Gracious snakes.

I post, I go to bed. I wake up earlier than God, and bang! Six comments in six hours.

Strike a nerve, much?

Some study I Googled last night said that 430,000 nurses report that they're victims of violence or intimidation on the job every year, and that that number is likely low due to under-reporting. Seems that a lot of nurses think that getting clocked or yelled at is just part of the business of being a nurse, and that some managers think it's whiny if you report being a victim of violence.

Hm.

You know, what pisses me off most about last night, is this: (well, two things, actually)

First, that the first-line person, my manager, did not automatically go to bat for me. Instead of laying out ground rules, he attempted to perform some weird magical act of conflict resolution that would somehow make it all okay. 

That has two results. The first is that the person who swang/swung/swinged at me has no incentive to change that behavior. "Act badly, get coddled" is the message.

The second result is that I know, now, that if I attempt to set firm boundaries with a person, like "Do not try to hit me. That behavior is unacceptable" I have absolutely nothing with which to back that up. I am really and truly on my own as a caregiver. If the person then complains, or tries to rough somebody up, we're back to Conflict Resolution and Good Customer Service.

And this makes me sit back and scratch my head and slurp my coffee thoughtfully.

The majority of comments left after yesterday's post talked about lawsuits and criminal charges, which tells me this: That I am not alone in working for a facility that has no plan in place for dealing with patient-on-caregiver or family-on-caregiver violence. I'll bet doghair to donuts that all of you guys have codes for civil disturbances or codes for when some nut comes onto the floor waving a gun, but that there's no code to call when a patient tries to cold-cock you.

So. Sunnydale has no plan. Sunnydale's Corporate Manglement has no plan. It's nursing, Three-Stooges style, except the pratfalls are real. So what will I do the next time this happens?

That's a hell of a question. If I'm feeling tough, I might well file charges and insist upon a root-cause analysis of the problem. (RCA's are when all the mucketies get together and go, seriously and with intent, over the entire history of something that has gone Very Wrong.) I might make noises about lawsuits and editorials for nursing magazines. I might even be serious.

Because, as I said before, the only way to get the folks on the carpet to listen is to threaten either their bottom line or their good public image. 

Now: one thing to get straight this second is that I would not, unless Manglement or the hospital were way, way in the wrong, sue anybody for money. I'm not really interested in that sort of drawn-out, pain-in-the-ass process, and it wouldn't end up solving a damned thing, as the facility (if somebody *were* to get hurt) would settle in return for a non-disclosure agreement.

What I *would* do is insist on new standards of behavior for patients, family members, and visitors. What I want is a policy in place that says, If you do X, then Y will happen. What would make me happy about working where I work is a recognition on the part of all the managers that The Customer Is Not Always Right, and that there are some things that are beyond the pale. 

Right now, all of us, whether we're in the ER or on the floor, are subject to threats that would never fly in any other business. If you holler abuse in a bar or try to start a fight, you get thrown out. If you throw a temper tantrum in a restaurant, you'll get thrown out. If you try to injure somebody in public, you're gonna have to talk to the police. But swing at or holler at a nurse? It's all part of the game.

Why are we less safe at work than we are in a bar? Why are the standards of behavior so much lower for the consumers of our product? Because, quite frankly, if the patient is going to be treated as a consumer of healthcare, they need to be subject to the same standards of behavior that consumers of alcohol, groceries, or cut flowers take for granted.

The answer to the problem of violence against nurses is simple: People who are violent or threatening need to be refused care. The way to get that policy implemented is much, much more difficult.

I think I'm going to lean back, furrow my brow, and slurp some more coffee while I think about it.

This "Customer Service" bullshit has got to stop.

Normally, I never post immediately on coming home from work. I'm too frazzled, too scattered, and unable to complete a spoken sentence, let alone a written one.

Today, though, it's different. Today, for the fourth or fifth time in as many years, I had a patient take a swing at me. What's different about today is that this particular patient was alert, oriented, knew where he was and what he was doing, and was trying to hurt me.

This patient was the typical Sunnydale Hospital* frequent-flier: pages and pages of old charts, all of them with extra pages attached from nurses who'd had run ins with him. The documentation was complete and careful and clear: this particular person was a nutjob. No way 'round it; he had enough baggage for the Rolling Stones on tour.

His course was also typical: noncompliance with the simplest of instructions, obscenities screamed at nurses, pharmacists, and doctors, and the final lovely touch of hiding narcotics in his room. That was just recent visits. It didn't take him long to get a file this (holds fingers apart at arms' length) thick.

So he took a swing at me. And screamed obscenities. And I reported it, as I was supposed to, to my boss, one of the Manglement Trifecta on the floor. (Winky, Blinky, and Nod, as I call them, do the work of one person, and do it.... Anyway.) Winky went on into the room, and there....

...Practiced Good Customer Service and Conflict Resolution.

The upshot? I got told the patient didn't like me--big shock, as he didn't like anybody--and was told not to do whatever it was I did to get him upset again.

Managers, read this, if you read nothing else:

Customer Service Does Not Mean Putting Your Nurses In Harm's Way.

This was a patient who'd already threatened to kill two surgeons. He had come up on out of the bed with a pharmacist and had caused three of the toughest nurses I know to refuse to take him on as a patient. Now, I am not the shrinkingest violet on the block, but one thing here ought to be perfectly clear: The only way to deal with a problem like this is to get rid of the source.

Patients like this ought not to be readmitted to the hospital. They ought not to be "counselled" about their behavior. There ought to be no quarter given: if you swing at a nurse, or scream obscenities, you should be told briefly and bluntly that that behavior is unacceptable, and if necessary, you should have a security guard posted outside your room.

The fact that this guy wasn't ditched from the hospital admit list tells me that Sunnydale doesn't give a good goddamn about their nurses' safety. The fact that my charge nurse, Winky, didn't lay down the law tells me that he cares more about our floor's customer satisfaction scores than about *my* safety.

And that tells me this: Managers, listen up: the only way you guys will ever pay attention is if we, the people on the front lines, start making a stink. 

Next time some direct descendent of Einstein swings at me, I am not going to get out of the way. I'm going to let them hit me.

And then I'm going to file battery charges.

And then I'll talk to your board of directors, Sunnydale, about the whole situation, and how much compensation I ought to get for mental anguish. Because the only way to get large groups of carpeted-area manglement types to pay attention is to talk about negative publicity and dollar amounts.

I'm not fucking kidding. There is no reason in the world that I ought to have to put up with somebody who's actively violent still being in the hospital after he's behaved like a beast. There's no reason that the charge nurse or house supervisor or whatever shouldn't march into the room and tell the person who's a nutjob that nutjobbiness is unacceptable and *will* stop, NOW, or the patient can go home. 

There is, in short, no reason for me to feel less safe working at Sunnydale than I did working at an abortion clinic. And I do. 

*w00t Buffy.

Butt Tufts and Other Hazards of Southern Life

Or, what I do on my day off.

Max is shedding. Among those of us with double-coated dogs, there's a less-polite, more-descriptive term: "Blowing the coat". Max is blowing his coat.

Yesterday it was close to 100* here. In one day, Maximus Doggitude went from looking like a gentleman, albeit a shaggy one, to looking like he'd earned the nickname "Banjo" by living under a bridge for six months. My neighbors, who live with a good-natured pug and a corgi who never ventures outside except under duress, were amazed to see me pulling handfuls of hair out of Max's coat, especially on his hindquarters. Anatolian shepherds, being a mountain breed, tend toward large poofs of fur to keep their hrbls warm in the winter. Max's hrbl frbls were out of control.

Doggie dreadlocks, only six days after his last intensive grooming session. Every sparrow and mockingbird on the block is wearing comical mustaches of Max Fur, soon to be lining their nests.

Speaking of sparrow nests, I had a heartbreaking moment the other day when I noticed that a piece of decorative trim had come off the side of the house, just around the soffit. It had exposed a long empty space, and in that empty space were shreds of grass and other material. That spells "sparrow nest", which in turn spells "rodents looking for prey" and "rotting wood", so I climbed up on the world's shakiest hand-me-down ladder to have a look. I got out the entire nest (why does a small bird need a nest as long as my arm?) and dropped it to the ground before noticing it contained unhatched eggs. Two were broken. Three were intact. The parent sparrows were flipping out.

I put the nest, as close to whole as I could manage it, in the crook of a tree nearby. Given that the only bird with a sense of smell is the vulture, I figured the parents would adopt the nest again with no problem. They did...until the next big thunderstorm. *sigh* I feel like a baby bird murderer.

In gardening news, things are mixed. The dill and lavender are doing well (though Max chewed up half the lavender plant today; why I do not know) and the tomatoes are fruiting. The Romas are behind time, having gotten munched by some unknown bug, but the cherry tomatoes and heirlooms are already setting tiny green fruit. The cilantro got as high as my shoulder before seeding out. I pulled it yesterday morning and tossed it on top of the compost pile, intending to dig it in later on, once I'd bought a pitchfork. Before I was able to do that, I saw Max, head and shoulders into the compost pile, delicately yanking strands of seeded cilantro out and eating them. 

I had wondered why, for weeks on end, the cilantro seemed to be self-pruning. I know now that the Weirdest Dog In The World had been chewing bits of it, perhaps to freshen his breath for the pug next door. Fortunately he doesn't seem to have the same taste for basil as he does for cilantro and lavender. The dill and basil are safe, which is good for him. If he were endangering my future pesto binges, we'd have to have a talk.

I'm already planning the garden for next year. I want to build four raised beds, two square and two long, with cedar poles and plenty of fencing to keep the dog and the neighborhood tomcat, who sleeps in my lettuce, out. One bed will be for perennial plantings, asparagus and strawberries. The other will be for things like carrots and tomatoes and radishes and bush beans. Lettuces and cabbages (fall crop), brussels sprouts (ditto), and pole beans will go into the long beds, along with cucumbers melons perhaps kiwis peppers herbs etcetera.

In the front beds, which I have yet to till and de-grass (dammit, sigh), will go perennial herbs like rosemary and lavender and dittany and oregano.

There's a lot to do when you have a house. I'm just now learning this. I've not even mentioned the difficulty of finding a black toilet seat (better in keeping with the theme of the bathroom and its historical roots) or an affordable vented oven hood. Or what it takes to find a really good screen door, or the spasms I'm having over whether to save the original, Art-Deco doorknob and plate from the back door when I replace it with something that's not mostly glass.

Even with the sleep I lose over such things as whether the wallpaper for the kitchen ought to be 1950's vintage repro or 1940's, it still makes a nice change from primary leptomeningeal melanoma and Ted Kennedy's brain tumor.

Today I got yelled at 4.3 times in twelve hours.

And it didn't bother me a bit.

I've grown inured to the yelling-at that some doctors, pharmacists, other nurses, house supervisors, patients, and facility management specialists (read: Janitors) do.

I used to bristle. I used to take offense. Occasionally I would vent.

Now, if the person doing the yelling is doing it face-to-face, I imagine that person covered with banana pudding. If the person doing the yelling is doing it over the phone, I giggle. Audibly.

Because, you see, *everybody* yells at nurses. We get caught between the proverbial rock and steel plate, and we are the recipients of everybody's frustrations. Toilet broken? Yell at the nurse. Did payroll fuck up your overtime again? Yell at the nurse. Can the pharmacist in Alabama not read your handwriting? Inform the nurse stuffily that that's the same DEA number you've used for the last five years. 

Then listen to the nurse (well, *this* nurse, at any rate) giggle helplessly at your stuffiness.

This is the time of year when I face both burnout and brilliant ideas simultaneously. The time I don't spend updating the blog is time I spend out weeding the garden and grooming the dog. This time of year, I'd like nothing better than to get fired for smarting off to somebody, just so I could work for triple or quadruple what I'm making now, with plenty of time off to weed and groom and just lie in the sun. I know I won't feel that way come January, though, when things are cold and rainy, so I mostly hold my tongue.

And giggle. Audibly. Audibly, but not offensively. Because, honestly? Not one damn thing I got yelled at today had anything to do with me or my nursing. One was a doc who was pissed at a pharmacist; the next was the pharmacist who was pissed at the doc. The third was a patient who had an entirely different nurse. The fourth was a manager who got annoyed that I actually followed hospital policy (and they wonder why I'm such a loose cannon) and did what I was supposed to do.

Keep your yellow "Live Strong" wristbands. You can have your pink ribbons and red dresses and grey ribbons and God knows what else. I am wearing, from here on out, a smiley face. Giggling is my new cause.

You may be next.

Take *that*, work frustrations.

This post was going to be titled "When Morons Attack".

But I ran a mile.

Then I lifted weights.

Then I stretched. And did some yoga.

And now I'm cheerful and warm and relaxed and no longer concerned with morons. Instead, I think I'll go buy some doggie nail-clippers and then hang out with Max for the rest of the day.

Spring. Sprang. Sprung.

This is the time of year when it's hard to go to work. The weather is beautiful, the birds are singing (did you know male mockingbirds will sing all night long in search of a mate? They will. Especially the ones in my back yard), Max is wanting belly-rubs, there are music festivals and art shows outside in the sun, and I'm stuck inside with patients with disseminated vasculitis and brain stem tumors and stupid, stupid families.

The past few weeks have been a sojurn in the Land of the Tiny-Brained.

For instance, if you have a family member with a fistula that communicates between esophagus and trachea, and that person is unable to swallow in the first place, and has a tracheostomy to make it possible for them to breathe without choking, and the nurse has said six times in the last three hours that you are NOT to FEED that person, why on earth would you try to make them eat oatmeal?

I spent ten minutes deep-suctioning oatmeal out of the guy's lung.

Likewise, if you have the nastiest chest wound in the history of ever, and you're going for your fifth surgery to debride it, and you've been told over and over not to eat or drink anything preparatory to surgery, why would you tell the anesthesiology resident who comes to consent you that, by damn, you *are* going to drink this Dr. Pepper, and he's not going to be around if and when you get aspiration pneumonia, so he shouldn't worry his pretty head?

 Just because you had an LPN license for six months twenty-five years ago does not mean you necessarily know more about anesthesia than the guy who does it for a living.

And, finally, if you have the nastiest stomach wound in the history of ever, one so bad that you had to stuff washcloths in it to keep the pus from pouring out and getting all over your clothing, why would you undo the work of two surgeons, a wound-care nurse, and an hour of OR time to undo your wound-vac dressing and stuff the wound with washcloths again?

"It needs air to heal" is not an acceptable explanation.

I'm not even going to tell you about the disseminated vasculitis patient who screamed. Constantly. And cried and whined and hollered. Not their fault; vasculitis in the brain makes you completely crazy. But still, it's difficult (note ironic use of understatement!) to deal with a screaming, crying, whining, abusive patient for twelve hours straight when the other three people you're caring for hit the call bell Every. Twenty. Minutes. Without. Fail. All. Shift. Long.

And this was, comparatively, a good assignment. The other patients on the floor were worse.

Nobody wants to go to the hospital. No sane person wants to spend any more time than necessary indoors during the six weeks of the year when the weather here isn't actively trying to kill you. That, unfortunately, means that the only people in the hospital right now are both very, very sick and completely nuts. And, according to a newly-delineated Universal Law, the amount of shit you get from a family is inversely proportional to the total number of teeth in the room.

I was considering throwing up my hands and becoming a bank robber yesterday. Or a train robber. On a pink Vespa scooter. With pink leathers and a white full-coverage Bell helmet with a reflective faceplate. And saddlebags with fringes. 

The pharmacist on call looked at me thoughtfully and said, "I'm a little concerned that you seem to have thought this out so thoroughly."

Well, yeah. The one thing that's stopping me is the knowledge that if you get caught robbing trains, your time inside doesn't end at 7 pm. 

A Day In The Life

Getting Better All The Time

There's been an outbreak of what I'm convinced is norovirus at work. Norovirus is That Nasty Stomach Bug family of viruses--the sort of bug that incubates in a day or so and takes a day or two to resolve. Since all nurses work some degree of sick most or all of the time, it makes sense that something that could only be eradicated by bleach and scrubbing might be lurking in the viral soup that is our hospital.

My turn was yesterday. I was pretty damned puny, but Chef Boy brought over bread and ginger ale, and I ate soup and laid on the couch, making noises like the cartoon woman in the introduction to "Mystery!" Today I am better, though not enough better to, say, climb the Matterhorn or work out. I shall (she says, determinedly) finish the laundry and nap.

Sky of Blue, and Brain of Green

What makes your brain the color and consistency of pea soup in about three days?

I wish that were a riddle. Instead, it's something that happened to one of my patients (now dead). Mayo took their sweet time over the biopsies and sent back a detailed pathology report that said, in essence, "We have no fucking clue. Try Hopkins."

It's been about five years since we had a patient who had a true God Only Knows diagnosis. That last one garnered laurels for a couple of fellows in neurology who presented a paper on the patient's decline. What it did not get anybody was a name for that person's condition, a cause, or a cure. 

Dr. Dink, the psychiatrist who writes my prescriptions for Happy Brain Pills, said, "Well, those are the interesting cases, you know." Yeah. Interesting. Because it's never any fun at all when somebody gets better. That gave me an insight into the shrink personality.

Fixing A Hole

Finally, a non-neuroscience happy ending. 

A couple years ago we had a patient with a big hole. I mean a *big* hole, the sort of thing you could easily put your head in. Mediastinitis, it's called, and it's an infection in your chest that's usually caused by rupture of one of the organs there. In this person's case, it was the result of surgical infection. The hole went from the middle of the breastbone down into the belly and tunnelled every which way. It was so badly infected, necrotic, and generally nasty that it took weeks and weeks to heal, and we had to repaint the room after the patient was gone--it smelled that bad.

He's fine. Two weeks ago, he came breezing in, more than a hundred pounds lighter and quite fit, totally recovered, and with only a half-dollar-sized, puckered white scar on his chest to show for his ten weeks of hell. That was nice.

Run For Your Life If You Can, Little Girl

In non-nursey news, I bought a treadmill. I am totally, totally in love with my treadmill, to the extent that I get up a bit earlier every day than I used to and hurple along for a few minutes before I get ready for work. It's quite fine. The cat has no opinion on it, while the dog looks at it with deep suspicion and loathing, but does not actually run off when I start it up. 

The damned thing weighs 300 pounds and has a control panel that looks like it belongs on the bridge of the Enterprise. I haven't yet discovered how to make it do laundry, but it does nearly everything else. It took two guys with experience in the process an hour and much multilingual cursing to put it together and get it working. Man, I love my treadmill.

You Like Me Too Much

I've finally had--and gotten rid of--my first patient-stalker.

It happens to everybody at some point: you take care of a patient who decides for some reason that you're the be-all, end-all, and that (to add to the weirdness) they simply must hang out with you outside of work and be your babydoll. This probably happens much more often to people in the brain business (be it psych or neuro), but hadn't as yet happened to me. 

Well, now it has. A traumatic brain injury will make a person think anything's possible. Thankfully, a combination of carefully-timed hiding in utility rooms and non-diplomatic "go aways" has made that patient, well, go *away*. 

If this ever happens to you, be aware: It's not always something you can predict or prevent. Especially with brain-injured patients, there's not going to be a way to control their reactions to your actions. The simple act of changing a dressing can, for them, become a declaration of your undying devotion. The best way to handle it is the way you'd handle a recalcitrant child: with firm repetition and without panic.

The End.

How to have a good stay in the hospital, or:

Driving your nurse crazy, in three hundred eighty four thousand, six hundred forty-two easy steps.*

Adopt a lofty tone. Nobody here will remember how important you are. Therefore, it's crucial that you remind them at every possible opportunity. Condescend as often as possible. Refer to your nurse as "The Girl". Refer to every female doctor as "Nurse"--they love that. If you can, work in a shadow of doubt about your nurse's or doctor's competence. Ask repeatedly if they've "ever done this before."

Don't forget to bring your four-page, single-spaced list of demands. Make certain that you've listed all of your drug allergies, even if they're not actually allergies, on the first page in bold type. List all of your previous surgeries on the second page, with editorial comments such as "spent six weeks in hospital--doctor's fault". On the third page, specify that you be transferred to the "VIP floor" only. The fourth page will have plenty of room for you to note your food preferences, the fact that you don't want to be served on plasticware, and that, regardless of your latest test results, you refuse to be put in isolation.

Refuse to have an IV placed in a spot where it is least painful and most convenient for all involved. If necessary, lie about previous surgeries to that extremity in order to manage this. Nobody reads your history, right?

Be noncompliant with treatments. If you can't turn off or change the settings on the IV pump because it's locked, the next best thing is to unplug it and leave it unplugged until the battery runs down. If you've been ordered to remain on flat bedrest because of a cerebrospinal fluid leak, by all means sit up as often as possible. Conversely, if you've been ordered to walk at least three times a day, make as dramatic a production as you can of getting out of bed. Moaning and groaning is required; sagging to the floor whimpering is optional but effective, especially when done in front of your family.

One very important note about treatment noncompliance: If you are diabetic, ensure that your family brings you huge amounts of sugary food. Hide it in your room. Hide it in your bed. Hide it on your person. The Girl needs exercise, which she will certainly get when your blood sugar comes back at 1300 mg/dl.

Work the occasional old-fashioned derogatory term for racial minorities into your conversation. Those People have to be reminded where they stand, after all. The Girl and the other nurses will be glad you're reinforcing the social order, even if they don't act like they are.

Invite all your friends, fellow gang members, remote family connections, and strangers on the street to come visit at all hours. Instruct them to talk loudly on cell phones in the hallways. Send whatever small children they bring into other patients' rooms. The pre-teens should be told to ask for ice cream and sodas, repeatedly, at the nurses' station.

If you can't get what you want, call your doctor at home. This is particularly effective if done at 3 am, and if your doctor doesn't have admitting privileges at the hospital where you are. Bonus points if you have a doctor who'll call the nurses' station and bluster.

Speaking of bluster, if you have a family member who's a doctor, use that person the way God intended: To attempt to bully the staff of the hospital into changing treatment protocols.

(Special note for those with medical family members: Be sure that if your son-in-law is a staff physician at the hospital, he is the primary physician on your case. It's been too long since the last ethics course refresher; the staff could use the training.)

Remember that medical people, nurses in particular and neuroscience nurses in especial particular, are too dumb to know if you're faking a seizure. A well-timed fake seizure will get you two extra days of Ativan and Dilaudid.

Instruct each and every one of your family members to call the nurses' station every sixteen minutes throughout the day for updates on your condition. Phone trees are for the hoi polloi. Extra points if you can arrange to have several family members call at once during shift change.

If all else fails, barrage the director of nursing, chief medical officer, and police with phone calls. People in management will have a better idea of your treatment needs and activity restrictions, your diet orders and medication regimen, your physical therapy schedule and dressing changes, than your nurse or doctor. 

*I wish I were capable of making this shit up. 

Things they don't tell you in nursing school

There are plenty of books and articles out there about how to survive your first year or two as a nurse. Most of 'em are pretty useful; they cover things like confidence and time management and self-examination, all of which are important. There's always a "transitions" class in nursing school that attempts to cover the same things.

Nobody, though, gives you the real dirt on being a nurse. Here, then, are ten things you didn't learn in school and which will become obvious soon:

1. Constipation: Your own, not the patient's.

Everybody poops, yes, but some of us have to learn to poop less often. If you're working three or four days in a row, your first day off will be spent pooping and sleeping. Accept this and do not attempt to buck the trend. The downside to not getting to poop when you'd like is hemorrhoids. The upside is stronger sphincters and the ability to work through a case of food poisoning.

2. Did something die, or did you just take off your shoes?

If you wear decent shoes (ie, supportive closed-toe-and-heel shoes made of leather), your feet will stink. If you work a full shift in them, your feet will stink to high heaven. Again, acceptance of your plight is key. Soap and water before bed do a lot to prevent both athlete's foot and the death of your bed partner.

3. Bleach is your friend.

The likelihood of getting something nasty splashed on your scrubs is directly proportional to the amount of white you wear. If, like me, you *have* to wear a white coat as part of your uniform, you should buy stock in bleach companies now. It'll subsidize your retirement.

4. You will become more cynical than you ever thought possible.

Look: It's impossible for a human being with a heart to do what nurses do on a daily basis and not become cynical, both about other people and about the universe we live in. Cynical doesn't mean evil; it just means that you're coping with the stresses of your job. I used to feel bad about the sort of whistling in the dark we do until I realized that it's the only way to keep from crying in the face of three patients dropping dead unexpectedly in one day.

5. You will become capable of both more tenderness and toughness than you ever thought possible.

Nurses soothe people. We ease their fears. The number-one thing that we do is educate our patients about what's going on, and knowledge is power. The number-two thing we do is stop pain. Those two things, taken together, will make you more tender and gentle than you ever imagined. Even turning a comatose patient can be done with gentleness, and you'll find yourself doing it. 

Nurses also have to hurt people. It's part of the job. Shots hurt. Dressing changes hurt. (Cue "Cruel To Be Kind", please.) When you're changing the dressing on a deep, awful wound that hurts, you'll find yourself wincing in sympathy--the first few times. Later on, you'll get tougher, but never to the point of cruelty. Change the dressing, get it over, and go on. This is not a bad thing.

6. Coping mechanisms can be good or bad.

I'm not talking about the people who sneak narcotics out of locked drawers. I'm talking about what I've heard other nurses say: "I never drank this much before I was a nurse."

There are good ways and not-so-good ways of dealing with the stress of the job. If you're coming home and pouring six shots of tequila down your throat, either you need a new coping mechanism or a new job. One glass of wine/liquor/beer, though, done properly and with ritual, can ease the transition from Nurse to Real Person. Do not be ashamed. 

If you *are* ashamed, then get a different way to cope. Buy a treadmill and go for a run after work. Get a puppy. Buy some Mister Bubble and use it. Adopt a new ritual.

7. Doctors are (mostly) people, too.

There are some doctors who came here from Planet Asshole. The same can be said of some chefs, some office bosses, and some bowling-alley customers. The majority of doctors, though, are nice, normal people with nice, normal needs and reactions to things. The same doctor who writes insane orders and demands that crazy things be charted does the in-car butt-dance every time she hears "Girlfriend" come on the radio. Remember that.

8. Dating somebody from the same facility is always, ALWAYS a bad idea.

No matter how discreet you think you're being, somebody's figured it out. 

9. Nurses are nice, normal (mostly) people, too.

All but two of my nursing instructors in school went on and on and on about how dysfunctional and co-dependent nurses are. I figured out pretty quickly that the instructors who were down on nurses were no longer working as nurses because they hated the job and couldn't cut it on the floor of even a moderately busy facility. The two instructors who still worked full-time as nurses had a much better, more realistic attitude. 

Yes, there are bitches and bastards. Yes, you'll run into the occasional young-munching nurse. But they're as rare in this field as they are in others, and you'll learn to avoid them the same way everybody else does. For the most part, nurses become smarter/faster/less inclined to bullshit the longer they work. This makes them good people to work and relax with, both.

If one or more of your instructors is pathological about hating nursing and nurses, ignore them.

10. If you hate it, you can always do something else.

Nursing school has a weird vibe: like this is the be-all, end-all, most important and worthy thing you've ever done. It's incredibly, indescribably stressful--more so than medical school, according to several people I know who've done both. It's also wrapped 'round with the whole Ethos Of Nurse. That makes it hard to admit that you've chosen wrong or that maybe you hate being a nurse.

Let me make this totally clear: If you don't feel like you're a fish finally dropped into water, you don't need to be doing this for a living. It's too hard, and the money's not *that* good. At any point in school or in your career, you are certainly allowed to back out and go be a banker. You haven't wasted your own or anybody else's time; remember all that great stuff you learned?

Don't let one bad day or one bad month or semester or year (whatever) make your decision for you, though. If you have a gut feeling you shouldn't be doing this, then for God's sake back out as soon as you can. If your gut is happy, though, and it's your brain or ego that's bruised, keep on. Things will improve.

Change of Shift!

It's here.

(Clever Title)

If you have to get one bizarre disease in your life, one that defies diagnosis and makes doctors scratch their heads, one that'd land you on a not-happy ending episode of "Medical Mysteries", one that would make Hugh Laurie sit outside your room with his chin resting on his cane, don't pick the one bizarre disease with the word "encephalopathy" in the name, okay?

'Cause it would suck. Hard.

"Encephalopathy" means "brain disease". It can be caused by a number of things: everything from kidney failure to liver failure to mitochondrial failure to viruses, bacteria, and fungi have been implicated in the different forms of encephalopathy. "Encephalopathy" is also used as a catch-all term for the "God Only Knows" diseases--the things we can't diagnose except on autopsy.

This has been Encephalopathy Fest Month. Every third person and his brother has some form of brain swelling, sterile meningitis, or GOK disease. What that means for us, practically, is that there are a lot of people with balance and cognition problems getting lumbar taps and having to be babysat so they don't wander naked down the halls.

Taking care of people is a weird business to be in. It's never weirder than when you're split in two (so to speak)--watching somebody go down the drain with astonishing speed and feeling bad about that, while at the same time being pissed off because their drain-circling is accompanied by annoying, time-consuming symptoms and problems. 

Taking care of people on a neuroscience ward is particularly pissing. There's so much that we do in hospitals that's routine--like giving pain medicine or various electrolyte solutions--that can cause symptoms that mimic the progression of disease. I've spent a lot of time over the last three weeks trying to figure out if the person who can't remember her own first name is suffering from a narcotic overdose or simply losing neurons at an ever-increasing pace.

I had a patient go down in a big, scary way. Not in a heart-stopped, start-compressions sort of way, but in a neuroscience nurse scary way: she forgot who her brother was. She forgot her name. She forgot what year it was. She couldn't repeat a phrase I said to her, and kept word-salading everything. She stopped making sense and started making trouble over the course of a shift.

So we stopped her drugs. I reversed the narcotics and benzos. We started one thing after another, tried to get an MRI (no go; as she got mentally less with-it, she became physically more active), tried to get a CT (ditto, even with me in a lead dress holding her hand), got an EEG, did neuro checks every hour, managed a lumbar tap somehow...I finally cracked in a quiet, professional way, after I'd spent two hours dodging punches and kicks while trying to keep her down after the lumbar tap.

And you know what? Every. Damn. Test. Came back negative. There's *something* wrong; there's *something* in her brain that's making it light up like Christmas in New York on an MRI film. But we don't know what it is. Meanwhile, her family is flipping out because she's obviously not right, I'm flipping out because she's a danger to herself and others, and the docs are flipping out because they don't know what's going on.

I've worked with one of our neurology residents now for better than six years. I've never had reason to doubt his competence or his intelligence. I've also never heard him say what he said that evening: "I don't know. I've never seen anything like this before."

So. Don't get a generic encephalopathy, okay? At least get something diagnosable. You'll save everybody, including yourself, a lot of trouble.

Fun Medical Words for the Non-Medical Type: A game the whole family can play!

Ever wish you had a really good excuse for not going to work? Ever wish you had a hellacious conversation starter for that cocktail party? Ever want to drop random words into conversation?

Well this, my friend, is your post.

Observe the wonders of medical terminology and pharmaceutical brand names! To wit:

Mucomyst: No, it's not a faerie land where everyone has bad sinus problems. It's the brand name of a drug (acetylcysteine) that thins and loosens inspissated phlegm. It's also used in cases of Tylenol overdose.

Inspissated: What a lovely word. It means to be hardened due to lack of moisture. Why say your hands are chapped, when you can say they're inspissated?

Whipple procedure: About the furthest thing from squeezing the Charmin you can imagine. In a Whipple procedure, the head (thick part) of the pancreas, the bile ducts, the gallbladder, and the duodenum are all taken out, along with (sometimes) a bit of the stomach. It's not something you necessarily want to undergo. It should be differentiated from...

Whipple's disease: Caused by bacteria, its signs and symptoms include joint pain, diarrhea, and malabsorption. 

Duodenum: Go ahead. Say it over and over: doo-WAH-duh-num. Doo-WAH-duh-num. Your duodenum connects your stomach to your....

Jejunum: That's the central part of your small intestine. The Doo-WAH-duh-num is the first bit and the ileum (which sounds like a town in Greece) is the last.

Zyvox: I wish, I wish this were the name of a Galactic Emperor. Unfortunately, it's not: it's the name of an IV antibiotic. Oh, well.

Melanoma: Sounds like a pretty girl's name, but is actually a nasty, invasive, scarily common form of skin cancer. Do. Not. Want.

Glioblastoma: Another pretty word for an ugly thing: in this case, it's invasive, incurable brain cancer. 

Frenulum: I love this word. It's the name of that little bit of tissue under your tongue (there's another under your upper lip, and several more here and there) that connects your tongue (etcetera) to the bottom of your mouth (and so on). 

Cachexia: Pronounced with a hard "K" sound rather than a "ch" sound. It means "starvation."

Stapes: AKA the "stirrup" bone in your ear. Technically, this bone is an...

Ossicle: a bonelet. No, I'm not making that last term up. "Ossicle" equals "small bone". If you have icicles on your ossicles, you're in deep trouble.

Buboe: Save this one for when you really need it: a buboe is the swollen lymph gland that accompanies bubonic plague.

The laws of Nature have been temporarily suspended. Please do not adjust your set.

It snowed yesterday.

March in central Texas is not a time when you'd expect snow, but sure enough, there it was. As I passed through the little nothing towns betweeen work and home, the snow fell harder and thicker and wetter, making for a bad case of CSS (Can't See Shit).

Max was outside when I got home. He hates rain and goes all Sarah Bernhardt on me when it thunders ("I can has snuggles? KTHNX.") but loves the snow. He was zipping (well, as much as a 100+-pound dog can zip) around the yard, making like a snowplow with his schnozz. If it hadn't been so dark, I would've gotten a picture.

In other news, I can hurt myself creatively. I know this will come as no surprise to those of you who are regular readers.

I fell the other day at work. I mean dropped to the floor without warning, without the chance to even *try* to catch myself, without even the barest hint of grace. 

It was a clean, non-slippery floor. I found the one thing within sixty square feet that would've caused me to fall over, and promptly stepped on it. And fell over. Like a short tree made out of sandbags, I toppled.

If the bruise on my leg weren't enough, I now have a nasty sneezy head cold. I don't feel bad, exactly; just disinclined to move fast. I'm sneezing, did I mention? And did you know that it is entirely possible--I have just proved this to myself--to bruise your own soft palate by sneezing convulsively several times in a row? I think I might've bruised my right tonsil as well, strange as that sounds. It didn't hurt, I sneezed a bunch, and now it hurts.

Then there's the bruise on my shoulder. I got that one in an interesting way, by lifting a patient who can't use her legs. We'd tried to get her back to bed with a two-person lift, but whatever bizarre thing she has going on in her brain (not my patient, so I don't know details) has taken both her legs and her sense of balance, so the two-person lift was a no-go. She swayed and buckled and the gait belt wasn't doing the job. Being safety-minded, I did a squat-lift to pivot her from her chair to the bed.

I didn't realize that her neck was as weak as her legs. Her forehead hit my left shoulder with an audible thud. Now I have a nice egg-shaped-and-sized bruise there, right above my collarbone. The patient is fine.

Finally, this news flash: Some Doctors Can Be Assholes. 

I don't know what it is about this particular guy, but every time I deal with him, things go from being normal to being a total clusterfuck in about five seconds. I'm not the only one with this problem, so I figure if the only common denominator is him, it's him. We'd had a run-in about a year ago involving his inability to follow directions in order to reach another physician and then being insulting about it, so I was primed.

What he wanted this time was a series of genetic tests so obscure that it took our lab manager the better part of a day just to figure out where to send the blood. I mean, when *Mayo* doesn't do a test, you know you're looking at something weird. Specialty Lab Of Fredsville faxed us the proper requisition, which contained lots of numbers and capital letters in strings next to check boxes somebody was supposed to tick off. The resident didn't know what to make of it, and I was totally flummoxed, never having heard of the genetic condition the attending wanted to test for, let alone the test for it.

So, when Attending With An Attitude showed up on the floor, I (waited until he wasn't busy and then) asked him to (pretty please) fill out this form so I could send it to Specialty Lab.

Whereupon he threw up his hands, sighed heavily, and made a comment about nurses being stupid. I stood there like a bump on a lump while he ticked boxes and scribbled his name at the bottom of the requisition, considering whether beating him to death with a chair was something I had the energy for. I decided against assault and battery and for simply ignoring his comment.

And you know what? With inveterate assholes, ignoring their comments is the best way to piss 'em off. He got a few more jabs in before he left the floor, some of them personal and not related to any clinical situation, and I just...pretended not to hear. At all. He was both annoyed and deflated when he left. I don't think we'll have any more trouble from him for a while.

God, that was fun.

An apology.

Dear Nursing Students Who Were On Our Floor Two Weeks Ago:

I'm really sorry about your last rotation with us. If I'd known my coworker Peevie McGripersons would be there, I would've taken each and every last one of you on, like a string of ducklings, to save you from McGripersons.

I probably should've realized there would be problems when I heard McGripersons berating a student about how Medication Sheets Are A Legal Document, Like Charts Are. I mean, yeah, you copy down all the meds your patient has and you learn all about 'em before you come in the next day, right? It's probably still not a good idea to go with your hand-copied notes when you start to pull meds, because something might've changed--but there's no reason for you to get excoriated about Legality and License and So On because you're inexperienced. 

It would've been better if McGripersons had said something like, "Oh, you copied everything? Damn, you're dedicated. Snag the med sheet out of the chart, willya, and let's go yank some pills out of the machine, eh?"

I *knew* there were problems when I watched one of you pull up a couple of different meds into the same syringe--something we do all the time--and watched your face change when it became obvious that the meds weren't compatible. Not one of us hasn't cursed inwardly when we've seen incompatible solutions crystallize in a syringe. Not one of us hasn't grumbled our way back to the med cart to grab two more syringes and re-up the meds. It happens all the time. We just don't give the crystallized solution, y'know?

But to hear McGripersons, you'd've thought the world came to an end. 

Seems to me that a better way to have done it would've either been to have warned you that Solution A isn't compatible with Solution B *before* you pulled 'em up, or to have sympathized and explained after it turned out they weren't. I don't see that you needed to be subjected to a pharmacological lesson *after* you'd screwed up, which does nothing to help you figure out what the hell is going on and a lot to make you feel an inch tall.

And, finally, I apologize for not stuffing Peevie's limp body down the laundry chute after he told one of you that you weren't to do *anything* without him there, because A Chart Is A Legal Document.

Yeah, Peevie, we know. There are better reasons, though, both to follow a nursing student pretty closely and to chart completely and correctly. Legality is a very minor concern.

First of all, your average student is scared to death of your average patients. They're not people to the nursing student; they're huge bundles of foreign problems who are likely to die suddenly while gasping out that it was all the student's fault. Having an experienced nurse at your side makes you a much less scared student (unless the nurse is Peevie McGripersons, that is).

Second of all, other nurses--and the occasional doctor, alors!-- read your charting every day. They do so to figure out what's been going on with the patient and to make sure they don't reinvent the wheel. Charting completely and correctly is about *safety* and *information* more than it is about legality. Yes, good charting will save your license in the event you're sued--but it's much more likely that it'll save your patient some trouble. Other people need to be able to read an informative, intelligent chart to decide if that numbness warrants reassurance or a call to the doc.

Guys, on behalf of my other coworkers and decent, humane nurses everywhere, I apologize for Peevie and his ilk. Please don't be scared away by one jerky nurse. I promise that I'll steer you away from him in the future if you'll just come back. 

And I promise, too, that you are not the idiot McGripersons made you out to be. You're inexperienced, yes, but that does not in any way equal stupid. You've gotta be smart and hardworking to have made it this far, okay? What remains is more hard work and a little more time with sick people and their pills, and you'll have it made. You may not feel confident until you've been a nurse for a couple of years (I didn't, and I don't know many people who did), but it'll come. Just avoid the McGripersons of the world in the meantime. 

Sorry, guys. I really am. Come find Auntie Jo next week and she will set you up, okay?

This was my day.

Nurse Jo Presents: The Top Ten Incredibly Stupid Ways To Fail Utterly To Kill Yourself.

Number Ten: Getting into a car with a soppy-drunk driver.

Drunk drivers rarely (sadly) die. They're usually too relaxed. The same can be said for their passengers, but only because the passengers are injured in ways too interesting for the surgeons to let go. 

Number Nine: Tylenol overdose.

Number Eight: Picking a fight with that aggressive guy at the bar.

Closed-head injuries are never fun. Closed-head injuries sustained because somebody whanged you head-first into the bar multiple times are even less fun.

Number Seven: Car surfing.

Number Six: Setting yourself on fire. More than once.

Look: You wanna die? Ask me. I can give you plenty of great, fool-proof tips. You wanna torture your loved ones? There are better ways of doing that than dousing yourself in some inflammable liquid and lighting a match. The general rule of killing yourself is as follows: If you can do it more than once, you're not doing it right.

Number Five: Falling (or diving) off a high place (or into shallow water) head-first.

At best, you'll end up a paraplegic with a lot of hardware in your spine. The paraplegic part is totally manageable; the hardware part less so, as that stuff eventually ends up working its way out of your spine and through your skin. Plus, given the time you'll spend in the hospital, you'll end up with lots of fun drug-resistant infections and cool bruises and scars. And then there's the whole "not walk again" or "not walk, *plus* not use your hands again" thing, which really kind of sucks.

Number Four: Popping wheelies on a busy highway on a rice-rocket when you're an inexperienced rider.

Number Three: Cocaine or heroin or whatever underdose.

If you're really serious, try something there's no cure for, like polonium or arsenic. Wanna end up in diapers with the mentation of a toddler and a fondness for cuss words? Heroin/coke/whatever is the way to go. If you want to really punish the people who love you, go 'head and have another line/syringeful/whatever.

Number Two: Have a poor understanding of trajectories and ballistics.

And the number one incredibly stupid way to fail utterly to kill yourself?

Stick your head in a combine.

Proof that I look nothing like my mother's side of the family.

My mom's mother on her wedding day.

Product Reviews: Stuff That Works edition!

Everything I'm reviewing this time actually works as advertised. Amazing!

Dirt Devil Corded Hand-Vac:

It's big. It's loud. It has two speeds; if you plan on using it on "high", invest in some good earplugs. It has a spinning brush and a clever way of storing the crevice tool. It has an immensely long cord. And it took all the damn dog hair off my car seats yesterday with no fuss whatsoever.

I briefly considered going as high-toned as one o' them $150 Dyson cordless hand-vacs, but the customer reviews convinced me otherwise. The charge on a Dyson lasts five minutes; every review I read said, "If you need to be vacuuming longer than five minutes, you need to get out the full-sized vacuum." Bah, humbug. For $30 at Target, you can get a hand vac--corded, it's true, but with such a long cord that it hardly matters--that works better than the upright I own.

Verdict: A+--but don't use it around your Chihuahua. The suction is quite strong.

Oster Classic Beehive Blender:

Another Target purchase, this time because my generic six-speed blender had started to complain and smoke every time I tried to make gazpacho. The Oster has two speeds: On and Not On. It also has a Pulse feature, which is On on Steroids. 

The base of the thing is shiny metal, and the top is very thick, confidence-inducing glass. When you put it together, everything fits in to everything else with nice solid clicks. The single toggle switch on the front moves up and down with a good, positive snap. And when you turn this sucker on, it has 600 watts of power (which I think is more than the local public radio station) and really works. You know you've got a blender when you use this.

Verdict: A+--but leave those earplugs in. It's noisy.

M.A.C. Loud Lash Mascara in Brown:

Beloved Sis sent me many tubes of mascara to play with. This is my so-far favorite.

M.A.C. is one of those cosmetic companies that cause people to develop lifelong obsessions. Their color range goes from the sweetly neo-punk to the outright drag-queeny, but everything tends to stick like the Devil and not wear off. This is true of this particular mascara: it does not come off.

Better than that, though, is the fact that it doesn't clump. You can put four coats on (which I do, liking a nice drag-queeny set of top lashes) with nary a problem, though a quick comb-through is never a bad idea. The formula dries stiff and rather shellac-y, but that's a small price to pay for something that works even better than Rimmel, my previous go-to mascara. 

I have no clue whatsoever what this costs in the real world. Whatever you spend on it, though, plan to invest another five bucks on makeup remover, or you'll walk around for days with huge drag-queen lashes on an otherwise bare face.

Verdict: A+, but best get some cold cream.

It was just another day until I got stuck in the elevator.

I had to wait the other day to get lunch. And I mean *wait*--the person to whom I felt comfortable handing off the guy who wasn't clotting and the other one with the weird tubes going everywhere was dillydallying and shillyshallying around about getting through *her* lunch.

So, by the time it was time for me to chow down, the cafeteria had closed. I figured a quick trip down the street to Holy Kamole was in order--their cafeteria stays open all day and usually has pretty good food. Out, then, I went, into the big world.

In order to get to Holy Kamole, you have to pass a McDonald's adjacent to a lot where every homeless person in town hangs out. There are also a number of aggressive and persistent pigeons. As a result, the city has put up signs saying not to feed either group.

There are regulars at the lot. One of them is That Guy Who Moves Things. He's got something seriously wrong with his worldview, and the way he deals with it is by moving things. Not much, just a few inches to the right or left or forward or backwards, depending on what the voices are saying. He's been there for years, he's harmless, we all know him. He's as much a part of the cityscape as the pigeons.

I discovered as I cut through the lot that That Guy Who Moves Things had become That Guy Who Moves Things, Then Without Warning Lunges At You And Screams. Between him and the toothless old dude feeding the pigeons, it was an adventure getting to Holy Kamole. I was dodging Lunging Screaming Guy and aggressive pigeons the whole way.

When I got to HK, I stood in line for a minute. I asked the person serving for a plate of delicious whatever-it-was and some what-the-hell as a side. She stared at me as though I'd grown three heads, and then rounded on the person behind her (who was just trying to refill the bins of food on the steamer table) and began screaming obscenities. The other woman responded, and pretty soon we had a full-fledged Ladies In Hairnets shoving match going on. 

The weirdest thing about it was that the other people in the serving line simply continued on with their work as though two of their coworkers going at it hammer-and-tongs was not a new thing. I eventually got my Delicious Something and Sides and headed for the cash register.

Where, apparently, I resembled a particularly fascinating space alien. It took me waving money in front of the guy behind the register to get him to quit staring openmouthed and charge me for my food. Not sure what was going on there.

Back, then, across the lot, past the Newly Lunging And Screaming Guy, through the cloud of increasingly pissed-off and freaky birds, dance across the street in front of oncoming traffic, and back to La Schwankienne, where I boarded the elevator.

Which creaked its way to the third floor, grunted, and died.

I blinked. I hit the buttons. I tapped my foot. I gave up, resigned myself to my fate, and decided that at least I could have a nice quiet lunch on my own, there in the broken elevator. I opened the box of food.

And the elevator juddered into life and took me to my floor.

Gracious.

You know you haven't blogged in a while when Your Mom sends you an email asking if everything is okay, or if you've grown tired of Teh Blog, or if you've just up and quit. 

Aside from having to call security when a confused, belligerent patient left the floor and tried to take a swing at me as I was stopping him from leaving the hospital entirely; and having to retrieve another confused patient from the cafeteria at Holy Kamole down the street; and dealing with Obtuse Russian Pathologists; and having a patient nearly tank because of low blood levels of calcium; and going hither and yon all over La Schwankienne Hospital and Holy Kamole, because everybody's out sick, it's been a quiet couple of weeks.

Probably the most interesting assignment I've had recently was taking care of a guy with air in his head--pneumocephalus--resulting from a fall in which he cracked his skull. Normally it wouldn't be a big deal to handle a patient with that, as symptoms are typically mild and resolve in a couple of weeks. 

Trouble was, he didn't speak much English. And he came from somewhere so far back of beyond that we didn't have a translator--not *one*--that spoke whatever it was he spoke. Considering that Translation maintains a stable of people who speak everything from Spanish and Mandarin to Romany and sixteen or so different Indian dialects, that's quite an accomplishment. There was one person (out of the six in the room) who spoke passable English, so she translated the sticky technical terms for me. The rest of my interactions with the entire family were conducted in slowly spoken, simple English with plenty of quick sketches on a sketch pad and lots of hand gestures and facial expressions.

Which, honestly, is one of my favorite parts of the job. If you want to get a taste of different cultures and lifeways but world travel isn't for you, by all means become a nurse. I've had encounters with Kurds, hill people from Vietnam, Lakota tribal leaders, Russian businessmen (scary; that guy had his own security force with him, with bumps in their coats where a gun ought to be), state legislators, national legislators of this and other countries, and people from places so remote that a skyscraper was a big deal. It's a little like the Peace Corps, but with more hot water and fewer body lice.

Make me a Saturday-night drunk, please.

She would have been a Hospital Hobbyist were it not for her late husband having donated ten gazillion dollars to the research center at the hospital. Because he had, she got the white-glove treatment (or as near as we can manage) from the minute she set foot in the door.

Food service dug up some real metal silverware from somewhere, and she got that rather than the disposable stuff everybody else gets. She got a newspaper every morning. And she thought she'd get to direct her own care to a degree commensurate with her husband's donations.

Two out of three ain't bad.

See, I have this philosophy: Everybody, when it comes to actual medical care, is on the same level as the poor bastard on charity care. In other words, it doesn't matter if your Secret Service agents get touchy or your personal assistants don't like it; I'm going to assess you head-to-toe at least twice during the day. I'm going to do those neuro checks every two or four hours, and I'm going to draw your blood even if it means getting you to delay that call to your broker.

Because, quite frankly, you are sick enough (or think you're sick enough) to be in the hospital. You are, therefore, a patient. Not a donor, not a politician, not a celebrity. You are a body in a bed (reductio ad absurdum) which needs diagnosis and intervention, just like the guy next door who speaks only broken English and is here by the grace of God and the indigent referral service.

So. She comes in, she lies down and begins to moan, and I get ready to assess her and fill up the paperwork that comes with an admission.

She didn't want to answer questions. She didn't want to let me check out the incision that was giving her problems. She refused a blood draw twice until I walked in with a needle and a face like grim death. She didn't want to talk to the residents.

What she wanted, and thought she would get, was a narcotic pain pump and plenty of Phenergan for the narcotic-induced nausea. Just enough, you know, to take the edge off and fill time between her Thursday admission and her Saturday discharge (in time for the boots-n-bows charity ball, or some such). Again, two out of three...

There's been a lot of debate here locally about how rich folks get better medical care than poor folks. To an extent, that's true: if you have decent insurance and the money to make up the difference, you have a wider range of choices and much better preventative care than the schlub who works four part-time jobs to barely make rent. But when you get into the realm of the Really Fucking Rich, the people who have buildings and sports fields named after themselves, things start to break down.

See, the problem with being Really Fucking Rich is that the people to whom you have donated money tend to take you at your word. If you say you don't want to be disturbed, they'll not disturb you. If you refuse blood draws, the phlebotomist will be encouraged (usually by someone connected with Patient Relations) not to press the issue. Tests will be delayed until you feel it's convenient for you to go to radiology. Residents will be so cowed by meeting Mrs. MRI Suite that they'll be too shy to do a full assessment.

I read somewhere that an ED attending training residents told them this: "If my wife comes in after a car wreck, I want you to treat her just like you would the Saturday-night drunk in the next bed." In other words, no special dispensation for rank or privilege--you get the same careful attention as the next guy.

The official position of the folks in the carpeted areas is that, while rich donors might get special perks like free parking, their level of medical care is the same as everybody else's. 

That's not true. Their level of care is *poorer*, because Those In The Nice Chairs allow them to pull rank and act like they themselves know best. And mostly, they don't.

The upshot of my three-day run with Mrs. Potsofcash was that I got to have a pleasant chat with the Patient Relations people. Mrs. Potsofcash was upset that I disturbed her afternoon naps to do things like assess her or clear her PCA pump or administer medications. She was unhappy that she didn't get to refused timed blood draws (to check things like drug levels; they're called "timed" because, well, they're sort of time-sensitive). She was peeved that she had to wear a hospital-issue gown to MRI and remove her jewelry for same.

What can you say to that? Her complaint wasn't with my demeanor or my language or my personality; it was with the fact that I was providing care to her as is necessary in a hospital setting.

My response to the Patient Relations person was this: "Um...she's mad because I treated her like a patient in a hospital, is that it?"

God save me from special treatment. And from Patient Relations. And from donors.

Cost/Benefit

Benefits of narcotics:

1. Freedom from pain.

2. Ability to hurple around house without cursing.

Drawbacks of narcotics:

1. Itch.

2. Weird sleeping patterns.

3. Inability to concentrate. Look! A chicken!

4. Itch.

5. Dizziness.

6. Apathy.

7. Short-term memory deficit.

8. Itch.

9. Strange dreams.

10. Inability to drive, do paperwork, file, or handle small objects without dropping them. Don't even think of cooking.

Analysis: Jo 0, Narcs 1. I'm going back to ibuprofen.

Product Review: tramadol!

Ultram: the bomb of all bombs.

Twelve hours ago, I was lying curled up on Chef Boy's bed, leaking tears because my foot hurt so much I was afraid to actually cry, because that would joggle the foot and make it hurt more.

I just walked (after a fashion) from one end of the house to the other without pain.

Tramadol (Ultram, Ultram ER) is the shit, man.

It's an atypical narcotic, which means it won't make you stupid or nauseated and will make you only mildly itchy and dizzy. It's not considered a controlled substance, and in some countries (according to Wikipedia) it can be bought over the counter. (Yow.) We use it a lot in people with post-surgical pain, both IV and orally. I'd heard great things about it from my patients who'd had, say, neck or brain surgery that disturbed a lot of muscles, but I'd never tried it until yesterday.

Mister Happy, the doctor I see at the Doc-In-The-Box, gave me the choice between Ultram ER and Darvocet. Now, if you feed me hydrocodone in any form, I'm goofy and happy and then go off to a sweet, refreshing sleep for, like, sixteen hours. So I wasn't crazy about trying Darvocet, which has a lower side effect profile but approximately the same effect as hydrocodone. Ultram it was, then, and I took my first pill about an hour later. I currently have the maximum allowable dosage swimming around in my bloodstream. I wouldn't drive or climb ladders or dance feeling like this (dizzy, a bit off-center), but I'm functional.

And I can walk. Well, I can hurple along on the side of my right foot (the injured one) and the flat of my left foot, but it's better than hopping.

The Verdict: If you're suffering with post-surgical pain that simply doesn't respond to anything else, or if you've got, say, sesamoiditis that makes you want to cut your foot off, try tramadol. If all you have is a normal tension headache or a sore shoulder, you're better off with ibuprofen (tramadol takes a while to kick in).

PS: The results of the X-ray Mr. Happy took yesterday show that I have more sesamoid bones in my foot than is strictly considered normal. That in itself isn't cause for concern, since most folk walk around with a couple extra or missing bits, but it does explain why I was hurting so badly--more things got knocked out of place and inflamed. Thanks, Mom and Dad, for the creepy genetic combination that led to extra sesamoid bones and a strangely-placed, horizontal wisdom tooth under my right cheekbone. You guys rock.

La-dee-dee-dum-di-dum-dah...feelin' stabby!

I had meant to sit down tonight and write an amusing story about all the cool stuff I've seen over the last couple of weeks: Hypospadias repair! White matter degeneration! Traumatic amputations! Wife of prominent politician with major paranoid fugue episode! Person run over by truck! Talking to a dude in X-ray who got run over by truck!

But instead, I find myself musing on feeling stabby.

I feel stabby because, as I should've known, the curse of Shared DNA has hit yet again.

My Beloved Sister is seven years my senior. I've been able to watch and learn as she goes through various life stages. Up to now, the educational value of this exercise has been borne out in my choosing entirely new ways to humiliate myself, worry our parents, or annoy others. I never knew that I would be finding new ways to be clumsy as well.

See, MBS went through a clumsy stage. I believe it was when she was about my age that she either got poison ivy all over her body after wrenching her back, or when she fell off a stepladder and narrowly missed the window. Or maybe it was when she nearly shattered her cheekbone in the bathtub. (I can't recall; the stories are many and my brain cells are few.) Either way, I had plenty of warning that That Clumsy Stage would soon be happening to me.

I figured stepping on a needle was an accident that could happen to anybody. Right? Right.

Not so much stepping on a needle and then, two weeks later, getting sesamoiditis in the very same foot. The two are not connected. The sesamoiditis and my tipping over and bonking myself on the head in the shower, however, are. As is the attempt to recover from bonking myself on the head in the shower and thus allowing the handheld shower head to turn wrong-way-up, spraying the ceiling of the bathroom and all of the bathroom's fixtures and floor with hot water.

Chef Boy, in answer to my desperate pleas (because sesamoiditis really fucking hurts a lot, as in the worst pain I've ever had) brought beer over. He did not go into the bathroom. He'll read this later, so the jig will be up, but it'll be up after he's gone home and I've barred the door so that the concerned officers of the law he will send for a home check will not be able to get in.

Meanwhile, I'm going to limp to the kitchen and get an ice pack.

Moral of this story? Don't get sesamoiditis. And if you do, don't be clumsy into the bargain.

I Pity The Fool: A Team versus B Team

Movin' Meat has a post up from a week or so ago about what it's like to work with the B Team of nurses.

It got me thinking about the differences between the B and A teams. I've been travelling a lot this past month to different units as staffing gets and stays wonky, and I've definitely had to adjust to the B teams on my own and other units. (Everybody thinks they're on the A team, but I think perhaps I'm not too far off-base with my thinking.) Some of the differences I've noticed:

1. With the B Team, shit simply does not get done.

Illustration: Two weeks ago I floated to another unit. Two hours prior to shift change, one of the day nurses had called in, and the night charge had not called anyone else to try to fill the spot. That's the charge's responsibility, working in tandem with staffing, at our facility. So I showed up, the floor was short-staffed as hell, and we all started with eight high-acuity med/surg patients.

Illustration Numero Dos: While on yet another unit, I got report on a postop patient who had a hemoglobin of 6 and a crit of 24, a blood pressure of 80/48, and a temp of 94.3F. The reporting nurse said, "You'll have to run two units of blood, stat." Uh, no, I replied, since the patient doesn't meet transfer criteria; you'll have to be the one running the blood. "But this guy's been down here four hours already, and I have two more patients coming in!" was the reply. (crickets...crickets) Quick cluebat: If you're postopping a patient for four hours, and he's your only patient during that time, and he's not stable, you have time to run blood. No, really. You do. Trust me.

Illustration Number C, or How It Should Be Done (The A Team): One week postop, a guy who'd had a radical prostatectomy showed up on the floor hemorrhaging from his penis, sweaty, with a temp of 95, HR 126, BP 90/50. By the time the resident had been able to cut out of surgery (half an hour later), I had drawn a rainbow of labs, typed and crossed two units of blood, started a saline bolus, administered a total of twelve milligrams of morphine for his excruciating pain, and started two large-bore IVs. I had a coudet cath set and urinometer at the bedside, along with dilators and lidocaine jelly and Versed.

I could not have done this all myself; the other nurses on the floor did things like start one IV while I did another, called the blood bank to give 'em the heads-up on the patient, and ran supplies back to the room. *That's* the A Team for you.

2. Attitude is everything. With the B Team, the attitudes suck.

Illustration: B Team tech/unit secretary/charge/staff nurse comes in, snaps the heads off co-workers, throws tantrums at the lab and radiology staff, belittles the respiratory therapists, and refuses to provide lift help. She or he spends most of the day on personal phone calls and surfing the Web. There's always a personal crisis that either takes up hours of the workday or necessitates the person leaving early. Best example? A secretary I'm fortunate enough not to work with all that often walked in and announced she'd have to leave mid-morning to attend the funeral of a relative, shot during a bungled drug deal.

How It Should Be Done (The A Team): Everybody on the unit shows up on time, clean, not hung over. Perhaps without the shiny-happy attitude that characterizes Disney employees who are still on the clock, true, but with coffee in hand and ready to work. Personal disputes are relegated to the back burner for twelve hours and cell phones are on vibrate. "Cute Overload" is checked for therapeutic reasons only. This is, thank God, where I work.

3. That certain indefinable something: The B Team Ain't Got It.

I don't know if it's experience (though newbies can certainly be A-Teamers) or perceptiveness or initiative or what, but the A-Team has something the B-Team ain't got. You'll notice that there are some nurses who rarely have patients go bad, unless circumstances are extreme. Some nurses seem always to be a step ahead of the docs when it comes to changes in their patients' conditions. Some nurses rarely if ever have patients who end up with decubitus ulcers or constipated. Those are A team nurses.

4. Humility and the ability to admit when you're in the weeds: See Above.

I work with really, really good people. Therefore, when I'm totally rag-assed and overwhelmed, I can ask for help. When any one of us doesn't remember what the hell a lipase value means or what a particular surgery involves, we ask about it, and nobody laughs. If somebody's in a bind with some procedure or other, or doesn't remember exactly how to level a ventriculostomy, we all are willing to help. And we're not afraid, any of us, to admit that there's somebody better at starting IVs or running NG tubes or putting in a catheter.

God help the nurse who works with the B team: she's on her own.

5. Finally, professionalism and calm: Not To Be Found on the B Floor.

Illustration: Fed-up attending throws temper tantrum at nurses' station. Charge nurse responds by getting in his face. Situation escalates. Nasty words fly. People start waving their arms around. Security is called to de-escalate the fight. (Yes, I've had a fun month, thanks for asking.)

How It's Done On the A Team: Fed-up attending throws tantrum at nurses' station. All the nurses stand around watching until he runs out of steam, then charge nurse remarks calmly that she's glad Attending feels the same way we all do, and why doesn't he write an email to the Carpeted People about it, since our complaints haven't made any difference? She then shows him how to operate the email system and thanks him for his concern. No longer fed-up, the Now Abashed Attending apologizes for his behavior. We accept the apology as a group and all go on taking care of business.

No screaming, no freaking out, no security, and everybody involved understands how professionalism was breached, how it was restored, and where we all stand individually and as a group. We're working together rather than at odds with each other.

Even A teams have B days, for sure. Sometimes everybody's a mess, or getting sick, or a mess *and* getting sick. The A teams, though, pull out of the weeds and keep going, while the B team floors fall to hell. I'm lucky enough to have landed on the A-est of the A-teams at our facility, and fortunate to be able to keep up with my coworkers. After the last few weeks, I am not going anywhere else. Ever. Period.

That's the kind of loyalty the A team inspires.

Change O' Shift is up!

Here.

'Twas the day after Xmas; all over the yard

A lone dog was chewing his prime rib bone hard.

He didn't believe when I gave him the bone;
He thought he'd spend Christmas night cold and alone.

But I came home at seven and gave him his treat,
Something better than kibble and raw egg to eat.
What a sight! Big brown dog-eyes with all the white all around,
As he went off to bury his bone in the ground.

Now it's the day after. His joy undiminished,
He searches for bits of the bone that aren't finished.
I have a surprise for him, here in the kitchen;
Two other prime-rib bones. Max's Christmas is *bitchin'*.

A Chrissolstikah Story

We were sitting around, doing nothing except trading stories of Irritating Family Christmas Traditions.

Munoz and Galindo had nothing to contribute, as Christmas Eve in Miami is celebrated (at least in their families) with huge pitchers of sangria and a slightly tipsy midnight Mass. Porchevsky likewise spent thirty years in the USSR keeping his Christmas traditions under wraps--and Possible Detention By The KGB is past irritating and on into scary. The one Jew in the room, a neurological oncology resident from Israel, was ignoring us and reading the paper. That left only the American nominal Christians to complain.

Becka started: "My mother makes us watch 'A Christmas Story' every year on Christmas Eve. I hate that movie. It annoys me. The business about 'You'll shoot your eye out' makes me pray every year that the kid actually does have some horrible accident and has to spend the rest of the movie in the hospital."

"You think that's bad?" responded James. "My family refuses to acknowledge that I'm gay, and I keep getting books on how to meet women, and free subscriptions to online dating services." He slumped in his chair. "The worst was when the family brought three different girls to meet me at Christmas dinner. They probably hoped I'd marry one of them by New Year's."

I knew I had the ace in the hole, so I waited until everyone else was finished, then cleared my throat.

"My father," I began, "has collected over thirty different singing, dancing, light- and motion-sensitive Christmas decorations."

The room was silent except for the scrape of the neuro resident turning pages.

"Every room in the house, and some of the closets, are fucking deathtraps. If you go into the bathroom on the ground floor, there's a wreath that sings to you. The kitchen is inhabited by a plastic Christmas tree that sings and dances and *tells jokes*. You can't cross the living room without something starting to whirr, click, and recite 'A Visit From Saint Nicholas.'"

"The only thing they lack is a dancing Menorah that sings 'Dreidel, Dreidel, Dreidel.'" I finished.

The neuro resident looked up from his paper and fixed me with a stern eye. "That is *not* Kosher," he said. "Hannukah is for making donuts and lighting candles. It is not about dancing Menorahs. Besides," he finished with a wail, "I HATE THAT SONG!!"

"No disrespect meant," I said, "But you have to admit that a toy fat guy in a red suit kicking his feet as he hangs out of the chimney isn't exactly embodying the spirit of Christmas, either."

"In fact," I said, struck by a sudden thought, "The only thing my folks lack, besides a dancing Menorah, is a Nativity scene in which the Virgin sings 'Papa, Don't Preach.'"*

That did it. Everybody, including the neuro resident, collapsed laughing, and then we all had some donuts.

Happy Holidays, everybody. Whether you spend it drinking sangria, praying in an onion-domed church, dancing around a fire, or eating potatoes in various forms, I hope it's a good one.



*I post this thought with some trepidation. I'm sure Dad will start looking for a singing Nativity now.

Blue

A bouquet of roses on the thigh of a woman who'd been a whore in Paris during the second world war.

A shirt and shorts of Japanese history on a pierced guy about my age in for back surgery. "Will the incision mess up my art?"

The names of three children arranged in a biohazard sign on the bicep of a Marine.

Tiny parachuting stick figures and a crudely-rendered plane on the upper arm of a man who'd been a Russian paratrooper during WWII.

Four dots on the foot of a woman with a huge brain injury.

A teardrop on the left cheek of a man who'd been shot in the head.

Two, in the same week: one on the inside of the left forearm, from Monowitz. One, upper left chest, tattooed all at once earlier in the war, from Auschwitz I.

Umpteeen trails of barbed wire around biceps.

A dragon over a mastectomy scar.

The names of four children, all born dead, winding around an ankle.

One very well-padded woman on the chest of a Korean war veteran. He was embarrassed to let me see it, thinking I'd be offended.

I wish I could take a camera to work.

When it hurts, I cuss.

Prodigally. Fluently. Creatively.

When it hurts a lot, I just make a sort of "Ehnnnggaaaahhh" noise

Today, because I know how to have fun, I stepped on a needle. It was large, but there's no such thing as a small needle when it's going through your foot.

It went straight through the ball of my foot, between two bones (thank FSM for that), and tented the skin on top of my foot, just north of the second and third toe space.

The going-through wasn't as bad as the tenting, and the tenting wasn't as bad as the pulling-out. Like babies and bad oysters, that sonofabitch hurt more coming out than going in. But, after I'd made the requisite "Ehnnnggaaahh" noise and sat down heavily on the side of the bed, there was nothing for it but to pull the damned thing out.

[My earliest memory is of looking through the French doors into the dining room of The Old House at my father as my mother rushed me upstairs. Seems I'd stepped on a needle at whatever age it was (two? Three?) and the needle had gone into the bone of my heel. I have vague memories of watching her pull it out as I sat on her lap in the rocking chair, but the strongest memory is of Dad looking up from his desk in the dining room (which was then his study) and seeing his face go slack.]

This was not that bad. In fact, the worst part of it was momentarily feeling the lump in my skin where the needle eye wanted to break through (because I had, of course, stepped on the thing wrong-end-up). Chef Boy was right there, grabbing my arm and keeping me from becoming hysterical. Bravo, Chef Boy.

So, after a moment for contemplation of the possibilities, off I went to see my friendly neighborhood Doc-In-A-Box. The MD entered the room with the words, "How's the seamstress today?"

Everybody's a comedian.

I have a tetanus shot in my left shoulder and 500 milligrams of Keflex to put in my belly thrice daily, as it would be a bad thing (as the MD pointed out) to get an abscess in my foot just before Christmas. Silly me, I thought an abscess was a bad thing at any time.

I also have about 300 ml. of Pommery POP champagne in my belly. Yes, it's only 13:24. Yes, it's a weekday. But dammit, I finished my Christmas shopping after getting a tetanus shot and stepping on a needle; I'll be damned if I face the rest of the day without help.

So I'm weird. What's it to you?

I find plumbworld.co.uk the most fascinating site on the Internet.

Macerators? Power showers? Bathrooms en suite? It's a whole new world.

Things I have learned on my winter vacation:

1. I am a cheap-ass S.O.B. Instead of dropping twenty-eight smackers on an in-drawer knife holder from Williams-Sonoma, I cut off part of the cardboard center from a roll of shelf liner and cut slits into it. Insta-knife-holder, for free, which not only keeps the knives from getting dull, but also prevents unwitting finger amputation! (I also use magazine subscription cards and those "Have You Seen Me?" things as coasters. Yes, I suck.)

2. I am a clumsy mother(shutyomouth) as well. Friend Pens the Lotion Slut and I were exiting the local shop-n-snack when I tripped and fell. Spectacularly. On dry, flat pavement. That was probably the highlight of Pens's trip, sadly.

3. I am not as good a cook as I thought. Friend Pens and I visited another friend of ours, who made such wonderful food I felt thoroughly spoiled in less than 12 hours. Of course, any recipe that starts with butternut squash and 3.5 cups of half-and-half will be good, but still. Plus, Bek and her husband live in a pastoral setting just up the hill from the Brazos and have a firepit. It was a perfect visit. Perfect.

4. Lane Bryant *rocks*. I went there just a few days ago for the first time and was amazed. I'm technically (in Big-Girl Speak) a "tweener"--somebody who can wear a 10, 12, or 14 depending on the cut. LB specializes in Big Girl clothes, and man, does their stuff *fit*. Every shirt I put on fit my lats and shoulders. Every pair of pants and skirt I tried fit my weightlifter's thighs and butt--*and*! you can buy pants with smaller or larger waists, so those of us with a size 10 waist and size 14 butt won't go naked! They're having a huge sale right now, so go. Seriously. I'm still not mentally over not being a size 6 any more, but the staff and clothes at LB made me feel normal and sexy and stylish.

5. My dog rocks more than I ever thought possible. Hanging out with Max for two weeks uninterrupted made me so grateful to have him around. He's smarter than most people I meet and better-lookin' than all of 'em.

6. I am capable of heretofore-unimagined feats of laziness. The first five days of vacation? Couch. Chair. Eat. Sleep. Beer at noon, with pizza. Couch again. The only time my metabolism got off baseline was when Atilla the Cheerleader showed up to make me run and lift weights. I have no memory of my first week off, and it was heaven.

7. I don't miss having a TV.

8. Not working is highly underrated. The most I did regarding work was to visit my work email and read the occasional, short email, then delete it.

9. If they'd pay me regular wages for staying home, I'd consider it.

10. I am going to be very sad to go back to work. Very sad. Especially when the alarm goes off at oh-dear-thirty on Monday.

11. But I still have two more days!

(Insert clever title here)

Change of Shift is up at Doctor Anonymous's place right now. Yes, yes, I'm a couple of days late. What's new?

Announcement:

I am going on vacation for two weeks. That means I may or may not be blogging. So if I'm not here, don't panic; it's just that I'm napping or walking the dog or something.

It's about damn time, too. I think this is the first real (read: no plans) vacation I've had since before I started nursing school. I didn't have ten full days off during those two years, let alone two weeks without homework. The last time I took time off was for Beloved Sister's wedding, which was lovely, but a house full of my family is not exactly relaxing.

So. I'm going to paint my nails. I'm going to wear my hair *down* for a couple of weeks, rather than *up*, and possibly wear high heels during the day, just for fun. I plan to un-stick the drawers in the kitchen and scrub the house top to bottom and rake leaves. Friend Pens the Lotion Slut is coming to visit for a few days, so that'll be a nice interlude. I might even go shopping. And, of course, drink champagne for no reason, eat artichoke hearts, and do silly crafty things with paint and glue.

I'll see you guys in a few days to a couple of weeks. If I remember something that happened that I simply have to talk about, I'll talk about it...but otherwise, Head Nurse will be Nap Nurse until mid-December.

You must immediately click the following link...

To Digital Cuttlefish.

Immediately.

I don't know how I lived without the Cuttlefish's blog for so long.

(Be certain to read the poem linked as Cute-Cute-Cute.)