scary nor train-track infested. There is a space just to the right of the front door for a rose bush grown from a clipping from Mom's bush up in Seattle, which originated at The Old House. That variety of rose is one nobody's ever been able to identify.

It's like having a brand-new boyfriend: I can't stop thinking about it, hoping it doesn't come to harm with the storms, wondering when I can see it again.

Dog won. Lack of maintenance lost. If you're ever in central Texas, look for the frazzled woman pushing a Green Mountain reel mower. That'll be me.

Freddy Mercury: Still Dead.

This has been one of those weeks in which you could look at the glass half-full or half-empty. Or half-empty or half-empty, unless it was filled with a good single-malt, in which case it'd be gone before you could tell.

Bad: La Schwankienne is cutting staff, cutting beds, but not cutting the number of surgeries its surgeons perform. This has led to understaffing and stressful bed crunches.

Good: La Schwankienne Hospital has announced its new program: Facilitating Patient Independence. Cardiac patients will now be taught to monitor their own rhythms, since there are no more monitor supervisors to do so. Orthopedic patients will perform their own physical therapy with the help of colorful instructional materials, since there aren't enough physical therapists. And patients with brain injuries will learn self-sufficiency by administering their own medications in the proper doses at the proper times, as there are no longer enough nurses. Those patients who are well enough to take care of other patients will receive an additional loaf of brown bread and an extra measure of gin with dinner.

Bad: I've tried to get in to two houses in the last two days, only to find that purchase contracts were signed on them Friday afternoon and this morning, respectively.

Good: My interest spells good luck for someone else.

Bad: We've had flooding here recently.

Good: It gives me an excuse other than seasonal writer's block for not blogging, as it's difficult to write with a snorkle on. Additionally, the rising waters are driving away the obnoxious Californians who moved in to the area five years ago and pushed real estate prices to an amazing level.

Bad: Holy Kamole, our sister hospital, had a nasty power surge that cut off the oxygen generators for an afternoon.

Good: We got to get rid of all those silly oxygen cylinders that were cluttering up the hallway. And some of those silly patients as well, as there won't be oxygen enough to get them down to the ICU if they code.

Bad: It just started to rain again.

Good: West Nile Virus-carrying mosquitoes are practically nonexistent this season, as they like to breed in stagnant water. There's been so much rain that they, like the Californians, have fled to less-turbulent climes.

Bad: Freddy Mercury is still dead.

Good: Someone, somewhere, is building a time machine that will allow me to go back to 1975 and warn him about GRID or HLTV-II before it becomes AIDS.

I can dream, can't I?

I can't decide...I can't decide....

So I have to move this summer.

I have a choice: house or apartment?

House comes with the possibility of a big, happy dog, like a Cane Corso or a lurcher or a big ol' Anatolian (my favorite breed, next to Greyhounds, which of course I'd have one of as well) and a place to plant herbs.

Apartment comes with less responsibility, free weight room, pool, somebody else to do the maintenance. But I can't paint, I can't plant herbs, and I certainly couldn't have a Molosser.

House I could do things to. Apartment I wouldn't have to.

House I could play around with. Apartment I couldn't...but there'd be somebody there to fix the faucets.

*sigh*

The thing that's swaying me is the dog issue. It's been *so* long since I had a dog.

Must...decide...by...July...first....argh.

Things that make the needle on the Baffleometer swing to the red, part 386

Why is it that the neurology residents, after ordering twelve tubes of blood drawn on one patient (yes, literally twelve tubes) for various obscure tests, return to the floor or call with a telephone order for one more test? And why is it always the test that can't be run from any of the tubes already drawn?

Why do tacos come in threes? Twinkies come in pairs. So did Noah's animals. So do senators. Are tacos like celebrity deaths and plane crashes? And if so, should I be eating them?

Why on earth is that resident wearing both bi-colored wingtip shoes *and* a bow tie?

Why do people think tan looks better?

Why did Louis Farrakhan record "Zombie Jamboree" as a young man? Did he really think it would be his ticket to fame? (Speaking of bow ties.)

Why do our urologists have such huge fucking egos? Would it kill them to be polite once in a while?

Why isn't there a decent Ethiopian restaurant in this town?

For Chef Boy

It's Change of Shift time!

Here.

Be sure to check the video "(I'm bringing) Patients Back". Hee!

Product Reviews: Mother's Day Edition

It's time again for non-professional product reviews. If you schlubs want me to review your book or your product or your salted pistachios, you gotta email me. Until that time, I review what I got.

Cutting Remarks: Insights and Recollections of a Surgeon, by Sidney M. Schwab, MD.

Sid is known to most of us as Dr. Sid, the proprietor and author of Surgeonsblog. Here he collects stories and cautionary tales from his training as a general surgeon (1970-76, UCSF). I have three words for you:

Buy this book.

More accessible than Oliver Sacks, funnier by far than Atul Gawande, totally devoid of snarky ego, and a fascinating insight into how surgeons are made and how they evolve. Buy this book. Read it. If you work with surgeons, read it again. Stick little bits of torn-up paper in between the pages you find particularly interesting, as I did. Keep it by the bedside.

I once reviewed a book here and had hellish trouble finding anything nice to say about it. I am now having hellish trouble not fawning over Cutting Remarks. Sid neither suggested I review this book, nor did he send me boxes full of cheese curds and poutine gravy. I'm doing it on my own.

Verdict: Buy the damned book already. If we're lucky, he'll write another one.

Everybody's Nuts Roasted and Salted Pistachios

The back of every Everybody's Nuts box contains a vignette about pistachios. They are less interesting than the nuts themselves. The nuts are big, as advertised; open, as advertised; crunchy and salty and easy to eat. I have a bag of them next to me right now.

Verdict: Recommended.

Land's End Women's Sleeveless Super-T

Extremely soft. The sleeve-less-es are wide enough that your bra straps don't hang out, and the neck is low enough that you avoid the Enormo Neck Problem (especially if you're me and have more trapezoids than neck). No show-through, even with the white ones. I'm five-foot-two, a size 12/14, and the large fits perfectly. It falls to the bottom of my butt while covering the sides of my bra at the arm holes.

Verdict: Why get anything else? Volume discounts so you can show off your guns in different brilliant colors.

How To Cook A Wolf, M.F.K. Fisher

This is the cookbook Fisher wrote (and later revised) for World War II shortages and rationing. You won't want to attempt most of the recipes here, but she does have excellent advice on how to deal when you got no money, no cheese, no butter.

Her best advice? Carry a (filled) flask with you at all times in case the air-raid sirens go off. That way you'll be set for several hours if you end up in a dark basement with strangers. I would follow this advice daily, since I deal with the dark-basement-and-strangers thing routinely, but I'd get fired.

Verdict: A good read, but optional.

Mirena intrauterine contraceptive

Not A Cramp In A Carload!

I had this bad boy installed on Wednesday. I won't lie: the insertion hurt like a sonofabitch, because I haven't had kids. I have not, however, had any trouble since. Days 1 and 2 I took ibuprofen to control the cramps and have not taken any since then.

It's good for five years and is for both multiparous and nulliparous women. It does *not* protect against STDs and can, in fact, raise the chances of a woman getting PID if she has multiple partners. The Mirena releases hormones that thin the uterine lining, making it a good choice for women who have heavy periods or lots of cramps.

My Mom

The best in the bunch. If you haven't had the opportunity to hang out with My Mom, you're missing out. My Mom is the finest-quality Mom available on the market currently; she uses less electricity than other Moms to accomplish the same tasks. She can also be left by herself for long periods in used bookstores without adverse consequences. My Mom should not be submersed in water for long periods of time. Hand wash with mild soap and hang to dry.

Verdict: You who don't have My Mom are big ol' losers.

Happy Mother's Day, Mom!

Things Jo Hates Today. And Loves. And Can Tolerate.

Jo hates it when a kit she puts together for a lumbar drain just...disappears, five minutes before the drain is due to be put in.

Jo hates it when the day is so confused and chaotic that she forgets to hang an antibiotic until 1800, at which time the patient has been discharged for six hours.

Jo hates it when all the cafeteria has for lunch is pulled pork sandwiches and chicken adobo.

Jo hates failed procedures.

Jo loves it when she's passed all her medications and opened all her charts by nine a.m.

Jo loves chicken salad with pecans and red grapes.

Jo loves it when a patient tells her, "Thank you for answering all my questions. I was scared before, but I feel better now."

Jo loves it when she can peg a neurology resident from twenty feet away with a thrown ball of paper.

Jo can tolerate delays in MRIs getting read, but she's not happy about it.

Jo can tolerate a twisted sock for almost twelve hours.

Jo can tolerate a two-mile run.

Jo can tolerate it when people just...disappear, sort of like that lumbar drain kit, be it through death or dismissal or Personal Journeying, but that doesn't mean she likes it.

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

I have ended up on somebody else's blog. Not *me* me, but my Mild-Mannered Alter Ego. One of my patient's fathers started a blog to document her brain surgery and had me pose with her for a few pictures. Those pictures are now up (or so they tell me) on the blog, with appropriate captions ("We don't know which ward this one escaped from, but she doesn't seem dangerous").

I just hope the Nurse Jo Cape didn't make telltale wrinkles under my scrub jacket.

CoS/Gracious, I'm tired.

Change of shift is up here. I'm an asshole and missed it last week. Sorry, Kim.

Goodness. I'm tired.

Something about hundred-mile-an-hour wind gusts and bits of the hospital flying off and having to drive through four-inch-an-hour rain will really take it out of a girl. (We're all fine, by the way.)

Something about medical service patients who are, in a word, all batshit crazy will take it out of a girl.

And there's something about learning entirely new protocols and care plans and how to take care of totally unfamilliar patients that will take it out of a girl, too. This week it's been urology patients; the specialty has moved to our unit to partner with neurology. And if you think that causes problems when we page people, because of the sound-alike qualities of "urology" and "neurology", you'd be right. We've started referring to them as "brains" and "bladders" to make things easier.

Guys who've had their prostates out will talk about *anything*. One gentleman compared his prostate exam to labor and childbirth. I did not laugh. Another regaled me with tales of where one finds blood after a prostate biopsy. I did not run out of the room screaming.

(And that crazy patient? The one I said no to? Was fired by her surgeon shortly thereafter. Sweet, sweet justification of my actions. Sweet.)

Don't get me wrong: I'm not complaining. I'm liking having to learn new things on the fly, and there's a lot of interesting stuff coming in with the medicine and surgery folks. Like Whipple procedures--I'd not heard of that since nursing school. I'm doing a lot of research between patient rounds and boning up on drugs I'm not familliar with. But it's exhausting.

How exhausting? It's 15:45 and I just got out of bed. Cancelled my workout with the trainer today, skipped eating, and slept. This is how tired I am: a box from Sephora arrived and I didn't open it right away. I laid back down on the couch and dozed off instead.

General surgery patients are heavy, primarily because they're not routine for me. Neurosurgery and neurology I could do in my sleep because, well, that's all I've done for nearly five years now. But surgery and medicine have all these new orders and care tracks and protocols and I'm just blown. Plus, they tend to get better faster, so instead of six high-acuity admissions in a day, we have seventeen low-acuity admissions and just as many discharges in the twelve hours.

Overall, though, it's fun. The surgery guys have great senses of humor and are good to work with: intelligent, humane, and good at returning pages. The urology guys are just as all-around good, plus they have a stable of nurses who are helping us out as we get comfortable with their patients.

I just wish I could take a nap in the middle of the shift. After a day when I start with five patients (usually one or two high-acuity neurosurgeries in there), discharge three, get three, discharge two of those, get two more, and pick up one last one at 1815, I'm *so* done.

I wonder what's in that box from Sephora.

Rules of Nursing, Revised and Updated!

1. All together now: If you have to jack with it, it's wrong.

2. The amount of time it takes a patient to announce "I'm not a junkie!" is inversely proportional to the probability that the patient is indeed a junkie.

3. The amount of irritation a particular order, procedure, patient, or request will produce is directly proportional to the number of sleepless nights the ordering resident has had.

4. The messiness of handwriting is directly proportional to the difficulty in getting hold of the person who wrote the order.

5. The amount of feces a patient produces during a shift is inversely proportional to his level of consciousness.

6. The difficulty level of a drug calculation is directly proportional to the drug's dangerousness.

7. Benzoin never washes out.

8. Bile will always land on whatever is white.

9. The patient on several different interacting medications will always have a general practitioner who does not do blood levels of those medications.

10. Everything happens after 0400/1600.

11. The probability that a patient will survive a code is inversely proportional to the likelihood that they will be declared DNR.

12. Any attempt at efficiency will, sooner rather than later, be met with Three-Stooges-like complications.

13. The lift is never on the floor when you need it.

14. The high-risk profile for terminal illness includes a happy family, a good job helping others, and a cadre of devoted friends and relatives.

15. Elevators fail to work during codes.

Say the word and be like me.

It's so fine; it's sunshine. It's the word "no."

A meditation on saying "no."

I had one of Those patients today. You know the sort; they come in with poorly defined abdominal pain that stays poorly defined and resists all efforts to diagnose it. The only thing that calms the pain is a patient-controlled pain pump with X number of milligrams every Y minutes (determined by the patient) with a Z bolus of A milligrams every B minutes.

You know the sort.

This one wanted to go smoke. Then she wanted to go to the gift shop. Then she wanted just to walk around outside. I told her she could do none of those things; that leaving the floor with that much narcotic was not allowed.

So she put an aide on the spot by asking *him* to take her out to smoke.

Which I called her on. Then she called the aide a liar, which I called her on. Then it became a huge joke, which I did not find funny.

The last straw, for That patient, was when I told her that, regardless of what she *wanted* to eat, she'd be getting a particular diet. Period. No argument.

Whereupon she, being an old hand at this hospital business, called the Big Boss and poured out her tale of woe. Oh, the cruel nurse! Oh, the inhumanity!

Immediate Boss dealt with it and came back with this ultimatum: either give up That patient and offer a "half-assed apology" or offer a "half-assed apology" (and I'm quoting, here) and go on for the rest of the shift.

I said "no."

As in, No, I will not apologize to the patient who will not follow the rules. As in, I was not rude or condescending or nasty; I simply stated how things would be. As in, No, That patient won't get an apology, and further, *you* get to handle her for the next four hours.

As in, No, I will not be abused in the name of customer service.

Because, you see, my job is not customer service. My job is to provide the safest and most therapeutic environment possible for my patients. If that means that they don't get to smoke their usual two packs a day while they're being evaluated for a duodenal perforation, so be it. I'm happy to offer nicotine replacement; it's their loss if they refuse.

My job is also to protect the people who have less power than me. If you call my aide a liar while trying to get him to do something he knows he can't, I'll call you on it. And if you continue to screw around, I will not tire of telling you "no."

The surgeon, thank God, is on my side.

The other nurses I work with are shocked. And admiring, that I had the huevos to say "no" to something that we'd all normally go along with in order to keep the peace.

I've had enough of saying "yes." It's time we, as a profession, got rid of this imagine of being pushovers who only want to please. I'm sure the first twenty-dozen nurses who refused to stand when the doctors entered the station got hell, as did the first twenty-dozen who refused to carry the MDs charts for them during rounds.

I'll take hell for saying "no." I've already defined my job; my bosses' job is to make sure I can do *my* job safely and without untoward interference.

I have the feeling I'll hear about this once Biggest Boss Of All gets back from vacation. In the meantime, I'll savor the feeling of "no."

*smack* *munch* Mmmm...new nurses.

That's a joke, people.

John (for whom I have immense respect and liking) has a post up on "lateral violence", aka "nurses eat their young with sprouts and bleu cheese." He posts some sobering stats on how many new nurses (defined here as nurses within the first couple of years of licensure) leave the profession entirely or change jobs.

Not to disagree entirely with John's point, but I have a thought on a couple of other issues that face new nurses. I thought I'd expound. Of course I did.

Issue Number One: Nobody Really Knows What The Hell It Is We Do.

We dare to care, yes. We dare to cry. We dare to work out BSA and dosages for neonates in a code. We dare to keep up with changes in legislation. We dare to influence that legislation. We dare to advocate for abused patients. We dare to work in a profession that is historically undervalued. We dare to protect our patients from doctors' errors. We dare to report our own.

In short, we do a whole lot more than caring and crying.

Yet, when I started nursing school, I was the only person in a class of forty who said something other than "I want to help people."

Nursing students are no less clueless than the rest of society. I would estimate that ninety percent of the folks I went to school with thought that a person's warm-fuzzosity was the primary determinant of how they'd do as a nurse. And all of those people got whacked upside the head with the reality of how tricky the job is--not just from the standpoint of interacting with sick people, but from the standpoint of having to be a scientist.

Aside from the one woman who went into school "to meet doctors" and the other who wanted her husband to stop bugging her about getting a job, *all* of the people who wanted to "help others" have left the profession.

All of them. That's fifteen nurses (of the ones that finished school) who have gone back to accounting, or bank tellering, or whatever they were doing before. I am one of six (SIX!) students from my graduating class who is still a nurse. Nobody, apparently, knew that it would be as hard and as intellectually demanding as it is.

At the same time, I'm watching smart young feminists of my acquaintance not enter nursing because of the helpmeet stereotype. Frankly, what this profession needs more of is smart young feminists. Yet we're not attracting them, because nursing is still seen as a pink-collar, nearly-service-industry, "helping" profession. When I talk to women who are working toward their premed degrees about what I do for a living, they're gobsmacked to discover that modern nursing is a hell of a lot more like their concept of being a doctor than they thought.

Solution? We need to be realistic about what we do. We need to tell people, every chance we get, that we are intelligent, trained, scientific professionals who are also able to steer a family through a health crisis or advocate for a rape victim. I am eternally grateful for Pal Angie, who will be getting a newly-minted RN this summer (hooray, Angie!) and who is one of the smartest, toughest, feminist, most realistic people I know. If more people could see nurses like her, we'd have no problem with a shortage.

And if more nurse-wanna-bes understood that it ain't all hugs, we'd have fewer people who ought to be somewhere else.

Harsh, but true.

Issue Number Two: It's About The Stupid Management

Sometimes I feel like a cross between Joe Hill and Emma Goldman, with the Pinkertons about to bust down my door, but it's true: Hospital management is hostile to nurses. Period.

A friend of mine who's also an RN got offered a fantastic bonus for signing on with a particular hospital which shall remain nameless. She showed up on the floor the first day after two weeks of orientation to find herself in charge of one practical nurse and twelve patients. Twelve. All of whom were in varying states of circling the drain because of nursing shortages at that hospital. She walked out after that first day and came to our facility, which (at the time) still cared about staffing rather than the latest technological widget.

We as nurses need to do two things to fix this problem: First, we need to stop signing up for extra work. When I see a nurse who's working ten days in a row without a day off, I don't see a dedicated professional. I see a person with serious issues about saying "No."

Quite frankly, the world will not end if we all start saying "No." The hospital will hire agency nurses or more full-timers, or start paying attention, at least, to staffing levels. Management might actually have to come in and work--and that, my friends, is a truly marvelous feeling, to watch your manager wipe ass for twelve hours because he hasn't had the huevos to hire new people.

Second, and more importantly, we need to agitate for safe staffing levels. When I say "agitate", I mean everything from my own technique (which involves yelling if necessary) to the technique of calmer colleagues (who speak in front of the state legislature). Every nurse can make a difference at some level in this fight. If you're crazy about writing letters and emailing representatives, you can do that. If you're nuts for making middle management uncomfortable, you can do that. And if you get a warm, fuzzy glow from saying "No" to extra shifts, you can do that.

We as nurses do need to shut the hell up and stop putting new nurses through a gauntlet. Nobody's going to be tougher, or faster, or smarter for being abused. There are, however, *systemic problems* that I think are a larger threat to the profession as a whole. We need to spend the breath we'd use debating how, exactly, we eat our young fixing those.

How not to be impressive.

It does not impress me if a nurse routinely complains at 1430 that she hasn't had a chance to open her charts. It makes me wonder where she learned her time-management skills.

It does not impress me if a nurse tells me he's never made a medication error. It makes me wonder how many of those medications he's taken himself.

It does not impress me if a nurse on our floor tells me she never has time for lunch. I qualify that with "on our floor" because we are very serious about food. See time-management skills, above.

It does not impress me if a nurse complains constantly about the fact that one of these days, he's gonna get sued and lose his license and isn't the culture of lawsuit-happiness awful. If that's his main focus, I wonder what and how he's charting and what the hell he's doing in the room.

It does not impress me to hear a nurse deny that she's wrong.

It does not impress me to learn of a nurse's difficult relations with doctors. There's no reason not to get along with doctors, with the possible exception of the occasional total nutcase. Even if you get off on the wrong foot with each other, careful negotiation can make a good working relationship possible. If you can't get along with any of 'em, the problem is you.

It makes me sad and does not impress me when a nurse obviously hates everything about nursing. I don't care if you felt trapped ten years ago when you got your RN; you can certainly afford to change now. If you hate it that much, take accounting classes or learn to throw pots on the wheel.

Drama fails to impress me. Totally.

What does impress me, and what I'd like to be eventually, is the sort of nurse whose patients rarely end up in the ICU, because she's caught problems early. I'd like to end up as one of those nurses whose gut feelings get taken seriously by residents and attendings alike, because he's been so careful in his assessment. I'd like to be one of those nurses whose charting is so complete and careful that you can tell, a week later, exactly what's been going on. I'd like to be the nurse who doesn't get flowery accolades from management, but whose patients always request her when they return after surgery.

I am very, very lucky to work with a passel of the latter sort of nurse and only a couple of the first sort.

But jiminy cricket, I need to work on my charting.

"what i don't know outweighs so much of what i do know, sometimes it's hard to believe"...

I have to, *have* to address this.

New nurses are ignorant.

So are old nurses who are faced with something they've never dealt with before.

So are medium-aged nurses who have to keep up with new technology.

So are doctors, old and new, rusty and in-practice.

Part of the practice of nursing is scrunching out ignorance: your own and other people's. I would argue that the most important thing that a nurse does is scrunch out that ignorance by giving her* patients the tools and knowledge to deal with their conditions. The second-most important thing she does is squish her own ignorance flat under the weight of her own research, learning, and auto-didact-icism.

Do not ever let your ignorance paralyze you. Hell, if I dwelled every day on how little I actually know about neuroscience, I'd never get out of bed. (Or, at least, I'd have another good excuse for not getting out of bed.) What I do know, I know really well--and I can put it into language that a mentally-deficient turnip could understand. What I don't know I'm not afraid to admit, even to an anxious patient.

Where nursing students excel is in the almost eidetic recall of new stuff a lot of the rest of us have missed. Where they excel is in the energy they put into learning new stuff. They also kick ass at taking a look at The Way Things Have Always Been Done and asking "Why?"

Don't let the fear of your own ignorance paralyze you, whether you're a brand-new nurse, or a brand-new student, or an old-guard nurse trying something new. The absolute worst thing that will happen to you if you show your ignorance is that you'll feel like an idiot for a few minutes. Nobody's going to die. Nobody's even going to get hurt. More than likely, you'll make some pedantic nurse's or doctor's day by giving them the chance to explain something near and dear to them.

I once asked an endocrinologist a fairly simple (I thought) question about something endocriny. He treated me as though I had a much broader base of knowledge on the subject than I actually do and lectured me for three minutes on the ins and outs of that particular problem. (What the original question was has been burnt out of my head by the answer.) Even after he left the English language and started saying "Gleep! Waggado, florischepup mmm nnaaagh wazuuuuu weeeep, *click*!!" I sat there and looked interested and nodded. I learned more than I had in a week that day, even without taking into account the detours I took through Google and dictionaries as I looked up the words he'd used.

I am also now his very favorite nurse. He mostly speaks real human speech to me, even.

That's a good lesson on admitting your ignorance. Remember: if it's too humiliating, you can always get Freixenet Cordon Negro in those itty-bitty bottles for after work.


*Standard disclaimer on using female pronouns to label nurses goes here.

Gosh, look at the time.

It's spring, the loveliest time of the year!

Those of you who are about to graduate from nursing school will no doubt have noticed that it's staying light later in the day, although other details might've escaped your notice. Since it's spring, it's time for the periodic Tips From Nurse Jo For New Grads...

1. The first rule of nursing is (sing it, everybody!): "If You Have To Jack With It, It's Wrong." Remember that when you have to connect tab A to slot B through connector C and widget D. If something doesn't come together in an idiot-proof way, be it lab results or equipment, take another look at it and figure out what's wrong.

2. You will not kill anybody. I promise. You will still pray, as I did, every single day that you won't kill somebody, but you won't. There are people looking out for you.

Which brings me to

3. If you've somehow landed in a hospital where the nurses are horrible, you can always leave and find a new GN internship. Don't feel like you have to put up with abuse in order to pay your dues or make it as a nurse.

Mother Jones has a big discussion on the backbiting and cattiness in the nursing profession. Honestly? If nursing is the cattiest, bitchiest profession you've been in, you've obviously never spent even five minutes in community or college theater (but that's sort of beside the point).

The point is that there are plenty of nurses out there who aren't looking for a GN to chew on. There are lots of internship programs dedicated to educating you, making you a confident and competent practitioner, and plenty of folks like me who love to teach and are proud of you for what you've done.

If you end up in one of the other sorts of internships, don't take the abuse. You can always walk.

Speaking of walking, there's

4. Do not be afraid to leave a room or the nurse's station if somebody is abusing you. That goes for patients and double for doctors.

When you're a new nurse, everydamnthing is so overwhelming that, even if you've dealt successfully with crises before, you tend to cave. Remember that walking away is often the best way--and sometimes the only way--to deal with shouting nutjobs. Yes, I've turned on my heel and walked away from patients, family members, and doctors. As I've gained more experience, I've had to do so fewer and fewer times, but it's still a valuable skill to have.

5. Shoes, scrubs, and fiber are the three most important components of daily life for a new nurse. Make sure your shoes are good and sturdy, be certain your scrubs won't fall down if you have to book it down the hall, and eat your veggies. Taking care of your body and making sure that your clothing is worry-proof isn't selfish; it allows you to concentrate on your job.

6. Don't lend your stethoscope to a resident unless you're absolutely sure you'll see her in the next ten minutes.

7. The volume of shit a patient can produce in one shift is inversely proportional to their level of consciousness.

8. Other nurses and doctors (didja notice? I said "other nurses! You're a nurse! Hooray!) are there to have their brains picked. Ask questions. Ask for help. Don't turn down help if it's offered. Don't be afraid of looking silly; we all look silly on a daily basis (or oftener, if you're me). And don't underestimate the knowledge base of the transporters, patient care aides, radiology guys, and pharmacists. Pester everyone, absorb information like a sponge, and sort it out later.

9. Being a nurse is much, much easier than being a nursing student.

10. Eventually, I promise, you will feel like a nurse. It might take a couple of years, but it will happen. The flow won't come immediately; you'll feel completely at sea for the first several months. Someday, though, you'll be wandering down the hall and be hit with the realization that you actually saw a patient and planned her care and thought through her case in a second-nature sort of way. You will suddenly realize what all that studying was for. You'll understand how all the pieces of a problem come together and what to do about some of them. You'll feel a glow of accomplishment and a surge in confidence.

And then your patient will go into respiratory distress, or you'll realize you've made a whopping med error, or you'll spill spaghetti on your pants. But for one shining moment, you'll feel good about what you're doing.

Hold on to that. Spilling spaghetti on pants, tragically, does not get any less frequent with experience, but the feeling that you're doing good comes more often.

A delicate, feminine, lace-trimmed rant

When did a size 12 become "full-figured" and a 14 become "obese"?

What the hell is up with the BMI?

And where are the athletic-cut shirts for women?

I got into a little discussion the other day with some people at work. I'm closer to 200 lbs. these days than to 100, but I wear a (loosening) size 12. According to the BMI charts, I'm obese. According to magazines like "People" and "Vogue" (not like I'm saying they're bastions of intellectualism and feminist cred, but they are popular), I am "full figured". According to some of my coworkers, I am getting "too big" from weightlifting.

The only one of those three I can shut up immediately and effectively is the last, usually by simply picking the second-biggest person in the group and lifting them clean off the floor without visible effort. (The first-biggest person in the group is usually some general-surgery resident who was a nose tackle in high school. I don't need a hernia.)

But I'm still getting charged more by my insurance company because I fall into the obese category on the BMI charts. Never mind that my blood pressure is fine, that my cholesterol is normalizing, that I can and do run an eight-minute mile. Yeah, I could stand to lose 20 pounds, but that would still put me in the overweight-to-obese range for the government and in the holy-kamole-to-oh-shit range for insurance charts. To weigh what my doctor, my insurance purveyor, and the Gubmint would like me to, I would have to lose about sixty pounds. Which would mean that I would quit menstruating and probably breathing.

To give you an idea of the genetics behind my biceps, consider this: Beloved Sister "should" weigh somewhere around 125 pounds at her height.

She carries that much in lean mass *alone* on her frame. We're blessed.

Anyway, I'm getting bugged. My pants are getting looser at the same time my shirts get tighter, which means I can buy jeans (for now) at "normal person" stores, but have to spend the extra dough on "woman's" clothing in order to get something on top that will go around my chest. Or I have to buy men's large shirts and taper the waist down. If I want a dress, I have to order women's sizes in order to fit my chest and back, then alter them to be small enough for my waist and (sometimes) hips. Or I have to buy a "normal person" 16 or 18 and then alter the whole damned thing, because I'm short.

I want some women's shirts that are cut to allow for shoulders, boobs, and a back. I don't even care if they fit around my biceps; I just want to be able to go out in a T-shirt or button-down without looking like Sheena, Queen Professional Wrestling Slut From Hell.

I'd also like for the societal expectations for women's bodies to change enough that total strangers don't find it necessary to comment on my shape. It's nice when it's a compliment, but more and more often (especially if I wear a normal-person T-shirt) it's getting into "Good Heavens, what on earth do you *do* to get that big a back?" territory.

I'd also like for the coworkers who bug me about my muscles but love me to help them move heavy patients to shut up for a while.

Please note that I do not intend to quit lifting. There's something viscerally satisfying about putting on a shirt and having it strain across my back, even if I then get irritated about the fit. I love the fact that I now walk with that bouncy, tight weightlifter's walk, rather than with the tired-nurse tread that I see so often at work. I also love that I can do sixty reps on bicep curls with fifteen pounds and be just a little tired.

Plus, it's nice to be able to pick up people who bug me. I may, if I continue to make huge gains in strength and bulk, someday be able to shake them like a terrier would and then toss them over my (massive, rippling) shoulder.

Not second-best.

It happened again: a raft of compliments from a patient and her husband, with the husband taking me aside and speaking seriously about what a pity and a waste it was that I didn't go to medical school. The implication is that I'm too smart, or too hard-working, or too marvelous overall to be a nurse; that I'd be doing the world more good as an MD.

This time I didn't scream. I didn't blow my top. I didn't even feel insulted. (Well, okay, I did. But I didn't let it affect my response.)

I went to nursing school not because I was too old or too tired to become a doctor, but because I wanted to be a nurse.

Doctors, by virtue of their training and specialization, focus on the disease process. Nurses focus on the person dealing with the disease process. (A lot of the narrow focus of doctors' work, unfortunately, is born of the medical system, with its emphasis on CYA shotgunning and rule-outs.) A nurse will view her* patients holistically, take the time to discover weird little underlying causes, and educate her patients about whatever's wrong with them and how to live with it. Because of the contraints under which doctors operate, if a doc does that, it gets him a book deal and a spot on NPR. Nurses do it every day.

Nursing and doctoring are equal professions. I predict a lot of flak from that, mostly coming from residents (grin), but listen up: I may not know the pharmacological profile of gentamycin like the back of my hand, but most doctors don't know how to deal with a clogged central line. I don't do as thorough a clinical neurological assessment as my neuro MD colleagues, but my neuro assessment will tell me (and them) more about how the patient is able/unable to operate in his or her daily life. I can't read an MRI reliably yet, but I have a gut feeling, honed through years of paid and volunteer work, that is pretty near infallible.

My two main foci as a nurse are assessment and education. It's because I'm a nurse that my assessment skills are more detail- and change-oriented than those of my medical colleagues: after all, they're in surgery or clinic all day, while I'm dealing with the same people for twelve hours at a stretch. When something minor changes, the nurse is often the first to notice--or the only one to notice--not just because she's there, but because she knows the patients better.

I also have time to educate. One of the biggest parts of nursing is translating what's just happen or what's about to happen into English. This can be worrying or reassuring, depending on the situation; it's up to me to deal with the patient's emotional and mental reactions. It's also my job to teach the patient how, for instance, not to rip the Harrington rods right out of his back immediately post-op. Doctors know the general outlines, like "do not lift anything heavier than ten pounds or do strenuous activity", but most can't translate that into "don't pick up anything heavier than a gallon of milk or vacuum your carpets." (It's worth mentioning that two-thirds of the education I do consists of putting instructions into fourth-grade reading-level form. This disturbs me on many levels.)

Doctors and nurses are two parts of a big symbiotic critter. Our skills are different, our education levels are different, our training is different--but we are equal despite those differences. I can't do what the folks on the neuro service do to brains, but they don't know how to mobilize their own patients, or prevent pressure ulcers, or treat the side effects of some medications without drugs. The healthiest nurse-doctor relationships (and I'm proud to say that, despite the current weirdness at L'Hospital Schwankienne, our professional relationships are top-notch) are those that recognize the inherent differences in skill and focus and give credit where credit is due.

I'm not a helpmate. I'm not a handmaiden. I'm certainly not a failed, frustrated doctor-wannabe. I'm a carefully-trained, careful-thinking, observant clinician with a wide range of disparate skills and some strange little tricks up her sleeve. You really can't compare the two professions; our tricks and skills are too different.

And my profession is certainly not second-best.



*Yes, I'm using "her" here, since most nurses are female.

Change o' Shift!

Right here.

How to kill a hospital

It's best if you can pick a really good hospital to kill. Try to find one that was started by surgeons and physicians for their most complex patients. It helps if the hospital is known nationally for its quality of care and its research facilities. Merge it with another, larger hospital, one in persistent financial difficulties. This sets the stage for a nice, slow, painful death for the better-run hospital.

If you're a member of management, remember: small demoralizations add up over time to a poisonous environment. Try to start small, with something like the laundry service. Contract with a different service provider, one who can guarantee that about 20% of your linens will come back stained, ink-marked, torn, or with melted tape on them. The extra five minutes a day each nurse or aide will spend looking for usable linens really adds up.

Once your employees have gotten used to hoarding clean, untorn sheets, you can merge supply rooms. Be absolutely certain that the research hospital is a minimum of two miles away from the central supply area, and be sure that their stocks of necessities are always just about to run out. The nurses and aides are used to sorting and hoarding linens; hoarding lumbar puncture kits and needles is one easy step beyond.

Don't forget your support staff! It's best if you can plead "budgetary constraints" before you fire all but three or four of your longest-working support people. With the money you save, you can re-fill those positions with people earning just over minimum wage and with few if any benefits. That way, you'll guarantee that the people who keep the hospital clean, who transport the patients, and who cook and serve the food will think of your facility as just a place to come to work, rather than a job that they're proud of.

Try to hire managers who are completely ineffective. It's better if they can be actively harmful to their units, but ineffective is good enough. Encourage them to promote to management positions those who carry on flaming affairs with coworkers, backstab, or are simply too lazy to move from a chair. It might take a while, but you'll find your patience more than repaid in frustrated and demoralized employees. Train your unit managers to respond late if at all to concerns.

If you have employees who are chronically late or absent, or who falsify documentation or who are unsafe practitioners, do your best to keep those employees around. Try to hire and retain people who complain of bullying if their mistakes are pointed out to them. If one or more of those people is sexist or racist, fantastic. Be sure to discipline good employees at the same time you let the others slide--otherwise, your staff might think you're simply incompetent rather than malicious.

Play favorites. It goes *such* a long way toward establishing cliques and employee unhappiness. Remember: little actions count! Leaving one employee out of the annual holiday-candy dump will be noticed and remarked upon.

Don't neglect the small perks that make working at a formerly-good hospital so satisfying. I'd strongly recommend stopping all employee recognition except that which has to be approved by management. Be sure you appreciate hard work, but not too much. If you have a unit secretary who hasn't taken a sick day in fifteen years, a five-dollar gift certificate to a chain restaurant is about the right level of congratulations.

And be sure that you lower the quality and raise the price of the food in the cafeteria. Nothing says "We could give a flying fuck less about you" than a widespread outbreak of E. coli poisoning, especially when the prices for bacteria-laden sandwiches have almost doubled in a year. Sure, some of your employees might go next door for a decent meal, but remember: you can always discipline them for leaving the floor for lunch.

Investment in new technologies is always a fine idea. Before you invest, though, be sure whatever new widget you're rolling out will be several thousand dollars more expensive than you'd expected, be months late in implementation, and be difficult and tricky to use. If the widget is computerized and crashes routinely, so much the better. Bonus points for replacing a trouble-free system with one that dies on the average of twice a week. Triple bonus points if it has something to do with either patient safety or medication administration. Just think: with the money you've spent on this latest boondoggle, you could've hired another pharmacist. As it is, though, you're increasing the pressure on *that* part of the hospital while frustrating nearly everyone else. Good job!

Keep it up for eight to ten months and watch morale and job satisfaction slide! Don't neglect the tiny details, either, like imposing fines in particular parking areas, then changing the rules without notifying your employees. There can never be enough paperwork. There can never be too few people in critical positions.

Give yourself a raise, manager! You've successfully killed another hospital!

It's official: Mom and Dad adopted me from the aliens.

So I went to the happy shrink guy for my follow-up appointment and told him what happened when I tried to taper off Effexor. His response? "Boy, that's weird." "Weird" means more, somehow, coming from a psychiatrist.

And then I got the results back from my latest round of blood tests. When the last ones came in, my cholesterol was in the mid-180's, which, combined with my family history, made me a little nervous. So I cut back on booze, cut out junk except for a treat now and then, and upped the amount of lean protein and veggies and fruits I eat. I also incorporated more cardio into the workouts I have with Attilla, and started cardio on my own.

Whereupon my cholesterol went up twenty-four points.

I'm going back to a diet of burgers and beer. I may start breathing methane; it's probably the oxygen in the atmosphere that's causing my problems.