Siding! Renovation! Gutulousness!

First, a new cat picture. This is, of course, Notamus. He is exhausted after his under-the-house adventures.

It's hard to get pictures of Flashes, because he's rarely this lazy. I have a number of great pictures of Flashes' butt, the corner of one ear, or a totally blank frame, because he's always moving at high speed.

Next, the new sill plate and patch work on the house. You can kind of see why I need new siding.

Aaaaand new windows. Look up there, in the corner of this window. That's a plant. No, it's not growing from the inside of the room. It's taken root in the rotting wood of the window and is sending shoots out into the inside of the window.

A lovely "before" shot of the front of the house. Note the cruddy gray Masonite siding, the bad paint-matching near the front door, and the white Dutch lap siding that was covered up until a couple of days ago. The original siding (the white stuff) is at least a half-inch thick and is solid wood. If I had a million dollars and unlimited time, I would get it scraped and painted and say to hell with vinyl. 

If you look just above the date stamp, where the bloom of the butterfly bush is pointing, you can see where the siding is beginning to pull away from the wall in a big wavy area. This is the east side of the house, where things were in pretty good shape--the north side was losing siding at a shocking rate. I could grab pieces of it and just crumble it in my hand.

And isn't that a nice half-assed patch job on the front stoop? The concrete shifted after a hundred-year flood a few years ago, and there's nothing anybody can do to shift it back. It's kind of obvious that there's a large crack in the concrete, but what the hell--nobody wearing stilettos will ever be able to ring my doorbell.

The new siding is mostly on the front of the house now, though there are a few spots where it's not *quite* done. I anticipate it'll all be finished by Thursday. Huzzah! I'm hoping against hope that new windows and doors can go in late this week or early next. The dust is beginning to bug me.

In the meantime, the nice man from the lumberyard delivered sixteen tons of dimensional lumber and Dek-Blocks and decomposed granite et cetera yesterday. If it doesn't rain buckets today and tomorrow, I plan to make at least a good start on a deck in the back yard. Pictures, of course, will be forthcoming.

The siding job has gone remarkably smoothly. Honestly? I think you get what you pay for, at least to a certain extent, with stuff like this. The company I went with was slightly more expensive than the others, but the project manager has been by a couple of times and has called to make sure it's all going well. The workers themselves, while scary-looking, have turned out to be really nice, really careful craftsmen. The only hang-up so far has been a permitting issue with the city, which takes a minimum of five days to do *anything*, including answer the phone.

It's nice to come home from work and see what they've done during the day. Makes me feel like I've got a real house now, rather than a mungy little dump.

I suppose this means I'll have to start mowing the grass and, you know, actually *cleaning*.

I laughed and laughed at this....

*sigh* >rubs forehead<

Very Simple Requests:

Please do not ride that stallion if you don't know for sure that he can be ridden. Stallions are not usually the first choice for riding. If the stallion can't be ridden, he will almost certainly either sweep you off his back by running under a low branch, or step on your head, or both.

Go to a bar with padded floors if you plan to fall off your barstool.

Do not--I repeat, do *not*--attempt to chew through the tubing that runs from your PCA pump to your IV line. PCAs have an anti-siphon device, which means that no matter how hard you suck on the tubing, you won't get extra medicine.

While we're at it, please don't try to hide Phenergan in your bed.

Or Oxycontin in your purse. I'll find it.

And don't steal the damn DVD player out of your room. I'll walk you down and find it when you're loading up your car. It'll be really embarrassing when I have to look you in the eye, smile brightly, and say, "I'll just take this back up to the room for you."

Helmets are a good idea if you're riding any sort of two-wheeled vehicle. This goes double for motorcycles and triple for bicycles, since the idiots riding bikes these days seem not to be able to stay upright. Or, for that matter, able to avoid running into large metal signs headfirst.

By the way: a 300-cc Vespa is not appropriate transportation on the interstate.

Graduation parties are nice. They're fun. They're not nice or fun, though, when they involve enough alcohol and cocaine to put you into an anoxic state for several minutes.

And speaking of cocaine, please don't try snorting it in your hospital room. I'll find out, and neither one of us will be happy.

If you really *want* to throw your IV pump across the room, go ahead. If you then want to protest to the police that you're ready to get the hell out of this dump, go ahead. We'll transfer you to County, where mama don't play. You'll discover the joys of five-point leather restraints. Have a nice day!

Live poultry is not allowed inside the hospital. Thank you for your cooperation.

Nobody ever said trying to dive from the second-story balcony into the pool was a good idea.

If you're trying to fake having had a stroke, please remember that one-sided weakness will always be present. It will not come and go depending on convenience. Also, please remember that everybody here knows who you are, so you might want to try slurring your words with everyone, not just with your nurse for the day and the doctors.

Likewise, if you're trying to fake a seizure, please be aware that seizures sometimes happen when there's nobody around. They don't happen suddenly, as you're reading a book, just when you hear me open the door. And they generally don't involve bending backwards in the bed and trying to touch your head with your heels. That's strychnine poisoning you're thinking of.

It's probably not wise to ask me out. Ever. My standards aren't brutally high, but "neurologically intact, mostly" is right there at the top of the list.

Sometimes I wonder who lets these people in.

Oh, what the hell. One more:

Saturday Silliness.

Music to rewire switches by: here. (Sadly, embedding is disabled.)

Music to plumb the kitchen sink by:

Music to consider hanging ceiling fans by:

Music to scrub the bathroom by:

Music to say "What the hell" to:

In Which Jo Reaches Out From Under The House To Post.

Notamus, the grey cat, is nicknamed Notty (homonym Naughty). This is for a reason.

He rushes doors. Any door, any portal, any open window is fair game. I had thought that this tendency to run straight for an open space was confined to those open spaces that were vertical, but I was wrong.

Today he went under the house. Not just under the house, but under the house while Felipe, Juan, Frederico, and Alberto were working on it. (Query: Why is every jefe of every leveling job named Felipe? Is it just the crews that work on my house, or what?)

Felipe is a short, taciturn guy who refuses to be shaken by anything. Alberto is young, voluble, and tended to giggle. I heard his giggles all morning through the floor whenever anything struck him as funny, which was about every thirty seconds. Frederico is a sharp-dressed vato with designs shaved into his beard and buzz cut and sparkly fronts on. And poor Juan was the guy over whose back Notamus ran to get under the house. The first I knew of it was a choked scream from the access hatch. Somehow the door to the office had come open, and Notamus had obeyed the Prime Kitteh Directive: If it's open, go for it.

After reassuring Juan that that enormous grey thing that ran past him was only a gato, and a friendly gato at that, I spent five minutes on my belly, head down in the hatch, calling here-kitty-kitty to no avail. I finally said the hell with it and got under the house with the boys, crawled to the very furthest corner of the very furthest row of piers, and played here-kitty-kitty there for twenty minutes as they worked around me.

I gave up after that and figured Notty would come out on his own. Which he did, thirty minutes later. I found him angry and freaked out, hanging by his claws on the outside of the kitchen screen door.

Poor Felipe handed me out of the access and, after taking a look at my front (I'd crawled under there in capri pants, a t-shirt, and sandals) said "Oooohhhhh my God." I think he saw angry letters about open access hatches in his future, but it wasn't their fault my cat went berzerkers.

It's not a bad crawlspace, as crawlspaces go. It's short, of course, which makes turning around and doubling back difficult--especially if you're more than four feet tall and busty and assy into the bargain. It's dry, I only saw one rat skeleton, and it's pretty well-ventilated. There aren't too many pipes to crawl over and nothing dropped down the back of my neck, thank God. 

The best part of all of it was this: When Felipe helped me out of the hatch, my pants didn't fall off. Almost, but not quite. I was pleased that I was able to get out of there with at least some dignity intact.

Oh, and did I mention? (Home renovation warning!)

The siding guys are going to be here tomorrow to start tearing off the rotting masonite siding.

See, masonite is great stuff--in a dry place. Why anybody would try to make siding out of it is beyond me, especially here, where we have two rainy seasons a year, followed by alternating heat and cold. This masonite has lasted, oh, about five years. It's now falling off the house in sheets, which is not good either esthetically or structurally.

So it's getting replaced. With vinyl siding which, thankfully, doesn't look like Vinyl Siding. Underneath it will be some sort of marvelous wrap that deters bugs and moisture buildup, and backing it will be insulation, ditto, that will give my walls an R-value of something like 15. The soffits, fascia, walls, porch ceiling--essentially anything that's wood--will be replaced with this stuff. 

I got a quote on having the rotten wood replaced and the whole place painted, and it came in at a couple grand more than having the joint resided, so residing it is. They're also putting cute little faux-colonial columns up in the front rather than the bizarre wrought-iron trellises (trelli?) that are there now. I'm going to have them save the trelli so I can use them on a deck I'm building in the back.

Also this week, there will be a group of very nice men coming out to reshim the house. It was levelled two years ago when I bought it, but it's shifted since and has dropped about an inch in spots. 

And then, about the time that the siding guys are done working their magic, the window and door guys will show up to replace all the grotty, rotten, unscreened, non-working windows in the joint with super-efficient double-glazed ones. And to put on two doors, both of which will be burglar, zombie, velociraptor, and salesman-proof. It struck me as I signed all the papers (and thus signed away my life, my paychecks, my liver, and my firstborn) that I have never lived in a house in which all the windows opened. This will be a new experience. 

All in all, this place will be way too nice for the likes of me when it's all said and done. 

In further plans, I'll be building a deck in the back (floating; not attached to the house) and constructing a Max-Approved Doghouse, since he really hates the one he has now and would prefer to sleep in the rain. Everybody is hereby invited to Jo's Siding, Window-and-Door, Deck, and Finally Nice Backyard party some time in August, during the hottest part of the year. Make your plans now.

And, if anybody has a few hours between now and then, I could sure use some help hauling dimensional lumber. Just sayin'.

Think you have what it takes to be a nurse? Let's find out!

I've come up with a list of things a person ought to have if they're going to be a nurse. They're not the qualities you'll find in your average Introduction To Nursing Practice course, no--these are real-life skills and personality traits that'll actually help you keep your sanity and your job.

1. A nurse must have the ability to call bullshit without making a Federal case out of it or getting into an argument.

This is a skill that's developed over time. Once, many moons ago, a resident berated me in the presence of a patient. Unfortunately for the resident, he not only flipped his lid, in a "you're going to kill this patient!!" sort of way, but he also was dead wrong. 

What I would do now is take said resident out of the room and tell him once, firmly, that a) he's not to talk that way in front of a patient; b) he's not to talk that way to me again, ever; and c) he read the tubing wrong and was mistaken. Instead, what I did then was try to be a Good Nurse.

I didn't do it over the patient's head, but I tried to somehow make up for the resident's mistake by double-checking everything and then gently approaching him about his mistake. That trick never works with people who are willing to accuse you of incompetence in front of a patient. Calling bullshit immediately, calmly, and without room for argument would've been a much better decision.

2. A nurse must have an unlimited tolerance for management's good ideas.

Which, let's face it, are rarely good ideas. Take, for instance, our TEAM initiative, which I've not talked about much lately. I haven't talked about it much because, frankly, it was a flaming failure and a giant clusterfuck, and pretty much has sunk below the surface.

Anyway. TEAM is an acronym that stood for "Together Everyone Assmunches Management". Or something like that. I don't recall. The purpose of the TEAM initiative was to recognize Stellar Team Players in the Hospital System, especially as it related to Customer Service. 

What actually happened was this: certain players solicited positive comments and notes and surveys (filled out in-house while the patient was still there) and so got good CS reviews regardless of their actual level of skill or competence. Other players made pacts with employees on their own and other floors to fill out surveys and send nice notes to Management whenever one of their bunch did something even vaguely out of the ordinary ("She didn't spit on me when I was lying in the ditch! What a doll!"). 

Management, being intelligent, took only a year and a half to notice that the same people who kept getting really, really crappy performance reviews were the ones who got stellar TEAM scores...and that the same people kept winning the TEAM Player awards over and over. So TEAM quietly went under after Management's attempt to clean it up failed.

3. A nurse must have a tin ear and no sense of smell.

This is becoming much more important as the focus on Customer Service increases. In an attempt to make hospitals less hospital-like, Muzak is now piped in to most patient care areas, all lobbies, and three-quarters of the cafeterias in hospitals across the country. If you think competing television shows at electronics stores are bad, try competing Muzak in the lobby/cafeteria area/outside patio at Sunnydale General. That stuff gets stuck in your right temporal lobe and replays until you want to take a DeWalt to your own head.

Also, in an attempt to make hospitals less hospital-like, a number of places, Sunnydale included, are laying carpet in the hallways and rooms of the acute-care floors. Now, I don't know about you, but my first instinct when it comes to places that people are likely to poop, bleed, barf, and pee unexpectedly is not to carpet it. Cover it with plastic, maybe, or tile, but not carpet. Besides the smell factor, the carpet will hold all the nasty bacteria that you can drop on it, and breed more--and make it nearly impossible to disinfect an isolation room. 

Which means that we're now getting designated isolation rooms. See number two above.

4. A nurse must be unafraid of bladder rupture, megacolon, or severe dehydration.

Let's face it, people: as the economy continues its slow slide into chaos, even nursing will start being a non-growth career. As such, hospital managements will work out ways to get even more work out of fewer people. Some of my colleagues at other hospitals already have designated times for bathroom breaks and little tags on their IDs that allow them to be tracked (just in case they cheat and go pee early, I guess). Pretty soon, just having a big bladder won't be enough. You'll have to court infection and rupture with a devil-may-care attitude and a smile, all while attending to the Customer Service needs of your Guests.

5. A nurse must have a cast-iron stomach.

As the focus on budget increases and costs rise, what's one of the first things to go (besides staffing, supplies, and support)? Food. And not food service for patients--which is a good thing, as you kind of need to eat when you're recovering from surgery. Instead, food service for employees gets more expensive and less reliable. I recently paid seven dollars for a salad that was brown in spots and rotten in others. When I took it back to the cafeteria, I was told that I couldn't get a refund; instead, I could take my pick of other salads on the salad line. 

I'm brown-bagging it from here on out.

So: Can you do it? Can you be a nurse? Do you have the skills, the balls, the brains, and the patience? Or would you rather go into accounting, or waste management, or hooking, or--worst of all--be a hospital manager?

Sometimes the strangest things strike me as hilarious.

Product Reviews: This Shit? Right Here? Is The Bomb. Edition.

This product review is brought to you by Sierra Nevada Torpedo Extra IPA. It's a good, solid, tasty IPA without too much bitterness. 

Product Review: This Shit? Right Here? Is The Bomb.

I read a review on Beauty Wonkette of diptyque's Huiles Precieuses (that's Precious Oils for you non-Francophones) that was positively pornographic and decided I had to try the stuff for myself. After all, I reasoned, I'd just broken up with my boyfriend; what better time to try a body oil that inspired one-handed typing on the part of the reviewer?

People, take note: I bought both the body wash (more on that in a second) and the body oil, and I have to say: Even Though It Cost Me As Much As Two Weeks' Worth Of Groceries, Both Are Worth Every Penny.

The body oil comes in a small glass bottle with its own eyedropper. That, I think, is so that you don't immediately compare the size of the bottle with the price that you paid for it and foam at the mouth. The benefit of the eyedropper becomes apparent once you start using the stuff--two drops of this oil will not only moisturize both of your arms (it absorbs insanely quickly) but will send you into herbal-scented reveries and make you forget where you are.

I'm not kidding. I got out of the shower after using the body wash and put the body oil on and was shocked to find myself still in my small bathroom with the vaguely grotty bathmat and cat hair everywhere.

It smells like...well, it's hard to describe. It's sweet, like irises. It's also spicy with sandalwood and vaguely musky, and there's a sharp note that I think might come from rosemary or rue. Once it's been on your skin for a few minutes, it smells powdery and flowery, but there's still that deep bass note of wood and musk that warns passers-by that this is some Serious Shit Goin' On. A little goes a long, long way.

Plus, you know, it absorbs fast and moisturizes. I even put some on my hair.

Now, as to the shower gel: you know those little shops in Paris or Montreal or Chicago that are full of herbs and fresh fruit? The ones where a little wizened granny presides over glass jars full of God-knows-what, and the smell of the place stays on your skin, but in a good way, for hours? Mix that with the smell of yarrow and dried cattails and my paternal grandmother's house and you have the body wash. It's complex, but it's not overbearing. 

And, again, a little goes a long way. I used, no shit, about a quarter teaspoon of the stuff on a maguey-leaf washcloth and had plenty of suds left over. The whole time I was washing the citronella and grass clippings and sweat off my skin, I was laughing. It smelled that good, and it left me that clean, but without being dried-out and itchy.

The body oil is $78 for 4.25 ounces. The body wash is $46 for just short of 7 ounces. Believe me when I say that these, given how little you have to use to get what you want, are actually a really good value. I can see the body wash lasting longer than my super-duper-sized bottles of store-brand Dove. I mean, seriously: the body wash has a top on it that allows you to dispense four microns of the stuff at a time, and that's about all you need. I used less than nine drops of the body oil *all over*, including my hair.

Still, I plan to save these both for very special occasions. Men of Texas, be warned: my shower routine is no longer taking prisoners.

Sometimes, those prayers aren't answered.

The best we could've hoped for was for the patient to end up with persistent weakness on one side and some word-finding difficulty, followed by a long decline and eventual demise. The worst we all feared was that he'd end up hemiplegic, mute, gorked out, and unable to provide for his wife and kids.

It was one of those cases. There was a nasty looking widget deep in his brain in a very bad spot that had been found incidentally. We'd scanned and done angiograms and generally worked him up eight ways from Sunday, and the general consensus was that something was going to kill him sooner or later, but it would be better not to die with whatever it was that was in his brain.

So off he went to surgery. About five hours in, my pager went off: did I have the patient's wife's contact information?

I called the OR floater: No, it's all there in the chart. Well, nobody's answering that number; did I have another? No? It's kind of important that the surgeon finds the family stat. Okay, okay, I'll hunt around for more contact information.

After a frantic half-hour of calling various numbers, I heard the overhead pager go off. Overhead pages at Sunnydale General are reserved for the most dire of emergencies, and here was my patient's name on the OHP, with the request that his family return to the first-floor consulting area immediately.

I started to pray for our best possible outcome. Moderate hemiplegia and aphasia seemed like a really good thing.

My prayers did not get answered.

When I finally found his family, about an hour and a half later, they were already in the ICU waiting room. I stepped off the elevator, met his wife's eyes, and was unsurprised when she burst into tears. I had already been leaking a bit myself, and started up again at the sight of her.

What I wasn't expecting was what happened when I finally got across the room to her and her parents and friends: they were all laughing and crying and hugging me and each other, all at once. Turns out that nasty mass in my patient's brain was totally benign. The surgeon had tried to get hold of the family to tell them that and ask if they wanted the mass in or out; he ended up making a decision on his own and simply leaving it in. It's not going to hurt anything or cause any more problems than the occasional headache, if that. Now that it's deflated and dealt with, he'll be perfectly fine.

People crying in the ICU waiting room is not unusual. What is unusual is a nurse whooping and laughing and dancing around, while tears run down her cheeks and she hugs and high-fives everybody in one corner.

I saw him a couple of hours after that, once he'd settled in and had a nap. He recognized me immediately, spoke clearly and fluently, and moved all his extremities well. 

"I am so totally gonna kick your ass for scaring me that way," I said.

"Yeah, I know," he replied, "but it all went okay, right?"

"Yep." I said. "It's perfect. You're perfect. You're fine."

He smiled and went back to sleep.

Well, gosh. That's kind of a drag.

This is Cinco de Mayo, right? So there are gonna be fireworks, right? Right.

I just heard a few fireworks go off. 

Then a few more. This was happening, by the way, just down the street.

Then I heard a noise like a spark had hit a box of fireworks and they'd all gone off within seconds of one another.

Now I'm hearing sirens.

Sucks to be you, dude. At least we've had enough rain lately that you won't catch the grass on fire. 

Wonder if whoever-it-was kept his hands intact.

A journey long and strange.

Seven hundred posts ago, I started blogging. That was April 25th of 2004. There was one post previous to that, but I think I deleted it, as it was the typical first post of the new blogger.

Just over five years and seven hundred posts. Wow.

In five years, I've become ACLS and stepdown qualified. I've learned how to level ventriculostomies and fix broken lumbar drains. I can tell when diabetes insipidus is coming and when a patient's just diuresing from surgery. I can handle a brain coming out of its confines into the open air, a patient with a fever of 104-plus, wounds that pop open, people that fall, seizures, heart attacks, and strokes. 

I've said goodbye to five classes of surgeons who've gone on to practicing independently, and I've said goodbye to at least that many colleagues who've died unexpectedly.

I've held people who were dying in my arms, sometimes in order to turn them and sometimes because they just needed comfort. 

I've been hit, kicked, cussed at, spit on, thrown up on, shit on, peed on, and generally frazzled by the needs of hundreds of people, a minority of whom were in full control of their faculties. 

I've argued with, cried with, drunk coffee with, and commiserated with doctors and other nurses. 

I've considered going back to waiting tables more than once. 

I've answered hundreds of emails from other nurses and nursing students. 

Once, as I put my hand on a dying patient's chest to say goodbye, I felt her heart stop.

Once, after a long, tricky surgery, I got the honor of letting a pregnant woman hear her fetus's heartbeat for the first time after she came out of anesthetic.

I have commuted more miles than I care to count and gone up three scrub sizes. I've made a lot of friends, some of whom were patients and some of whom weren't. I haven't made, I'm glad to say, too many enemies.

I've fallen out of love, in love, out of love, in love....my personal life has been like the drive thru at an In-N-Out Burger. 

I held one cat while she was dying and welcomed two more fur-suited terrorists into my house a few months later. I re-acquired a big shaggy loveable dog, the only thing I missed from my marriage. 

I bought a house, helped ChefBoy rebuild the bathroom, painted everything in different brilliant colors, and am getting ready to do the painting thing again. 

I've reviewed beers, mascaras, toothpaste, frozen pizza, and shoes. 

I've sprained my ankle once, had at least three bouts of stomach flu, two cases of flu-flu, and gone up on my dose of antidepressants. 

I've gotten off the Pill. 

I'm facing dating again at nearly forty.

Five years ago, after I'd been a nurse for not-quite-a-year, I still prayed every day that I wouldn't kill or injure anyone during my shift. I don't do that any more. Instead, I pray that somebody, at some point during my shift, will feel like I made a difference. Once in a while my prayer gets answered, when a patient tells me that I gave her hope, or made him feel better, or believed her when she said she hurt.

I have more wrinkles now, and more pounds. I'm cynical and twisted and bitter sometimes. Occasionally I give up hope for a few minutes. Very occasionally you might see me leaning my head against the cool marble facade of the lobby, praying that I can make it through the rest of my shift and still want to come back in the morning.

And I still love what I do. I said a couple of posts ago that I felt like a fish finally dropped into water, and that's true today. I opened a tiny bottle of very good champagne just now and am celebrating five years of loving what I do, both work-wise and blog-wise.

This blog would not have survived as long as it has, and I would not have survived as long as I have in this business, had it not been for people who read, emailed, commented, and sometimes ranted at me or corrected my mistakes. Thank you. I can't say any more than that: you guys are the reason I am still here.

BWAHA!!

Fuck passion.

Oh, for cryin' out loud.

Some well-meaning person told me yesterday, after I excoriated him for using a toothbrush on an incision, that I must have a real passion for my work.

No. I do not have a passion for my work. I have a commitment to it, and a love for it, and I felt like a fish finally in water for the first time in my finny life when I got to nursing school, but I do not. Have. A passion. For nursing. I have a deep, consuming dislike of people who scrub incision lines with toothbrushes, though.*

I certainly do not have a passion for people who use the word "passion" as a positive term.

"Passion" is like "artistic". People who are artistic tend not to show up for work on time. They tend to be a little ADD. They tend to freak out and need a certain level of excitement in their lives that normal people can't tolerate. In short, they're drama queens. "Passionate" people are the same way: try to live a normal life with one of 'em and you'll find yourself on the receiving end of invented crises and tearful midnight phone calls as they attempt to keep things off-balance enough to make themselves happy.

A patient's wife told me the other day, as I was tranferring him to the ICU with a raging case of bacterial meningitis, that he had ignored two cerebrospinal fluid leaks following surgery because, you know, he's an artist. He has a mind above such things, don't'cha know. He had apparently ignored the clear, yellowish fluid running out of his nose in favor of demolishing old car parts, or whatever the hell it is he does for art, until the headache and nuchal rigidity got to be so bad that he couldn't stand up. The pus leaking from his incision should've been the first clue, but oh, you know these artistic, passionate people--he felt he simply had to finish chopsawing that radiator to get his Vision out into the world.

My ex-husband told me, after he and my best friend had started screwing like rabbits, that he'd done it because he missed the Passion in our Relationship. Uh...dude. Passion, with a few exceptions, does not last for fifteen damn years. If you're lucky, you can build a good, strong, solid, deep-rooted something that outlasts passion and over-reaches it. You were not lucky. You were, in fact, a drama queen asshole, which is pretty much what I told him after I finished laughing. 

See? Passion bad. Workhorse good. Boredom positive. Excitement debatable. Butterflies early, good; butterflies late, a sign of needing to up your Xanax.

I am sick and tired of artists and passionate people. Give me a good, strong, not-too-brilliant workhorse of a surgeon any day rather than the passionate, artistic guy with a gift who tells patients to shut up when he's talking and is prone to fits of the sulks. Give me the uninspired, hardworking nurse who shows up on time, doesn't miss details, and gives a decent report rather than the one who feels drawn by some Higher Shiny Cosmic Power to the field. The ones who are so very drawn to this marvelous, wonderful, fulfilling thing are the same ones who either end up in management, fucking things up for the rest of us, or who go back to accounting or truck-driving or whatever it was that they could actually pay attention to and be good at.

Give me a nice, good, workhorse of a boyfriend, while you're at it. I don't care if he bradys down into the 50's when he's relaxed; it'd be a nice change from constant tachycardia. If he spends days silent, punctuated by the occasional grunt, so much the better. Keep your Jack Russell terriers and your people in search of something all-consuming; I want somebody dull and reliable and not prone to causing crises for the sake of excitement.

Which is why I love my dog. Max is passionate about one thing only: bully sticks. Even then, he won't bite my fingers taking one from me, or stay out in the yard with one when it's raining. He's my new benchmark for sensible behavior.

*And while I'm bitching, what is it with you people scrubbing your incision lines with a damn toothbrush? Doesn't common sense tell you that that is a bad idea of the first order? Don't you think about things before you do them? What posessed you to...oh, wait. I'm getting back into excoriation mode. Sorry.

Margaret vs. Pauline

Two patients, both with problems.

One is on Medicaid. She was hit a couple of years ago by a drunk driver in a big SUV; her youngest child died. The older two survived. She was paralyzed from the belly down. She has Brown-Sequard Syndrome, which means her touch sensitivity and her movement ability are both completely out of whack and she has constant pain, even from gentle stimulus. She had to come back for a revision after surgery to repair a bone-deep bedsore didn't work out well.

The other is a privately-insured patient with money to burn. After years of plastic surgery and expensive beauty treatments, she decided to get her lower back pain fixed with a lumbar laminectomy. She has an inch-long incision in her back, private duty nurses around the clock, a Dilaudid pain pump with a basal rate, and a husband who waits on her hand and foot.

Guess which patient was more willing to get out of bed this morning? Guess which one cried and moaned and complained about having to have physical therapy today? Guess which patient refused to walk in the hall, while the patient next door would've given her eyeteeth for the chance?

*** *** *** *** *** 

You're the one that I still miss

She has vascular dementia and doesn't remember that her husband died three years ago. Her kids kept reminding her of that until I told them to stop it, that making her go through that grief again and again was cruel and unhelpful. She still asks where John is, though.

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

Can't give up actin' tough; it's all that I'm made of

One of the new nurses asked me tonight how I managed not to burst into tears every time something sad or pathetic happened. I replied, half-joking, that it's because I'm cynical and bitter. Looking back, that answer made more sense than I realized at the time.

It's not that certain things don't break my heart; they do. It's just that you learn a certain distance over time that allows you to keep working, to keep doing unpleasant things to pleasant people and not obsess about it later.

I used to obsess all the time. Occasionally I still do. Mostly, though, it's out of anger at a person's situation rather than from grief.

I told the chaplain once that nurses believe in God primarily so that they'll have somebody to blame. This is still true.

In which Head Nurse turns back into a nursing blog, at least temporarily....

I'm back at work. That means I'm too tired to blog at the moment, but trust me: big things are coming.

And it won't just be about siding, windows, doors, bedroom paint, my choice of Roman shades for the new windows, and deck building. It'll be sexy, exciting posts about OMG GONNA KILL US ALL HOLY SHIT WHADDA WE DO RUN RUN RUN AWAY SWINE FLU FROM MEXICO!!

More later. I promise. Meanwhile, keep washing your hands, and keep tuned to this channel. Here at HN we're more committed to the truth than, say, Lou Dobbs.

PS: Cover your nose when you sneeze.

Can we all please just take a deep breath through our masks?

As some of you might have gathered through careful perusal of this blog, I live in Texas. I live, in fact, not too terribly far from San Antonio, where several cases of THE MOST HORRIBLE PANDEMIC AWFUL ZOMG FLU EVER SEEN were discovered.

And yet, I am not locking myself in my house and refusing to go out. (Well, actually, I am, but that's for reasons totally unrelated to swine flu. It's more like that's my normal routine.) I am not panicking or avoiding large public spaces like the grocery store. I am not dousing myself in bleach or drinking whole pots of green tea. I am not stocking up on ammo or bottled water. I am, in short, while not sanguine, not freaking out.

How come?

Because epidemics *happen*. Once one gets started--and there's ample evidence that this particular flu bug has been moving around both Mexico and the U.S. all season, quietly infecting people--there's not a whole lot you can do besides quarantining the infected and washing your hands. Even before one gets started, there's not much you can do to stay away from viruses on a daily basis besides avoiding sick people and washing your hands.

Given that I can't exactly avoid sick people unless I want to move into a cardboard box, I'm washing my hands. I'm brushing up on the management of cytokine storm (for you non-medical types out there, that's an immune reaction that goes overboard and overloads your organs and kills you) and reviewing what I know about things like respiratory and droplet isolation. I'm gonna put an extra set of scrubs in the car today, since it's likely that at some point, if this dadratted bug continues to spread, I'll be killin' time at the hospital rather than at home.

I'm more worried about the level of ignorance in the general public about viral infections and the transmission of the flu than I am about the flu itself. I'm seeing comments on public message boards from people who want to stock up on antibiotics or just start taking Tamiflu as a preventive measure (neither will work). I'm seeing evidence that most people don't really understand the difference between viruses and bacteria and how their infections differ. I'm hearing talk from people here Deep In The Heart about moving off to Wisconsin and building a hideout.

If there's going to be fallout from this bug, it'll be because people are kinda dumb, not because they fall over dead.

Unless the Gubmint reports that this particular strain of swine flu turns people into zombies, I will continue simply to wash my hands and cover my mouth when I sneeze. I ask you all to please do the same. 

And maybe next time there's a scary epidemic, it can happen *during* the  Nationally Recognized Music Festival, so NRMF will get closed down and I can finally find some parking near the bar. That would be nice.

In Which Jo Explains Why She's All About The Teeth

Teeth, my friends, are a big deal. When they work properly and are relatively sound, they don't inspire much thought beyond whitening and straightening. When they're not sound, all sorts of nasty things can happen.

First of all, they can fall out. Let's take as read the nutritional problems and aesthetic considerations of having no teeth: I'm more interested in the second possibility: they can rot. That hurts. It looks bad, smells bad, keeps you from eating nice crunchy things like vegetables, keeps you from smiling as widely as you otherwise might. It can also leave you with what's known in the medical biz as a flaming clusterfuck of problems. To wit:

Let's say you're a sixteen-year-old girl who's had minimal access to medical care and no access to fluoridated water all your life. You come to me with a history of a heart valve replacement, complaining now of constant severe headaches and dizziness. What do these two things have in common?

Believe it or not, rotten teeth.

See, if you have really, *really* bad teeth, you're setting yourself up for bacterial infections that can lodge in your heart valves. If the infection in your heart gets bad enough, you'll end up having to have one or more valves replaced because they'll be so damaged that they won't work correctly. *That* means you'll have to be on warfarin, a blood thinner, for the rest of your life so that you don't get clots in the new valves that could travel to your brain and cause you to stroke.

The trouble is, if you don't have access to comprehensive medical care, the original problem (teeth) won't be taken care of. That'll lead to bacterial infections that travel to other places. One of those places might be one or more of the arteries that feed your brain. That, my friends, is known as a mycotic aneurysm, and it is no fun at all. 

Further, since you're already on blood thinners to take care of the clotting possibility, that aneurysm (which is nothing more than a stretched-out, thin spot in an artery) will probably leak blood now and then, damaging your brain.

Oh, and you're four months pregnant.

So let's review the bidding: no medical care, no dental care (to speak of), rotten teeth. Rotten teeth lead to an infection lodging in a heart valve that goes undiagnosed and untreated until the damage is so extensive that the valve has to be replaced. Blood thinners to reduce the risk of clotting from the new heart valve, but (again, poor medical care) the levels of drug in your bloodstream aren't monitored, so your blood gets too thin. Meanwhile, another infection has lodged in your brain and stretched out an artery, which then bleeds a bit now and then and makes you miserable. And warfarin and early pregnancy do not, in the least little bit, mix.

And you're sixteen.

I have never, in all the years I've been at Sunnydale General, seen as many consults on one patient as I saw on this one. We had dental, OB, cardiology, internal med, neurosurgery, neurology, pediatrics...and those were just the medical consults. Her chart was overflowing and she hadn't even been there a week.

The end result was this: we took her off warfarin and put her on a heparin drip. Later, when she was ready for surgery, we took her *off* the heparin and fixed her aneurysm. She miscarried her pregnancy and had to be followed carefully by OB so that she didn't bleed out. Mom and Dad and I sat down for a long, long talk about how on earth to get her teeth fixed and get her on some sort of contraceptive so this didn't happen again. I was gobsmacked by the difficulties they faced just getting her to the hospital in the first place.

I thank the gods who on my birth have smiled. If I lived like she does--and, not to put too fine a point on it, but it's in a house that isn't square and is about six hours away from the nearest clinic, where the weather reports are all in a language that was used as code in World War II--I would be dead by now.

She's lucky she's not. She's lucky one of her parents can read. She's lucky the U.S. Government, in its unending wisdom, decided that several million dollars spent fixing her various problems was a better investment than a couple hundred spent preventing them in the first place.

*sigh*

Fluoride, people. Regular dental visits. If you can afford 'em, do 'em. If you can't, well, you might be lucky enough to find a clinic or university nearby that can do basic care for cheap. If you find yourself flush, you might help a friend get a cleaning.

And floss.

What makes a tough day

Somebody younger than me with a projected survival time of three months (we can do better with glioblastoma; renal cell carcinoma is "not responsive to treatment" once it's spread).

Somebody my age with an aggressive, bizarre, rare form of multiple-sclerosis-like neuromuscular disorder that takes your sight first, then your speech, but leaves your motor skills intact.

Somebody older than me with a family that treats her like a leper because she has MRSA.

Deciding, once and for all, to hold my tongue.

Kitten Update

This is why Max is sleeping on the dining room floor rather than on his bed:

Because, really, who could go against this extreme gutulousness?

...and little brother is catching up:

Getting rid of dead wood

Or, In Which Head Nurse Turns Into A Remodeling Blog. Temporarily. Again.

The 75-foot-tall, 60-year-old maple in the back yard has been reduced to a very large pile of extremely massy logs. The lean-to that sat off the kitchen and blocked the view of the window, and which I hated with everything including my toenails, has been reduced to a very large pile of trash and siding.

A whole bunch of different guys came and invaded my back yard this morning. Half of 'em were your typical tree crew, with ropes and great big chainsaws and leather straps hither and yon and one very tough woman who was roping off with the rest of 'em. The other half were the cheerful, dreadlocked hippies from across the street, who'd agreed to take down the shed in exchange for all the wood from the maple and a small consideration. By ten they were all hard at work; by one-thirty the entire character of the back yard had changed.

Boy, is it gonna be hot in here come summer. I hadn't realized how much shade the tree was providing. That, combined with the fact that it held two different species of woodpecker and a group of bushtits (BUSHTIT! BUSHTIT! Hi, Mom!) and a whole colony of squirrels, made it hard to get rid of. When the one-armed tree guy showed up, though, and looked doubtfully at it before saying, "Ma'am, thar ain't no way we can make this here tree safe," I knew it had to come down. The next big storm would've sent it onto the house, probably killing me and possibly killing Max.

The cheerful hippies uncovered a nest of baby rats at one point. Mama sped away as soon as that part of the wall came down, so I lifted up the babies on a shovel (their eyes weren't even open yet) and put them down in a protected place. Mama had gotten them within about fifteen minutes. I'll deal with that later; I didn't have the heart to kill little baby *anythings* whose eyes weren't yet open and who crawled around squeaking pathetically.

I don't have the heart for much, lately. Chef Boy and I are dunzo after five years. The only respectful way to put it is that we had irreconcilable differences and leave it at that. Part of all the chopping down and clearing away the dead, dying, and rotted stuff is so that I can see my way clear to what I have to do with the house. I'm sure there's a juicy metaphor there, but right now I'm not going to examine it.

Anyway, the whole damn shebang of tree and shed was accomplished without too much blood loss and no maiming. Only one person stepped on a nail, and only one person ended up under a falling wall. Luckily, it was a very light, poorly constructed falling wall.

When the tree guys had topped the tree (which was the really dangerous part; past a certain point, it was so rotten they couldn't climb it and had to work overhead) there was, for about ten minutes, a huge solid mass of trunk standing in the yard. All the branches had been cut off, and I could see the shape of the trunk, how it had twisted with the prevailing winds for years, where the critters had built nests, all of its history right there. 

Then all of the tree crew and all of the hippies grabbed the end of a rope and held the top of the trunk steady as one person chainsawed through the bottom of the trunk. You'd think it would take forever to get a tree like that down, but it pulled down surprisingly easily. One big cut, and the whole thing was on the ground. Turns out the trunk was rotten clear through and it never showed.

I'm sure there's some juicy metaphor there, but right now I'm not going to examine that one either.

Product Reviews: Paired X Chromosomes Edition!

It's product review time again, kids! This one is more gender-specific than usual. Boys are welcome to read, but are unlikely to come away with any useful information.

Girly, Foofy Product Review Number One: 1000 Hours Eyelash and Brow Tint

Yeah, I tinted my eyelashes yesterday. Before anybody gets all het up about blindness and skin reactions and so on, let me say that I had no trouble at all with this stuff--no eye irritation, no skin irritation, no nothing. It didn't even stain my skin when I accidentally glopped it all over.

1000 Hours is an Australian product that you can get online. I bought it because I've got white-rabbit eyelashes; they're totally invisible unless I'm wearing tons of mascara. I've been considering dyeing my eyelashes now for a few years, but had been scared off by stories of people getting horrible corneal scarring from the dyes available in the States. After doing some research online and talking to various beauty mavens I know, I went ahead and dropped $25 on the 1000 Hours black/brown tint and tried it out.

The verdict? It rocks. My eyelashes are now visible, but not artificial-looking. The application was easy and fast, and there was no horrible dye smell. I'm keeping this one.

Girly, Foofy Product Review Number Two: Boden dresses

Whoever designs dresses for Boden really likes women. Like, really a lot. I have three dresses from there, and they're all different, and they're all bangin'.

The first is a clingy jersey number with a deep V-neck that gives me a waist. The second is a more structured cotton dress with a U-neck and a full skirt that doesn't make me look like a munchkin. The third, which I just purchased with an eye toward one-hundred degree, one-hundred percent humidity days, is a lightweight crinkle cotton thing with an empire waist that doesn't make me look pregnant.

The verdict? Spendy, but totally worth it. Plus, if these dresses hold up the way other stuff I've gotten from Boden does, I'll be wearing them for years. 

Girly, Foofy Product Review Number Three: OPI nail polish

I don't use anything else any more. I don't paint my fingernails--why bother, when they're short and being scrubbed constantly?--but I do paint my toenails in the spring and keep 'em done through the summer. After brief flirtations with Revlon and other, lesser brands, I'm sticking to OPI from here on out. The polish wears well, the color in the bottle is what you'll get on your nails, and it's easy to take off, no sanding required.

The verdict? Why use anything else? You can get bottles for cheap(er) at places like Sally or your local Drug Emporium.

Untitled.

If you want your things, they're on the front step.

I finally watched WALL-E.

And it was the damn CG cockroach that got me.

You know? As the ship is taking off, and Wall-E is on it, and the cockroach is yelling, "Come back!"

It got me.

Sheesh.

Cryin' over a damn CG cockroach. This has got to be 1) a new low in Head Nurse History, and 2) a sign I need a week off.

Do Not Want: The brain edition.

Yeah, yeah, I know. I'm a lazy blogger, posting videos from YouTube and graphics from National Geographic. Tra friggin' la; I have the day off.

Which leads, of course, to what I've been doing recently. 

Which is dealing with encephalomalacia. 

Not my own, thankfully; the brain softening of other people.

See, your brain isn't supposed to be soft. It's kinda firm and resillient (in vivo, that is), with its own lovely network of venous sinuses and arteries and linings and ventricles. It's a thing of beauty, whether you're watching it live through a dissecting scope in the OR or on video.

Except when it gets soft. Then it's not so beautiful. Worse, though, than the aesthetic considerations is what encephalomalacia does to a person. Basically, it takes a productive, happy, loving member of society and turns them into a nonresponsive, snoring shell of a person who's getting fed through a tube.

And sometimes we simply don't know what causes it. We can take biopsies galore, we can run every single test on blood and CSF and urine and what-have-you that the most specialized specialists can think up, we can scan and X-ray and poke and prod...and we still don't know why you've all of a sudden become a lump in the bed.

It's frustrating. More than that, it enrages me. Bad enough that somebody that I grew to know a little and like a lot is dying; why on earth can't we figure out why?

The last time this happened, the diagnosis came back primary leptomeningeal melanoma. That happened years and years ago, when I was first starting out in neuroscience. That particular diagnosis was obtained on autopsy. This one probably will be, too.

*sigh*

This, my friends, is the bad thing about nursing: seeing somebody you thought was getting better suddenly get worse and having no hope of an explanation in time to fix them. The only bright spot is that, since we're hip-deep in researchers, maybe the *next* person won't be so badly off. If we can catch whatever-it-is in time. If they have the same thing. If we can figure out what this is in the first place.

Because it's been a while since poutine was mentioned on this blog...

Whatchoo lookin' at?

Five by Five

It's been a while since I've done a meme, so here's one:

1. Five posts from the blog which I particularly like:

This is the coin

Dear Joey

A Chrissolstikah Story

Nursing Students: A Love Letter

The Nurse's Guide To Specialists

2. Five things of which I am proud:

a. That I work out three to four times a week and thus can lift heavy things

b. That I started the prerequisites for nursing school at 30, despite feeling quite old

c. That of all my colleagues at the hospital, I only really have problems personally with one

d. That my dog likes me

e. That I can get pretty much anything to grow--outside.

3. Five things I'm a bit ashamed of:

a. My temper

b. My foul mouth

c. That I'm a beer snob

d. That I have a terrible weakness for beauty products

e. That every present I wrap looks like a mentally-deficient orangutan went at it with a chop saw.

4. Five things you'll never find in my house:

a. Miracle Whip

b. Far-right periodicals

c. Coors Light

d. A non-dusty surface

e. Anything you can't touch, use, or sit on.

5. Five things you'll always find in my house:

a. Coffee

b. Toilet paper (I have a morbid fear of running out)

c. Brain drugs (ibid)

d. Lots of books

e. Dog and cat hair

What're yours?

Strange Surprise, Endless Science

One of the biggest parts of a nurse's job is education. You teach patients how to take care of themselves in the hospital and at home, you teach family members what to expect from a particular diagnosis, you teach doctors how to write orders for labs that have to be done just so.

One of the hardest parts of a nurse's job is education. You have to make sure that what you're saying is comprehensible and that you're not going too fast for somebody who's already overwhelmed and frightened. You have to be sure that the message is getting across; sometimes, just saying "Don't scrub your incision with a toothbrush" isn't as obvious as it sounds to you, because that person will then go home and scrub their incision with a hairbrush instead (true story). 

And one of the hardest things about educating people is that sometimes you come face-to-face with the maxim "A little learning is a dangerous thing". 

We all have horror stories about taking care of other nurses, or doctors, or people whose family members are nurses or doctors. The main reason those are horror stories is because people who know *something* about something automatically assume that they know more than they do about that thing. In other words, they try to apply what works for them in their own particular branch of medicine to the branch of medicine they're now dealing with. Sometimes it works. Mostly, it doesn't. It's kind of like trying to install plumbing in a new house when all you've done is fix kitchen sinks for twenty years.

So the education part of the nurse's job gets harder. Most of the time, you're starting with a blank slate in terms of teaching a patient. With people who are medical to start with, you have to correct misunderstandings and revise what they know already before you can get down to the basics. 

Nurses have a fun job when they're in this position. See, a doctor or other medical person who's not a nurse will get a totally different picture of what's going on with a patient than the nurse taking care of the patient will. Sometimes the difference is in the details; sometimes it's more overarching than that. Usually the conflict, if there is one, has to do with the nurse's care of the patient rather than, say, a difference of opinion with the doctors on the case. 

No, I'm not taking the catheter out. I understand your concerns about a UTI, and I share them, but right now my bigger concern is keeping accurate records of intake and output, because the person in the bed has a condition that causes trouble with their electrolytes. Yes, it is typical to use anticoagulants in addition to mechanical therapies to prevent DVTs, but in this case, anticoagulants could potentially cause harm, so we're going with mechanical therapies and frequent turning. Yes, I agree with you on the pulmonary toilet angle, and I'm going off right now to rewrite the respiratory therapy orders. 

It's hard to remember, when you're getting quizzed by the guy with the MD whose daughter is in the bed, that it's not about you. It's about the care that his daughter is getting, and you just happen to be the person in line for questions today. It's also hard not to simply say, "Look; you might know more about allergies/rheumatology/endocrinology/dermatology, but I know more about *nursing*" and leave it at that. It's hard to educate, explain, and clarify with someone who is just as frightened (or more so) and overwhelmed (ditto) than the average bear, yet still keeps jumping ahead of you or going off on tangents.

So what to do? Keep calm. Explain everything, and don't assume that because the person you're talking to is medically-inclined you can gloss over things or skip stuff. Respect their opinions. After all, this is a doctor/nurse/RT/PT/whatever you're talking to; there's a good chance that their knowledge of your patient combined with their knowledge of the sciences will show up things you've missed. Remember that they know more, so they're liable to be more aware of possible complications and Scary Stuff than a layperson. Be kind. It can't be easy to know what they know and be seeing what they see, especially when it's their Baby Daughter/Beloved Husband in the bed. Keep in mind that medical folks are people too and might sometimes forget to eat or sleep, or might just need to be sent home to relax for a while. 

And don't act too amused when they express surprise that you know so much about what's going on. 

Squeeee.

North, northwest, the stones of Faroe*

Some days do not suck.

Those are the days when, against all odds, everything goes right. The meds you need are there on time, without you having to call the pharmacy four times. The equipment you need somehow magically appears on the shelf in the clean utility room, despite nobody having needed that particular machine in four months.

And those are the days when your demented patient, who has advanced Alzheimer's, remembers only one person, and remembers them well: the man she's been married to for sixty years.

For a few hours, as long as he's at her bedside, she's completely oriented and alert. She understands that she's in the hospital, that she's not well at the moment and that she needs the antibiotics you're putting into her PICC line, that she's not to pull out whatever lines and leads you have attached to her. She doesn't fight you, she doesn't try to get out of bed. She just stays in bed or up in the chair, talking to her husband, perfectly happy.

You see a lot of things as a nurse. I've seen people die, and seen people born, and seen people end up trapped somewhere between the two states, with no way of resolving the issue. I've seen people forget everything they were, and people come back from what we all thought were insurmountable injuries. The best thing ever? Was watching my confused, distressed, combative patient become the person she was before she was admitted--all due to the man she'd spent two-thirds of her life with.

Would to God we should all have somebody like that.

Things They Don't Tell You In Nursing School, Part Four Hundred Seventy-Two:

Some days suck.

They're not the days with three codes and a couple near-misses. They're not the days when some idiot resident decides now is the time to scream at you in the nurses' station. They're not the days when big things go wrong; they're the days when a multitude of tiny things don't go quite right.

Mostly, it's because of people. Not patients--people. Patients are, though we tend to forget it, basically people just like we are; they just happen to feel like shit and need good drugs. 

There's the patient who has a dozen excuses for why he simply can't walk right now. There's the patient who is inexplicably rude to you, or the one who's offensively rude about you in front of a doctor or family member. There's the patient who, for some reason, you just can't do anything right for, no matter how hard you try. They're all people, and most of 'em aren't as big of assholes as they seem while they're in your hospital.

Some days it's easy to channel your inner Cherry Ames and just keep on plugging. Other days, the sorts of days I'm talking about, you get frustrated and have to stop yourself from running screaming out into the night (or dawn) as soon as your shift ends.

I once had a patient who had a big, nasty brain tumor in her frontal lobes. It turned her from a bearable, if brusque, person into the sort of alkaline bitch you wouldn't want your worst enemy to meet. For a week, I had no problems at all dealing with her, and could even sweeten her mood a bit--all while getting charts open on time and handling five other patients with varied (and more pressing) needs.

This has not been one of those weeks. When a patient was insulting about a resident to me, I snapped back, "Keep a civil tongue in your head" and handed her off to my (angelic) charge nurse without a backward glance. When a patient gave me yet another reason why she simply couldn't turn over in bed just now, I growled "You're turning, and that's final" and then hauled her over on her side before she could protest. When one other patient said to me, after I finished starting a particularly tricky IV, "I bet you don't have a boyfriend; it hurts to hold your hand," I had to get out of the room quickly in order to hide the ridiculous tears that started in my eyes.

That's what they don't tell you in nursing school: that dealing with people is hard. It's rewarding and satisfying, yes, but it's also really, really hard at times. You get lessons on how to handle the really difficult, insane people, but nobody prepares you for the exhausting, grinding, disillusioning work that makes up some days. 

What's worst about those days is how lonely you feel during and after them. It feels like, no matter how much your coworkers sympathize, you're the only person who's ever had a day this bad in the history of nursing. You feel inadequate, you wonder what the hell is wrong with you that you can't manage to take care of four or five sick people without nearly losing your mind by noon, you think seriously about applying at Starbucks. 

The good news is that those days, those weeks don't last forever. Eventually something turns around: the surgeon who's known as a stickler compliments you spontaneously, or the raving bitch in room 9 decides you hung the moon. Sometimes it's as simple as having all your meds and equipment there when you need them, and avoiding the running-around that characterizes so much of the average nurse's day.

So: If you're a new nurse, or a more experienced nurse, or an old, old, old nurse (and, believe me, after a week like the one I've had, you feel old-old-old), don't lose heart. Eventually the moon will move out of Klutz and things will stop sucking as much as they do now.

In the meantime, you still have the end of the shift to look forward to.

The following communication will not be therapeutic.

If you have a patient-controlled pain relief pump that is giving you thirty micrograms of fentanyl every five minutes with an optional bolus of one hundred micrograms of the same drug every hour, and you've been taking advantage of that bolus every hour on the hour for the past twelve hours, and you've also been taking more than one hundred milligrams of baclofen and more than one hundred and twenty milligrams of oxycontin and various other milligrammage of narcotics twice or three times daily, please do not try to get me to believe that you are going into withdrawal because I have removed your fentanyl patch, which expired three days ago.

Because I will look at you and say, "Really?"

Then, when you do not respond, I will say, "Really?"

And when you tell me that you're feeling queasy and you want Phenergan, because ondansetron doesn't work for you, I will say, "Of course it doesn't."

It has been a long week.

This has been running through my head all day long...

...as I dealt with five people who all had interesting, obscure things wrong.

Yes, I know there's nothing to look at. Just listen. 

Lyrics here.

I heard this song first on a Weekend Edition broadcast; Case said she'd often heard love referred to metaphorically as a force of nature, and wondered what would happen if an actual force of nature fell in love with a person.

It would make even *my* most Crazypants McStalkerson of boyfriends look sane, that's what.

Random 0557 musings, or, how having kittens means never having to say...

"Honey, let's sleep in in the morning."

Kittens love to play at night. Kittens love to play in the morning. In fact, kittens (these kittens, at least) play all the time, with short breaks for naps and eating and using the litterbox. It's mostly playtime at all times, though. Which means, between kittens and Max waking me up ("It's four a.m.! C'mon! Time to get up!") I've gotten about....oh, nine hours of sleep in the last two days.

I got an email the other day from a patient's family member. Yes, I do occasionally--very occasionally--give out my email address when I've been taking care of somebody for a really long time and have gotten close to the patient or family. Anyway, the patient's brother wanted me to know that the patient had died.

Just like that. And it was somebody that we all had expected to get better.

Sometimes inexplicable things happen, and you're left holding the various bits of the story, wondering what the hell went wrong. It's hard when it's somebody you've cared for who's been really, really sick and nobody expects them to live, but it's not as shocking and kick-in-the-gut as it is when it's somebody who, two weeks ago, was doing relatively fine.

I mean, they come in sick as a dog, you pop 'em into the ICU, spend a month or so balancing electrolytes and stabilizing them to the point that they won't croak during surgery. Then you do the surgery, and it goes well, and you transfer 'em to acute care. And, in acute care, you spend a couple of weeks (or more) getting 'em up, making them eat on their own, rebalancing their electrolytes, making sure they pee, walking 'em around the hall...and finally discharge them to rehab.

Where they suddenly drop dead. Not the rehab's fault, by the way. Sometimes things happen.

It makes you really good at dealing with loss in a healthy way, I'll say that. If you don't figure out how to handle things well, you won't be working/alive very long. 

If you're me, you lift very heavy things and run in between sets until you're about ready to barf. Then you do lots of heavy yardwork. Then you have a nice dinner with your favorite chef and then play with kittens, and finally go to bed and hope to sleep. When you wake up, it might be three seconds before you remember why you've got that lump in your gut.

And then you pick up the bits and look them over again, wondering what the hell went wrong.

Sometimes people just decide to die. I've seen it happen--where a person makes a conscious decision to kick off, and a day or two later, they're dead. There's not enough time to get them into hospice or even transition to comfort care: they've made up their mind, and that's it. Maybe that's what happened here. Could be.

What to Expect When You're Expecting A Ventriculostomy!

Back to work, kids! Today, we'll learn about (cue music) Tubes In Your Brain!

(I really wish I could hire James Earl Jones to say "tubes in your brain". That would be cool.)

What's a ventriculostomy, anyway?

Simply put, a ventriculostomy is a tube that goes into a ventricle in your brain to drain off CSF.

Simply put into English, it's a tube that a surgeon runs through your skull and into one of the big, fluid-filled spaces on the inside of your brain (yes, your brain has big fluid-filled spaces on the inside) in order to drain off what's called cerebrospinal fluid. Cerebrospinal fluid surrounds your brain, penetrates it...oh, sorry. *ahem* It does surround your brain, though, and it cushions it and provides a number of different benefits.

So why the hell would I need a tube in my brain?

The reasons aren't good reasons. That is, you're obviously not doing all that well if we're needing to stick a tube in your brain.

The three big reasons to get a ventriculostomy (or "ventric", for those who sling the lingo) are head trauma, including brain bleeds; hydrocephalus that happens really fast, or an infection inside the brain itself that needs to be dosed directly with drugs. We also sometimes put them in during or before surgery, or use them for chemotherapy, though those are less common, at least that I've seen.

Okay, great. What's in this for me?

Well, if you remember your anatomy, you'll remember that there's only room for your brain inside your skull. If you should add more stuff there, like extra CSF or extra blood, your brain gets squished. A ventric can help your brain not get squished by giving it more elbow room. Not that your brain has elbows, mind you.

If you stayed awake during the second hour of anatomy, you might remember that there's something called the blood-brain barrier. Normally, this nifty anatomical trick keeps your brain safe by filtering out all the harmful stuff that could get into your bloodstream, thus keeping it away from the delicate and mostly-defenseless brain. Unfortunately for us, the blood-brain barrier also keeps things like chemotherapy drugs and antibiotics out of the brain. We occasionally have to stick 'em into the brain directly to see an effect.

How do you get one of those ventriculowhatevers?

Sit down. You're gonna love this.

A neurosurgeon drills a hole in your skull at the crown of your head (roughly speaking) and sticks a tube in, aiming for your nose.

Best part? At our facility, it's done at the bedside. With a nurse holding your head and speaking soothing words of comfort (unless it's me, in which case the nurse is humming a little tune and trying to block out what's happening). It's done with a hand drill, usually, unless it's in the operating room, in which case it's done with a power drill. Oh, and lidocaine. Lots of lidocaine.

Yikes. What happens next?

Well, a ventriculostomy, unlike a lumbar drain, is open all the time. It's connected (as with a lumbar drain) to a sterile, closed system. It's also connected to a leveling apparatus that in some cases is kind of fancy and in others involves, like, an old radio antenna* and a marked pole. 

What happens next is "not a lot, really". In other words, if you're the recipient of a ventric, you should begin to feel better fairly quickly (if you're in a state to feel much of anything at all). You might have a dull headache for a while, given that somebody's punched a hole in your brainbox, but that's it. 

Your nurse will watch you like a hawk, making sure that the ventriculostomy drain stays at a particular level, ordered by the doctor, and that there's not too much or too little fluid draining out. If you need drugs administered through the ventric, you'll get those administered by a doctor, through a syringe connected to the tube setup.

What can go wrong?

The biggest threats are infection and overdraining.

See, whenever you penetrate into the brain, you're opening that box of troubles right up. Ventriculostomies are done in a sterile field, of course, and we're paranoid about making sure nothing horrible gets in to the hole. Sometimes, though, things can happen that mean you end up with an infection in the ventricle. In that case, we treat it with stuff instilled--you guessed it--through that ventric.

If your brain is overdrained of CSF, it sags. Sometimes it can herniate (bulge through) the hole in the bottom of your skull. This normally leads to death. That's why the nurse who'll be taking care of you is hopped up on caffeine and hovering over you like a hen with one chick: it's her responsibility to make sure nothing happens (like a sudden position change) that could cause you to overdrain CSF.

The whole infection threat is why she's drawing blood and constantly checking your temperature and asking if your neck is stiff, too. 

What happens when you guys are done with tubes in my brain?

Well, we take it out. The ventric tubing gets pulled out by a doctor, and that's it.

No, really. Sometimes you might get a stitch to close the hole in your scalp, but usually we just slap a piece of sterile gauze or a bandaid on there and let it be.

Holy shit! You're kidding, right?

Nope. Not in the least. The skull itself might take a while to heal, but your scalp heals really quickly--and your brain just sort of squooshes shut around where the tubing used to be.

Uh...so...then what?

Well, presumably, if we've taken out the tube, we've solved the problem.

If your problem is hydrocephalus, we've probably put a shunt in (more about that in a week or so) to help keep your CSF pressures normal. If the problem is an infection, we're done with instilling drugs into your brain. If the problem is a tumor in your brain, we've installed something called an Ommaya reservoir to pump little doses of chemo toward that tumor on a continuous basis. Whatever it is, we're done with tubes in your brain.

That's all, folks! Now you can be happy you've never had to have a ventriculostomy!

*No, really. I had a confused patient once who kept fiddling with and breaking off the leveling arms on his ventric setup, so I had to replace the leveling arm with an old radio antenna I scavenged from the surgeon's lounge. Just call me MacGyver.