44-38-44; Or, Jo Has A HOLY SHIT Moment

Welcome to the inaugural Wednesday Whine here at Head Nurse.

I bought a swimsuit the other day. Not just any swimsuit, but the swimsuit I've dreamed of for years: A very modest tank top (black, with red seaming, but you can't have everything), shorts that come midway down my thighs (solid black), a keypocket in the shorts (closes with Velcro!); in short, the only thing I could wear that covers nearly as much as a swim burqa without looking like an idiot. (I should mention here emphatically that swim burqas are the bomb. The only reason I would look like an idiot is that I am Not Muslim. It would be like me dressing up in, oh, a kimono. Or a hula skirt. I would not be workin' it.)

I got this swimsuit in a size 16W.

I am not pleased by this.

Not at all.

Now, I'm fairly mobile. I'm short and stocky and still quite strong, despite not having seriously lifted (read: lifted at all) since Atilla moved off to the Big City. But I am Not Happy with wearing a size 16W.

I should mention here emphatically, and not at all parenthetically, that I am not fat hating. People come in different shapes and sizes, period. What is healthy for a woman who was born to be a 16W is much different from what is healthy for me, who has the bone structure and genetics to be a size six. I am not fit or healthy (look at that waist measurement: it speaks of increased risk of stroke, heart attack, diabetes) at the size I am now.

So it's going to change. I thought about starting another blog to chronicle what I'm doing fitness-wise and diet-wise, but I got stumped by the title. "Fat, Flatulent, and Forty"? "Dammit, No, I'm Not A 16W"? "Holy Shit, That's A Lot of Beer"?

I decided to just do a weekly check-in here. According to SiteMeter, I get about 10,000 hits here a month (Hi, everybody!) and I am going to need every single last one of you to keep me accountable. Weight Watchers might be easier and more personal, but I am counting on the level of impeccable snark that you guys have displayed over the last five years to get me where I need to go.

Because not everybody wants to hear a blogger whine about how haaaard it is to do 3 miles in 44 minutes on the treadmill (Dammit! I used to be able to do it in 25!), I'm segregating the Wednesday Whining posts with a tag, with title, and sticking to one day a week. Y'all can scroll on by if you don't want to read about what I did with my treadmill during the past seven days.

It's scary to do this. I'm scared it's too personal. I'm scared I'll fail. I'm scared that there's some weird metabolic thing that has nothing to do with Cheetos or sedentary living or too much Mirror Pond going on, even though I know that that's highly unlikely. I'm frightened of putting this much of my not-anonymized life out on the Intarwebs, though you've read damn near everything else I've done in the last five years.

Join me. Bitch away in the comments about the cramp in your lats or how much you hate eating frigging vegetables in the morning.

One very important note: Anybody who posts fat-hating or attack-dog bullshit will be deleted. I don't care if it's about me or toward another commenter, it's going to go. Save your keystrokes for something else; you get a predetermined number in this life. (I wouldn't be this cranky about it, but I've been reading comments about Regina Benjamin and whether she's qualified to be Surgeon General because (*gasp*) she's fat!)

Next Wednesday: First week's schedule, goals, and comprehensive bitching about shinsplints.

How to tell if you live in Texas, and What I Do On My Day Off, part 2:

I opened the refrigerator this morning to get milk for my coffee. Something green and scaly, with nice big claws, handed me the milk carton. I'd said "Oh, thanks" and shut the door again before I realized that whatever's in the Tupperware in there probably shouldn't have opposable thumbs. Looks like I'm going to be cleaning out the fridge today.

On the upside, whatever it is is keeping Notamus from leaping into the fridge every time I open the door. So there's that.

HOW TO TELL IF YOU LIVE IN TEXAS:

1. An oh-six-hundred opening time for the garden center sounds like a plan.

2. You grocery shop when it's dark, to avoid having your milk sour in the car during the three-block ride home.

3. Sweat is an accessory.

4. You have a refrigerator full of noncaffeinated liquids and very little else.

5. Not only do you know what "raspas" are, you have a favorite flavor, and you know that raspas are essential to surviving July.

6. Instead of lotion, you use Benadryl cream on your legs, for the mosquito bites.

7. The TV weatherman stands in front of banners that say "COOL" when the high is supposed to be only 91*F.

8. You can tell the difference between 104* and 109* when you walk outside.

9. You have a kiddie pool in the backyard for your dog. And you fill it with ice.

10. A margarita on a hot day qualifies as dinner--and nobody thinks you're a lush.

Lest any Yankees think I'm joking about any of this, let me tell you a true story about the weekend of the Fourth:

I was at my neighbor's house, on their back deck. It was a nice day, only 101* for the high. The temperature, though, doesn't drop much when the sun goes down, so we were all sitting out on the deck, with:

Two fans

A couple of galvanized tanks full of ice across which the fans were blowing

Misters going overhead

Gallons of bug spray

A baby pool full of ice water in which to soak our feet.

It struck us all that we were sitting in the midst of a whole lot of technology and ingenuity, all dedicated to keeping us cool enough after dark that we wouldn't get heatstroke.

And yet we did not go inside.

*That's* how you know you live in Texas.

What I do on my day off.

I woke up this morning, detached two cats from my chest, and swung my feet over the edge of the bed.

My feet landed on a combination of wood screws, rubber bands, the plastic pull-tabs from milk cartons, and twist-ties that the cats had brought, like inanimate sacrifices, and laid at the edge of the bed during the night. Max was unhappy; the constant close proximity of Dreadful CATS had made him nervous, so he'd slept in the living room. After putting my feet on all of that, I kind of wish I'd slept in the living room, too.

I do not know why my dog doesn't recognize the kittens he loved to nom as the cats who now inhabit the house. All I know is that they make him very nervous indeed.

I wandered into the kitchen, fixed two drawers and a shelf, and then decided to bolt the top two tiers of a stackable bookcase to the wall in the living room. Surprisingly, all of that went off without injury or inconvenience.

Then I did some laundry.

Then I made what's about the best omelette in the history of ever:

Jo's Four-Egg, Use-Yer-Leftovers Omelette

Slice:

Five mini-portabello mushrooms (Or the usual button type; I just had the mini-bellas lying around)

A thumb-sized hunk of yellow onion

And sear in a nonstick frying pan without added fat. When the 'shrooms have got brown edges to them, remove from the pan and put in:

A handful of mixed shredded cooked chicken and ham (or whatever chopped meat you have. Taco meat or shredded pork chop would be acceptable, bacon would be fantastic; I'd have to draw the line at barbecue or roast beef.)

Some cayenne pepper

A small handful of chopped up zucchini (Or some other soft-ish veggie. Artichoke hearts would be good here)

And cook until the zucchini gets soft and most of the liquid has evaporated.

Remove the food from the pan, scrape it out, and spray with oil. Beat four eggs with a little water, and dump them into the pan.

Let the eggs sit in the pan, over medium heat, until they're mostly solid. If you can't leave food alone (I can't), you can pry up the edge of the set eggs and allow some of the unset eggs to run underneath.

When the eggs are mostly solid, add a little cheese. I like Muenster for this.

Then dump in the vegetables and meat. Allow the whole shebang to sit for a little longer, call it five minutes. By this time, the eggs should be smelling done and have bubbles in them.

Using a spatula and a rubber scraper, carefully fold or roll the omelette and flip it over. If the wind is setting right and all the stars are correctly aligned, you'll be able to do this first try. If not, you'll end up with a broken omelette, but that's okay: the cheese will melt out and toast and be extra-yummy.

You can eat half of this and save the other half to make your coworkers envious the next day.

If you're really, really expert at chopping, you can talk to your Brother In Beer while slicing mushrooms. I am not expert, and so hung up on him while attempting to hold the mushrooms with my fingers and cradle the phone between my shoulder and ear. I ended up holding the mushrooms steady with my elbow and slicing them that way. It wasn't as convenient, but I didn't hang up on him again.

In other news, Friend Suzie the Rat Wrangler starts her new job today as Sub-Chief Rat Wrangler for a Large Nonprofit Research Organization. Shout it out for Suz!

Now it's time for a nap. I might paint my toenails later.

Welcome, new residents!

He came out of the isolation room in full isolation gear, strode to the nurses' station, removed one glove, and began to return a page.

"Hey," I said, "Take off that gown and glove and wash your hands before you use the telephone."

"I don't have time for that" he said. "Besides, I took off this glove." He waved an ungloved hand at me.

"Dude. You're not Michael Jackson. Get that gown off, go wash your hands, and don't come out of an isolation room with gear on again" I said, feeling a little growly.

"They let me do this on the cardiac floor!" was his parting shot.

"You gotta be a grown-up over here!" was mine.

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

The neurosurgery residents aren't bad at all. Neither are most of the other residents. All of 'em have been on our unit before, because of the weird residency program we have. It doesn't matter what service you're with; you're going to round with psychiatry, neurology, neurosurgery, or internal med at some point, and that means you'll end up with us.

The two exceptions to that are urology, for some strange reason, and cardiology. And, given that the head of the urology department was a nurse before he was an MD, we don't have too many problems with those residents and things like respect and infection control and signing orders in a timely fashion.

Cardiology, though? Makes me want to tear my hair out.

They're nice people. Really. They're not the arrogant assholes portrayed on popular TV shows. There's not a prima donna in the bunch. They're very hardworking (almost as hardworking as the junior residents on neurosurgery), polite, knowlegeable, thoughtful folks. But they've been spoiled by the nurses on the cardiac unit, who don't care what you do as long as you keep the patient alive.

I, personally, care a whole lot what you do. I'm not going to go through every chart you've touched to make sure you didn't rack an order; I have better things to do, and besides, that's on your watch. And it doesn't make much sense to me to keep one patient in isolation alive if you're going to transfer bits of that isolated bug to other patients and the nurses' station. By the same token, I know a little about drug interactions, but it would probably be a fine idea to consult the pharmacy if you have questions. And, for God's sake, don't attack me because a patient's on a particular antibiotic for which you have a personal antipathy. (Not coincidentally, that was the same resident who didn't take off his isolation gown. Hmmm.)

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

Other than that one service, whom we thankfully don't see much of, things have gone smoothly. We have two new residents in surgery and two in neurology. The surgical residents look, as they all do, about twelve years old. One walks with his arms straight down by his side, peering short-sightedly through granny glasses, with his shoulders a little hunched. I want to feed him sandwiches and pinch his cheeks. The other has such an unfortunate surname that a nickname is superrogatory. That'll save us some time, at least.

The neurology residents may take some getting used to. The senior this time around is a brilliant woman--one of the smartest, most well-rounded people I've ever met--and a total bear to work with. Like a lot of geniuses, she's impatient with us normal folks and doesn't bother to try to hide it. The junior will be a whole lot more pleasant to work with once he gets over his shyness. Speak to him and he jumps. With the patients, though, he's great--he's careful, friendly, explains stuff in English, and never seems to be in a hurry. He's also trilingual in Spanish, Arabic, and English, which will be a huge help. He speaks a smattering of French, Farsi, German, and Russian as well. He's promised to teach me how to cuss in Farsi, which'll be my sixth obscene-word language.

So. All things considered, it's been a better week than I could've hoped for. Nobody's gotten horribly sick, my dehydrated patient with CHF didn't fill her lungs with fluid, and the number of racked orders hasn't been so large that we've had to mount a full-on offensive.

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

In non-work-related news, it's one hundred and bloody four degrees here just now. The projected high for today is 106 to 107. The only things moving are the cicaidas' vocal apparatus. Max is sacked out on the kitchen floor, just in front of the air vent. For those of you without a good idea of what 104 feels like, I offer this: I just went outside and hung up a load of wash on the line. It was scrubs and jackets. After I finished hanging up the last pair of scrub pants, I went back to the first ones I'd hung up and took them down. They were bone-dry.

The kittens, apparently unaffected by the general heat-related malaise, have destroyed a makeup box, my CD player, two shelves full of books, a hot-pan-holder, a box of drill bits, and two stuffed animals (those last are theirs to destroy) in the last three days. I'm going to have to bolt the bookshelves that my grandfather built to the walls, as Notamus is such a fatass he's going to bring them down one of these days.

Friend Elizabeth has a 1949 stove to get rid of. Does anybody want it? It lacks a thermostat for the oven, but is otherwise in good shape. It weighs about three hundred pounds and is currently in Manhattan, Kansas. Anybody in the area from Wichita to KC who might want a vintage stove and oven, please let me know. We'll work something out.

Updated: Jo's Rules For Living.

General:

1. Pick up after yourself.

2. Don't be an asshole.

3. Say "thank you."

On Work:

1. If you have to jack with it, it's wrong.

2. Every surface should be thought of as dirty until proven otherwise.

3. Have an extra pair of scrubs.

4. Always take extra supplies into the room with you.

5. Wear shoes you won't fall out of.

On Drinking and Eating:

1. If the ingredients list has words beginning with "para" or "quasi", don't eat it.

2. Cheese always helps.

3. Good bread is worth the money.

4. It's not worth getting drunk on fine wine; you won't remember how good it is, and your head will hurt just as much as with the cheap stuff.

5. Eat butter, not margarine or Promise.

On Partying:

1. If you drink, pace yourself.

2. Don't say it drunk if you wouldn't say it sober.

3. Remember: If you start something, *somebody* is going to have to finish it. It might not be you.

4. Always have an alternate plan in case your designated driver craps out on you.

5. No, that's not a good idea.

On Relationships:

1. Pick up after yourself.

2. Don't be an asshole.

3. Say "thank you."

Aaaaaand as an antidote for that last post, possibly the weirdest rendition of "Working in a Coal Mine" ever. It's Swedish.

From Jezebel, strangely enough, and about Mark Sanford...

...but it still punched me in the snoot. To wit:

Lots of people do get into relationships that require way more work to hold together than it seems like is healthy for anyone. I'm as guilty of this as anyone else: I've had my ultimatum-issuing moments; my moments of pretending everything's okay for the sake of keeping the peace ; my moments of silently weeping in bed, waiting for someone to fall asleep, pretending that not talking about it can make the problems go away and that just trying harder will make us not-unhappy and that not being miserable is a step along the path back to happiness. Commitment is important, right?

And, sometimes, I suppose, it can be. But other times — many other times — the betrayal is too great and the emotions are too dark and the road ahead doesn't go back to being nicely paved, but turns into gravel, then dirt and then mud.

Random 4 am musings

One of the best things ever is waking up at 0400 and realizing you don't have to work today.

Add to that that the cats were all over me, doing their "We love you so much; here, let us lie on your belly" act, and it's been a good morning so far (all fifteen minutes of it, anyway). 

I wonder what the house's previous owners were thinking when they painted the office ceiling high-gloss beige.

It's time I defrosted the freezer. Yes, I have a non-frost-free freezer; my refrigerator is Polish. It's the only one I could find that fit the space I had for it in the kitchen. Plus, who needs 120 cubic feet of refrigerator space when it's just one person?

We need a new definition of patients eligible for rehab. If they're strong enough to get themselves into a wheelchair, get out the door of the hospital, get 300 yards down the street, and score some meth, they're not candidates for rehab and can head on back to the house.

Max is thrilled that his girlfriend is back. Sophie lives next door. She can play "So's *Your* Mama" through the fence like nobody else, and loves to wrestle when they're in the same yard. She'd been gone for a week on a camping trip, and Max was bereft. 

It's a really good feeling to wake up and know that not only do you not have to go to work, but you cleaned house yesterday and so have a free schedule today. I might, I dunno, fix some drawers in the kitchen this afternoon.

I just remembered that July 1st is coming up, and with that date, a whole new crop of residents will start rotations. It should be a fun month. 

Texts From Last Night is one of the funniest things I have ever read. I went through about 20 pages of it and was crying, I was laughing so hard. (Link not safe for work; not safe for Mom.)

If you're hitting your PCA button 122 times in an hour, and you're half-asleep while doing it, there's something not right.

I need some new light-blocking curtains for the bedroom. Hm. Time to go to Target, I guess.

One of my coworkers and I did a little song-and-dance routine while chanting the lyrics to "Short Skirt/Long Jacket" the other day. It went over big. We may have found a weekend job.

Somebody added stickers with the words "Don't" and "Believin'" to the stop sign at the end of my street. Whoever you are, I salute you.

Friend Suzie's mom apparently just killed her third rosemary plant. I have got to head over there and see what she's doing wrong. Killing rosemary is damned near impossible, even for me.

When I was told that I had to fill out a requisition for a 20-gauge coudet catheter, I simply went up three floors and swiped one from another unit. This is why the supply situation is so bad.

I wonder what I'm doing this weekend. For the first time in seven years, I am not working over the Fourth. Not quite sure how that happened, either. Something tells me the weekend will involve Prosecco and good Mexican food and a mariachi band.

Notamus just leaped from the futon to my shoulder. He is HEAVY.

And now it's time to stop musing and have some more coffee.

Zhausted, Take Two.

I'm ready for my exit interview, Mister DeMille; or, Don't Ask If You Don't Wanna Know

"Why are you leaving?"

It's a question I get asked on a daily (at least) basis. Do you really want to know?

It's because, when I asked not to be assigned to a patient who'd been sexually aggressive with me and harassed me both verbally and physically, I was told I couldn't refuse an assignment....yet Manglement did nothing to protect me or the other nurses from that winner.

It's because, when I go into the clean supply room, I can no longer count on finding the things I need to take basic care of a patient. In the name of saving money, we now don't have enough urinals. Or bedpans. Or bandages. Or catheters. Apparently, we were being entirely too profligate with our Foleys.

It's because, though I've worked on the same unit for seven years, Friends of Manglement get preference for assignments, vacation requests, and scheduling. 

It's because, in the name of saving money, Manglement has reduced our staffing to unsafe levels.

It's because, if a patient or a patient's family member has a complaint about a nurse/care aide/cleaning person, that complaint is taken seriously and the response is punitive. Conversely, if a nurse/care aide/cleaning person has a problem with a patient or "guest", even if that problem extends to threats of violence, "customer service" techniques are used to "resolve the issue", and the professional person's concerns are belittled.

It's because I'm tired of fighting every single damn day to be able to care for my patients in a safe way. It's because I'm tired of getting saddled with six or seven patients of varying acuities because the staffing office says that's how it ought to be. I'm tired of big decisions being made for the acute-care units by people who live on carpet and haven't worked a 12-hour shift at the bedside in twenty years. It's because I'm sick to my eyeteeth of the notion that "customer service" is more important than "good nursing care". It's because I'm exhausted by chasing around whatever person it is that needs to approve a request for a chest tube kit or extra IV pumps or more crackers for the patient pantry. It's because I'm tired of every single thing I do being evaluated, not on the basis of quality of care, but on customer service.

All I can say is, it must suck to be the manager of my unit. My manager's stuck between the very real needs of the nurses and staff and the insane demands of Manglement. Manglement makes it almost impossible for the manager of any of our acute units to actually do his or her job; instead, there's a bizarre combination of micro-management and total indifference that has got to be raising blood pressures on all ten floors. 

Fortunately for me (and anybody else who wants to go into or is already in critical care), the critical care pods are managed by a totally different group. The nurses get what they need, from equipment to staffing, and their worries and problems are taken seriously. I get a real sense of community and teamwork, since there's not a culture of "rat out your coworker, get a gold star" there. The managers of the CC pods are working nurses who pull shifts at the bedside every week, not just when they feel like they're getting rusty. The upper management of the CC pod, likewise, are CC nurses who hold down a job in management and one in actual bedside nursing as well.

Several years ago, Manglement instituted a number of changes on one of our acute units. Mostly they had to do with staffing and the types of patients the nurses would be caring for. Within six months, there had been a complete staff turnover on that unit, with a number of the nurses ending up, surprise surprise, in the critical care pods. 

This year Manglement did the same thing to my home unit. Nothing like learning from your mistakes, hm?

I'm the first to go. Somehow, given how many of my coworkers have taken me aside and asked me about the application process for the CCPs, I doubt I'll be the last.

Saturday subtlety.

So, yeah. It was a bad day the other day.

She'd been fine when I saw her at 0730. A little groggy, yeah, but that was because she was on tremendous amounts of Neurontin and various painkillers, a result of her having had a spontaneous epidural hematoma. (Note to Googlers: spontaneous epidural hematomas are extremely rare; two of my patients on the same day had had them. Such is life at Sunnydale General.) At any rate, she was moving all the limbs that she had been moving before, and could speak fluently, if sleepily, in response to questions.

Then, at ten past eight, her daughter called. She was concerned because Mom wasn't picking up the phone. Daughter is the sort of thorn-in-the-side, pain-in-the-ass advocate for a patient that we simultaneously dread and admire: she'd enlisted the help of a couple of family friends who were nurses, and she called regularly for updates. 

Anyway, Mom wasn't answering the phone. This wasn't unusual, as Mom tended to sleep in. Plus, as I'd said before, she was groggy that morning anyhow. But, because my Spidey-Sense started to tingle, I went into her room anyhow, to see if she needed help ordering breakfast.

I found an obtunded patient who couldn't move her right side and couldn't speak. She'd stroked out at some point in the last forty minutes.

After the usual stat CT scans, administration of Narcan and a bolus of normal saline in the vain hope that this was merely dehydration, rushing around notifying family members (thank God I didn't have to do that), and transferring her to the ICU, I sat down with the intensivist for a post-mortem of what might've happened.

Turns out she'd had an episode the day before of having one arm go dead. Her legs were already gone, thanks to that spontaneous epidural hematoma, and we couldn't feed her coumadin or heparin or any of the usual anti-clotting drugs, thanks to that spontaneous epidural hematoma. Although she'd recovered her arms in a matter of seconds the day before, the fact that she'd lost one at all (and by "lost one" I mean "lost all motion and sensation") led us to believe that she had some sort of clotting disorder besides the original one.

And, sure enough, she had a previously-undiagnosed bit of atrial fibrillation. A-fib, as we call it in the biz, is a condition in which the top chambers of the heart don't squeeze regularly. Instead, they sort of shiver. This doesn't affect how you feel, much, but it allows small clots to form in the backed-up blood that isn't cleared from the atria. When the heart muscle finally gets its shit together and manages to actually contract the atria, clots can shoot into the brain.

Which is what happened in this case.

The bitch of it is, the utter, total, black-furred bitch dog of it is, there was nothing at all we could've done. Some part of her clot cascade was impaired to the point that she had an eleven-inch long hematoma in her spine with no rational cause, so it's not like we could anticoagulate her. Doing so would've caused the hematoma to restart, and would've certainly killed her.

So, instead, she gets to live with only one (partially) working arm, no speech, and no ability to recognize her daughter.

The daughter was on the way to the hospital later that afternoon. I am not looking forward to seeing her. Even though there was nothing I could've done differently, and nothing would've changed even if I had witnessed the stroke, I still feel responsible.

Conversation over dinner

Me: "I can't help it. I'm feeling cranky. And grouchy. And disillusioned. And bitter. And grumpy. I no longer believe in love or the sanctity of romance. I hate everybody."

Friend Suzie, deadpan: "Take. A. Fucking. Motrin."

Product Review: Why the Germans are kicking our asses on the cleanliness front

Many, many years ago, I moved into an apartment where the previous tenant had been a middle-aged German woman. Everything was spotless. The coils on the back of the fridge were clean. The closet that housed the water heater was clean. The rug squeaked when you walked across it. The walls had been scrubbed. The tiny galley kitchen, off of which the back door opened, was so clean that I didn't waste any time wiping things down when I moved in.

Germans have a longstanding bad attitude about dirt, and now I now why.

Product Review: Miele Neptune

So I bought a vacuum.

A five-hundred dollar vacuum.

Sainted Father is slapping his thigh right now and making a noise of utter disbelief. Beloved Mother is raising one eyebrow skeptically. Beloved Sister is going "Nnnnggg" with envy. The Brother In Beer is wondering if I've ever vacuumed before in my life.

I bought a Miele Neptune after reading thousands--and I mean literally thousands; it took me weeks--of reviews online and finding very few negative ones. The negative reviews I found had to do with things like the length of the power cord and how easy it is to reduce the suction if you're clumsy and hit the suction-reduction button by mistake. Every model of Dyson I read about, by contrast, had volumes of bitching about noise, reduced suction, bits breaking off, things catching fire (!!!), and attachments not fitting correctly.

The Neptune arrived today. It is compact (about twelve by twenty inches), light (about six pounds) powerful (watch out for jewelry on the floor!), and quiet. Max, who gets nervous about noise of any sort, raised his head when I turned it on, glanced at the machine, and laid his head back on his paws and went back to sleep. The kittens had to be physically removed from the area; they were playing with the parquet head.

First I vacuumed the bare floors and wondered why the old vacuum/dust mop/Swiffer combination hadn't picked up all the dirt. The floors shine like they've been waxed, now. Then I moved on to the big jute rug in the living room, and wondered again what the old vacuum had been doing. After that I vacuumed all the walls and the ceilings and the top of the refrigerator and the bookshelves and a pleated fabric lampshade that I thought was cream-colored but, on vacuuming, turns out to be white. Then I vacuumed the top of the fridge, the bathroom floor, the utility room (aieee!), and the woodwork.

The entire time, the animals were totally unmoved. I heard a text-message alert come on my phone, and listened to NPR without having to turn up the volume. 

If I could vacuum myself without injury, I would. I think I would be clean enough to perform surgery without a preliminary scrub.

Drawbacks, if they can be called that, include the fact that if you're trying to pull the vacuum over a rug and around a corner simultaneously, it will tip over and turn itself on. Also, the cord is only about ten feet long. My house is a whopping 900 square feet, not including the utility/everything room, so that isn't a problem. The instructions that come with the machine are Germanic in the extreme, so you might want a couple of slugs of good liquor before you read them. The Miele cannot be used on animals or in wet environments. It also probably should not be used under water or in zero gravity, though it'd probably work in that last. And the suction control on the wand is easy to open by mistake, but only if you're as clumsy as I am.

Verdict: Save up. Spend five clams on a vacuum. Within fifteen minutes I knew this was the best five bills I'd ever spent on anything.

I had a wonderful post all written in my head....

...about how I watered the tomatoes last night and found that, although the neighborhood raccoon had tried to eat all of them, he'd missed a few.

Also about how it was the solstice, and thus how the sun had hung on the horizon for what seemed like forever on Sunday night, lighting the dinner and Rogue that my friends next door gave me.

Also about how the solstice reminds me of watching eagles hanging in midair over the mountains, with sunset not happening until nearly midnight, and the sense of infinite possibility.

Also about how yesterday was full of kittens and dogs and gardens and my basil blooming.

Instead, one of my patients went very, very bad today. It's nobody's fault, but I'll be taking a couple of days off. Because you kind of have to, after a day like today.

What To Expect When You're Expecting A Central Line!

So. You're in the hospital, stuck with a disorder or disease that requires multiple infusions of something nasty like chemotherapy or Vancomycin or suchlike, and your doctor tells you you need a "central line". What the bejimminy blazes is a central line, and how do they work? And why the hell is this a good idea, anyhow?

Listen up: you'll thank yourself for getting one, especially if your particular condition requires not only infusions of Nasty Stuff but also frequent blood tests.

Central lines are, as the name implies, intravenous lines that go into one of the really big veins that drains into the center of the body. They come in three types: Really Temporary, Sorta Permanent, and Really Permanent.

The Really Temporary type is most common if you're having something like plasmapheresis done for CIDP or MS. Normally it's inserted at the bedside by a surgeon, and it goes into the internal jugular vein (that's the big one in your neck). Very occasionally they'll put one into the big vein in your groin, but that's kind of a pain in the ass, so it's to be avoided if at all possible.

Most likely, your IJ (internal jugular) central line will have two separate toggles on it and will be short and sort of curled on the ends. Through this, nurses and doctors can draw blood and do plasma exchanges. It saves you from getting large-bore IVs started every time you need a plasma exchange, and saves you from getting stuck multiple times for blood draws....but there's a drawback: no matter how carefully-inserted the thing is, it has to come out after a week, two weeks at the most.

The Sorta-Permanent type of CL used most often is something called a PICC line. PICC stands for Peripherally-Inserted Central Catheter. It goes into your arm and threads up the big brachial vein, to end just above your heart. PICCs are very handy indeed, as they come in one, two, and three-lumen (opening) versions and can be used for everything from injections of IV contrast (provided they're the right sort) to blood draws to chemotherapy infusions. 

PICCs can stay in for weeks to months; I've seen 'em stay in and be usable for six months or more. Generally speaking, though, you want the thing out within about 14 weeks, just to reduce the risk of infection.

The Really-Permanent type of central line is called a Mediport. (This, by the way, is a brand name. Please don't sue me. Thank you.) Mediports are cute little buttons that sit under your collarbone and attach to a line that runs, again, into the big vein above your heart. The advantage of Mediports is that they can stay in basically forever, be used for blood draws and suchlike for years, and don't have as great a risk for infection as the other types of central lines. The drawback, of course, is that you're getting something implanted under the skin of your chest, so you're gonna need anesthesia and stitches and so on. Plus, they're kind of a pain to take out. However, if you're going to need chemo for a long time, like if you have MS and need periodic infusions of Rituxan, they're a good bet.

Mediports are accessed by a stick. That's another drawback if you really hate needles, but hey: it beats getting stuck with enormous needles over and over in one or both arms, right? Right.

The drawbacks of all central lines are pretty much the same: you could get a whopping infection either at insertion or later on. To combat that, they're put in using sterile technique, and everybody's very careful about using them. 

Another possible complication is that the line either busts through the vein wall or doesn't go where it ought to, leading to punctured chest cavities, internal bleeding, or other screwy stuff. Luckily, lines are what we call "radio-opaque", which means they'll show up on X-ray. Once they're placed, we can check that they're in the right spot with an X-ray, and reposition that sucker if necessary.

A final complication, and the most common one by far, is that the central line will form what's called a fibrin sheath on the end, so you can neither draw blood nor infuse drugs through it. Fibrin, by the way, is a component of blood clots. When this happens, we have a cool drug called TPA that can dissolve the fibrin, thus making the line usable again. And no, it doesn't mean a clot will go shooting toward your head; it dissolves the blockage into such small pieces that your body doesn't even notice them. I do a LOT of central line declotting at work.

That's your Central Line Primer for the week. Consider asking for one if you're undergoing treatment for MS, MRSA, cancer, or anything that'll require frequent sticks and blood draws. Your peripheral veins will thank you. 

Thursday.... .... ....somethings.

last of all

It's official.

I have seen people who have had various body parts kicked in or off by various animals.

I have seen people who have been hit by drunk drivers, popped ill-advised wheelies on overpowered motorcycles, been hit by lightning, and fallen off structures of varying heights.

I have seen people who have grabbed the end of a downed power line, been run over by a truck on ice, been hit in the head with a keg of beer (full), been hit in the face with a trailer hitch at 70 mph, and who have failed utterly at trying to kill themselves.

I had never before seen somebody who's been scalped by a mixer.

Therefore, I have this to say: I believe that I have now seen it all. 

And this, come to think of it: Those plastic guards on five-foot-tall commercial mixers are there for a reason. Do not remove the guard, then lean over into the mixer to see how things are going in there, with the 300 rpm whatsis going round and round. Okay? Okay.

I wish the guy who stuck his head under the running combine to see what was making that funny noise were still around. We could double-room those two.

Hey, guys. This is kind of important.

Let's talk for a minute about donating organs and tissues, shall we? 

There are three big things that you need to know about organ donation. The first is the most serious: There Are Not Enough Organs For Everybody Who Needs One.

The second is this: Nobody Is Going To Kill You In Order To Harvest Your Organs.

And the third is this 'un: We Can Use More Than Just Organs.

Point Number One:

There simply aren't enough organs to go around. Kidneys, livers, hearts and lungs, you name it: there ain't enough. The problem is particularly acute in minority communities, as there are certain immunity factors that make successful transplantation more likely if you transplant, say, a kidney from an African-American or Asian-American into another African- or Asian-American. People die every day--thousands of them--because they've run out of time on a waiting list. You can donate even if your religion recommends that you stay in one piece for burial (Orthodox Judaism has an allowance for donation; I don't know about Jehovah's Witnesses), even if you're old, even if you're sick with certain things.

Point The Second:

When you (or somebody you love) dies of trauma or some "allowable" disease, the folks who keep your body alive and the folks who decide if you're a donor candidate are NOT the same people. Likewise, if you're wheeled into an ER after a motorcycle crash during which you weren't wearing a helmet, nobody's gonna look at you right off and say, "Hey, this is a potential organ donor; slow down on that intubation, okay?"

There are no doctors looking covetously at your liver. There are no nurses who're gonna slip you a little somethin'-somethin' to hurry you along. We're in the business of exhausting all possible resources until somebody says "stop", at which point we turn the possibility of donation over to some totally other different group that's not associated with us.

Point Numero Tres:

Even if you leave your organs in bad shape, we can still use your tendons (for people who need knee or hip surgery), bone (for trauma), skin (burns), intestines (yikes) and other bits, like corneas, to help other people. On the back of my driver's license is the notation: ALL USABLE ORGANS AND TISSUES. My family knows to compost the rest and plant a garden on top of it.

Please make arrangements to donate. Tell your family and friends. Fill out a "Live, Then Give" card--you can search online for local organ donation organizations that can hook you up.

And, if you're not in the mood to donate, or the thought of somebody using your leftovers totally squicks you out, try this: Faithful Reader Hallie has started a fundraising effort for the United Network For Organ Sharing. They're a great group--they work on national policy to make sure that organs are distributed in the most fair way possible, raise awareness, and get people set up with new bits when they need 'em. 

Hallie's dad got a new heart through their good offices and is still going strong six years later. I encourage you to learn what you can about UNOS and what they do, and donate if you have the wherewithal.

Information is here.

And thank you, from the bottom of my eventually-to-be-reused heart.

Product Reviews: Pale redhead edition

Back in the day, my Beloved Mother used to sigh resignedly when I left the house in pale base, black eyeliner, purple lipstick, and a flattop.

Beloved Mother will probably not be happy to learn that black eyeliner, black mascara, and purple lipstick have returned to my makeup box, on regular rotation, as part of a professional look.

Those of you who are well-versed in girly stuff will already have known that you can't wear the same makeup as a nearly-forty-year-old as you did when you were a teenager. I did not know that, so I had been wearing the same brown eyeliner/brown mascara/clear gloss combo for the last...oh, twenty years? as I had when I was not Going Out and trying to make Beloved Mother Sigh Deeply.

However. This summer I seem to have acquired a tan. A fairly deep tan, for a fair redhead, which means I'm approximately apricot-colored with darker freckles (it looks better than it sounds, I swear). The brown/brown/clear thing simply wasn't working. I looked tired.

So, on a whim the other morning, I yanked out the black eyeliner and mascara. Despite the fact that Flashes had chewed the end of the blending brush I use for smudging eyeliner, I perservered (and will probably end up with some obscure eye infection caused by cat saliva).  I used black eyeliner, smudged it with nearly-black/still vaguely brownish/kinda charcoal liner, and added two coats of mascara. 

Hm. Okay. I don't look like a Goth or a trollop. Hm. What's this? Purple lipstick? What's the color? "Prince's Toenail Bruise"? Sounds good. Slap some of that bitch on up, then.

And all day? People told me what pretty eyes I have. And how awake and rested I looked. Strangely enough, the solid black liner and lashes look more natural than brown. It's very odd. And the purple lipstick? Sparingly applied, it looks like I've just eaten a dozen habaneros, which, for a girl with my lippage, is saying something.

I'm going off to find that old Einsturzende Neubaten T-shirt now. And maybe consider a flattop. Because I am the epitome of femininity. 

Tessalon, Omnicef, and a heat index of 108.

According to Herr Doktor Babyface, I do indeed have a sinus infection; a bacterial superinfection after my summer cold. Which sucks, I must say, rocks. The bad news is that I'll feel rotten for a couple more days. The good news is that Herr Doktor Babyface believes me when I say I hate narcotics, and so hooked me up with some Tessalon for the cough. I'll sleep tonight, wake up in the morning (sadly), and not have to worry about itching and being dopey.

Which is good. With a heat index of 108*, I have enough to worry about. When it's this hot and humid (101*, 60%), the air conditioners at work tend to start getting overburdened and not working quite as well as they ought to. The temperature inside the building on the ground floor when I left today (early, to see HDB) was near 80. It was hotter upstairs. 

Patients don't like it when it's hot. Nurses don't like it when it's hot, but aside from sweating through scrubs and smelling worse than usual, there's not a lot about heat that's going to hurt us. People who've had large sections of their brains fingered, though, tend to have really crappy temperature-management systems internally: they get hot and cold quite easily. Add to that the usual number of people with high cervical spine injuries (who tend not to be able to regulate their own temperature either), and you're in for a fun day of ice bags and fans.

I'm thinking of moving, once my two years in the ICU is up, to somewhere with slightly less obnoxious summer weather. Spring here is such that you can go on a picnic during it, provided it doesn't happen while you're in the shower. Fall here is great, if you don't mind hay fever from hell. Winter is quite mild....but summer? Kills people. For reals.

Meanwhile, friends of mine a few hundred to a thousand miles north are talking cheerfully about camping and gardening and going for long walks in the balmy afternoon. If I went for a long walk in the balmy afternoon today, I'd be coming back in an ambulance with an IV of 3% saline. 

Y'know how people in Northern cities like Anchorage and Montreal and Toledo come out in droves in the springtime, squinting at the sun? And how all the great street festivals and so on are held in the summer? And how some people wear sweaters, even, after the sun goes down in the summer? 

Summer for us is like winter for them. We come out, squinting at the sun, in early October. Oktoberfests are huge here, partly because it's finally cool enough to dance again. We hang out all winter (with the exceptions of the two days it's really cold) and most of the spring, then go back inside in early June and stay there until the next cool front blows through on September 30th. 

Yow. I've grouched myself out. I have a sinus headache, four months of over-100* temperatures to look forward to, and I'll stop right here.

Meanwhile: does anybody have a house in, say, Portland that they'll be looking to sublet in late 2011?

Because I will be non compos mentis the next few days:

Sometimes things get really hard.

Sometimes it's really, really hard to view patients as people. Sometimes you just want to smack them instead.

When you meet somebody who is so very unpleasant in every way that being around them makes you want to take a shower with Brillo and then bleach your brain, it's hard to remember that you're there to help. It's hard to remember that your help is not contingent on their helping themselves; it's to be given, period, full stop, without conditions.

We had a patient years ago who was one of those brain-bleach folks. She was bitter, angry, mean...you name it, she'd say it to you. She couldn't strike out physically, so she was nasty with words and bodily functions. She weighed in at a little over five hundred pounds and refused to do anything at all for herself, from answering the phone to cutting up her own meat. Turning her was an adventure we had to undertake several times a day, dressed in rubber gowns, as she'd defecate and urinate on herself and others during the process. She was an absolute frigging nightmare to deal with, and ran through every nurse on the floor in a matter of a couple of weeks.

She was also a "private-pay" patient, which meant she was essentially there through the charity of the hospital. Private-pay patients are either very rich or have no money whatsoever, but we take care of 'em all without asking details. 

Most of the time, the nurses at our facility have no idea what financial arrangements our patients have made; that's handled by the folks in the carpeted areas. In this case, though, it was different, because this particular patient needed a long series of IVIG infusions. IVIG (intravenous immunoglobulin) is hideously expensive--about ten grand will buy you a liter, depending on market rates, and the average person needs several liters over several days to complete a course of treatment. 

This particular patient had already been through two other treatment options, both mindbogglingly expensive, on our dime. The question now was whether we could afford to continue treating her when the expectation of full functionality returning was slim and her commitment to her own care was nil. We all had to sit down as a group and talk about the ethical quandaries involved in treating/not treating her.

We ended up treating her, period, full stop, and rehabbing her for several months at no cost to her.

She was brought up this week by a pal of mine, as a contrast to another patient we'd had recently.

The recent patient was one of those folks you can't help but love. She was also a charity patient, but couldn't have been more different from the first woman. She was funny, and smart, and sassy, and sweet, and had a perfectly treatable tumor on her brainstem. It had affected her ability to move, but not her brain. She worked hard to regain the functionality she'd lost, insisting on feeding herself even though it took a long time and she tended to be messy. She had a small, tight-knit group of friends who came every day just to hang out. She had good family support and had managed to make every single treatment appointment she had.

She died a couple of weeks ago. The carpeted folks decided we could no longer afford to continue to treat her tumor, and she didn't have any other options. She died with her mental faculties intact as her body shut down.

These are the sorts of scenarios that make you want to just sit down and not move for about a year. The first patient got treated, at the cost of Frog only knows how many millions of dollars and how many shreds of patience, for *months*. She got that treatment because, at the time, the economy was going full-bore and the carpeted folks figured we could afford to spend money on somebody who wasn't compliant with her treatment plan or her own care. 

The second patient died because money got tight. She had a much better potential outcome than the first patient; it was only her timing that sucked.

It would be easy to throw my hands up in the air and say, "Fine. You don't wanna take a hand in getting better? Then we won't treat you. Work with the physical therapists and quit spitting at the nurses if you want your IVIG this week." It's easy to feel that People Like That somehow are less deserving than Nice People, even if what they're less deserving of is lifesaving care.

Then, though, you're faced with the question of where to draw the line. Long-time smoker and drinker? Fine: you can die of esophageal cancer, and it's all on you. Pregnancy-induced hypertension? Fine: go ahead and get eclampsia, you fat pig; you should've been skinnier before you got knocked up. Brain tumor of a strange and rare sort? Fine: obviously, you have bad kharma. It's easy to see where blaming people leads.

I've been thinking about this for a few days, now, and I haven't come up with any solid solutions to this dilemma. Should we make compliance with care a prerequisite to receiving that care in the first place? Should we force patients to sign something? Play nice? Be pleasant? At least give a damn? Can we realistically do any of that? 

And then, on the micro level (as my sociology prof used to say), you get the problem of providing care to somebody that you, personally, would rather leave out on an ice floe. I got cussed at, screamed at, and peed upon by a person whom I'd'a rather just left alone, but I had to deal with all of that because I have a commitment to taking care of people, period, full stop.

It's never easy to do this stuff for a living, but this last couple of weeks have reminded me how very hard it sometimes gets.

There ain't nothing like a Dane, a sinus infection, and Scotch.

So I'm getting the mail today (I was too tired last night, due to this sinus infection I've got brewing) and I feel something cold....and wet....on my neck....and I hear heavy breathing.

Behind me, wagging his tail, is the down-the-street Great Dane, out on a walk with his people.

There ain't nothing like a Dane, I tell ya. As far as Stealth Fear dogs go, they rank near the top, especially when they've got uncropped ears and a long tail. Turn around and find a guy like that on your porch, looking at you eye to eye, and you'll use up your adrenaline for the month.

*** *** *** *** *** 

Sinus infection. Yeah. Hate 'em. Got a couple of things to write, and a couple of deadlines to meet, and nothing is going to be happening (sorry, Hannah!) until after I get some antibiotics and some cough stuff. Scotch is good and all, but I can't keep drinking it in the quantities necessary to keep a) the cough at bay and b) some sort of functionality in my brain. The costs are too high. My liver is already on strike this month.

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

Note to My Favorite Resident: I understand that you really need to get ahold of whoever it is you need to get ahold of, and that you've given me six phone numbers that might work for that person.

Please understand, on your end, that I have spent most of three hours calling those six numbers over and over and over and over and.... and have still not gotten any sort of response. I've left messages, I've paged people, I've called repeatedly. Is that clear? Nobody is responding. If your attending managed to raise somebody at those numbers a week ago, good on him--whatever he did worked, so maybe you should call *him* and task him with reaching those folks. 

Whatever you decide, please don't yell at me.

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

And, finally, a little Sunday Night Lindy to get you in gear for the week:

Please note the young woman in the nurse cap. That, my friends, is what every day at Sunnydale General is like.

Gentlemen:

Chuck Palahniuk is gay.

Ayn Rand was a Communist.

You are not the shee-it because you are a surgeon.

Please go tie a brick to it so it's a little bigger, then come back and talk to me when you feel like you don't have to yell any more.

Thank you.

Dear God, I hope this is the last time HN is a remodeling blog for a while.

I have eleven new windows and two new doors and a man who needs to get his ass in here, silicone-caulk a couple of things, and get the hell out.

Watching other people work hard is exhausting. Time to break out the LST.

Hump Day Cat Nap

He's zhaustid.

Yet Another Freaking Brilliant Idea, Offered Free Of Charge

You know what you need when you have a head cold, a ton of homework, or some nasty chores to get done?

MOMS.

Not just any MOMS, but my new idea: Mediation Of Malady Service.

It'll work like this: There will be a force of several thousand women in their mid- to late-middle age (say 55 to 75) who will arrive at your door with whatever's needed to make you feel better in the midst of a cold or personal crisis.

Break up with a boyfriend? MOMS will send a calm, cheerful woman in a flowered top and elastic-waist pants to your house. She'll be carrying a gallon of ice cream, a couple of Liz Phair CDs, and a teddy bear.

Got a head cold? MOMS has a wide selection of MOMS from which to choose. There's the Jewish MOM, who shows up with kosher chicken soup and crackers. There's the Thai MOM, who comes in all energy and grit, with a pot of tom kha so hot it'll singe your eyebrows. There's the Midwestern Methodist MOM, who carries a casserole and some back issues of "Good Housekeeping". And then there's Jo's MOM, who arrives in a sweatshirt and jeans, with some home-made chicken enchiladas and a remarkably powerful hot whiskey-and-lemon.

Got a deadline that's making you sweat? MOMS will dispatch one of their qualified technicians to make quietly kitcheny noises in the background while you work. Once every two hours,your MOM will come in with a plate of cookies or a sandwich and make you take a break. 

Got a house that needs cleaning, stat? MOMS has the specialist you need. Your carefully-screened MOM will arrive with bucket, mop, broom, can of Endust, and all the energy of a pack of laborador retriever puppies on speed. Dust bunnies won't stand a chance.

If you have the flu, a *really* bad cold, or have just gone through more than one personal crisis at once, MOMS has a special product: GrandMOM. GrandMOMS are a little older, a little rounder, and smell like sugar cookies. They come armed with whatever you need to weather your storm, plus a radio that only plays big band tunes from the 1940's and a purring cat. Extra charges will apply for GrandMOM service, but when you need it, you need it.

See? With ideas like this, I could retire next week. Except that I've got a nasty cold and no energy to implement my plan. One of you tigers will have to do it. Then send me a MOM, willya?

Unusually political:

The Network has also received many requests from women who received care from Dr. Tiller and from activists in the reproductive justice community to set up a Fund in Dr. Tiller’s name. In response, we have established the George Tiller Memorial Abortion Fund to assist the women to whom George Tiller dedicated his life. The Fund will assist women in the second trimester to pay for abortion care, as well as pay for travel and lodging en route to providers. To donate to the Fund in Dr. Tiller’s name, please send contributions to:

George Tiller Memorial Abortion Fund
c/o National Network of Abortion Funds
42 Seaverns Ave.
Boston, MA 02130

You may also donate online at http://www.nnaf.org/tiller.html

Eight years after I worked at the local abortion clinic, I am still getting harassed. Please consider donating if you have the money, volunteering if you have the time, or speaking out if you have the balls.

My new bumper sticker will read: "I'M PRO-CHOICE AND I RETURN FIRE."

In Which Jo Responds To Panicked Emails

I am not shutting Head Nurse down. 

All I'm doing--honest!--is switching departments inside Sunnydale General, so I'll be an ICU nurse rather than an acute care neuro nurse. My job will still be about 70% neuro, so you'll still get stories about people with big holes in their heads. You'll get those stories as the people are a little closer to the OR, but you'll get 'em.

So why the hell did I decide to switch gears seven years in? 

Easy answer, and the one I gave the interviewers at Sunnydale: I got bored. There's a lot of truth to that, actually; after seven years in one place, doing pretty much the same thing every day, I started to want something a little more complex and a little deeper. With ICU nursing, you learn a whole lot about five or six systems per patient. With acute care, your concerns are primarily with one system, and your knowledge of each patient is broader and shallower.

I was getting itchy, and getting bitchy as a result. 

One of the ICU nurses told me that she wished she'd made the switch from acute to critical care years before she did, that this was the most interesting, fulfilling job she'd ever done. I hope that's what it turns out to be like for me.

The other reason I'm switching is the management of the acute care floors. I've gotten tired of being everybody's spokesperson when they're unhappy, simply by virtue of my big mouth and relative skill with the language. The emphasis on "customer service" rather than "nursing care" was getting to me, as were some of the specific actions of the management on the acute care units. I decided it was better to leave than to have a heart attack...and no, I didn't tell the interviewers that.

I am going to miss the education aspect of the job. That's my big strength: translating medicalese into English in a non-threatening, understandable way. You don't get to do a whole lot of that with the patient when the patient is intubated, but I look forward to working with patients' families.

You'll still get your crazy patient stories. You'll get other stories, too: about what it's like to be a New Nurse with seven years of experience, about the differences in relationships with doctors between ICU and acute care, about my ginormous fuckups early on and later in. I'm not going anywhere.

It's going to be a slow summer, but one hell of a ride come October. Who's up for it with me?

It's a new day.

There will be some changes a'coming to Head Nurse, peeps.

I have accepted a job that will make me Critical Care Nurse, which means I'll be about 30% Vascular, Medical, and Surgical Nurse and about 70% Head Nurse.

Until I'm done with the internship and training (around Christmas), though, I'll still be focused on brains and spines, just like always. Oh, and dithering and second-guessing myself.

Quick update

Between three posts in two days, a long chat with the Brother In Beer, and computer charting, I have worked up a lovely case of tendonitis in my right paw. 

I'll be taking a break through the weekend to allow that paw to heal up. Keep those cards and letters coming, people, and don't forget to tip your waitress!

An excellent question

we are not so dissimilar, new nurses and new doctors. so why the disconnect? if we can all acknowledge that we're all here for the same reason - to learn how to do our jobs, and to do as much good as possible, with as little harm - can't we meet in the middle? with the greater good as our goal?

That particular question came from the comments on the post before last, and it's a hell of a poser. Why can't we, in the immortal words of R. King, all just get along?

Ego. Fear. Exhaustion. Territorialness (well, it's a word *now*). Bad examples set by other people. 

I have heard, oh my friends, horror stories from residents and nurses alike about how they're treated by each other. I read once, on another blog, of how an older nurse told the new nurses in her charge to treat residents badly so they'd know their place. I once witnessed an attending telling a resident that nurses tended to get hysterical over nothing. That was the same guy who swept an entire counter full of charts off into the face of a charge nurse, so consider the source--but it goes to show you that there are bad, bad examples on both sides.

There's also the issue of turfing, or of being territorial. We all want what's best for the people in our care, and sometimes we disagree on how to accomplish what's best for those people. If two people have equally compelling arguments on two sides of an issue, and they're both convinced they're right, you tend to get discord. Sometimes it's hard to admit that, even though you have a good plan, somebody else might have a *better* one. We tend to fall a little in love with both our patients and our treatment ideas; getting over that posessiveness can be difficult. So we fight.

And exhaustion. Imagine, if you're a new nurse, doing everything you're doing now, but with increased power and no sleep for the last 48 hours. (Yeah, yeah, I know there are work-week limits now, but they're honored more in the breach.) Imagine that everything that you do will be gone over with a fine-toothed comb by people whose job it is to teach you hard lessons quickly and sharply. Imagine that, if you screw up, it could easily kill somebody--and you feel like there's nobody checking your work.

Contrariwise, residents, imagine being a new nurse: you're dropped onto the floor after a couple of years of school and told--and it's really true--that you are ultimately responsible for every single thing that happens to your patient. Doc writes a bad order? Pharmacy doesn't catch it? Charge nurse and second nurse go ahead and sign it off, and you give that drug or perform that treatment and it hurts that patient? That is, ultimately, the nurse's responsibility. You're also expected to supervise other people, play peacemaker with family members, coordinate getting the person to radiology/ultrasound/CT/whatever, and still find time to make sure they're not lying in their own shit.

Ego and fear go hand in hand. Everybody's afraid of screwing up and looking stupid. Everybody's afraid of losing some perceived power they have in any situation. And that tends to make people jerky at best and assholish at worst. 

The thing is, though, that doctors and nurses have the same feelings and the same reactions to situations. We all get frustrated, we all remind ourselves that you can't medicate crazy, and sometimes we all just need a cup of caffeine and a shower. 

My advice? If you want to work with people who aren't jerks, find a facility that fosters respect among colleagues. If you're unlucky enough to have an attending who shoves charts off of counters and yells at his residents and nurses in common areas, try to be the opposite of that person. Likewise, if you're a new nurse with a preceptor or mentor who views residents and interns with disdain, ask for another preceptor or find another person to hang out with.

Most of all, when you get angry or frustrated, try to remember that the other person is likely just as angry, frustrated, and frightened as you are. If you yell, apologize. If you break down in tears of frustration, that's okay. If you need to, you can take a deep breath, give the issue a rest for two minutes, and return to it in a calmer state of mind.

All of us are in the same boat. Rather than smacking each other with the oars, we ought to dig in and start rowing. Forgiveness, a sense of humor, and keeping hold of your self-respect helps a lot.

Speaking of Learning Experiences....

I intend the following as a comfort, not as a cautionary tale. If ever you feel like you've really blown it, come on back and re-read this entry.

It was one of those days with a vengeance. We were short on both sides of the staffing sheet, had a unit full of high-acuity patients, it was a weekend, and I was in charge of the floor. Any one of those things would be a recipe for suckage, but combine them all (because I am *not* a good charge nurse *at all*) and you have pure, unmitigated Hell.

It was so bad that I got on the horn and had lunch delivered, because I knew nobody would have time to even hit a vending machine.

So. It's a bad, crazy, things-going-wrong-everywhere day. One of our patients took a sudden turn for the worse and had to have a lumbar tap in order to get some cerebrospinal fluid for various tests.

Now, CSF is considered a "precious" fluid. It's hard to get, you don't want to take too much of it at once, and it's very delicate. It has to make it to the lab in, like, ten minutes or it's no good for testing.

Our patient not only was a hard tap, she had to be tapped under fluoroscopy. That means necessary exposure to X-rays, which you want to avoid if at all possible.

We sent the patient down to radiology and she had the tap done. The chart came back up with the patient, we put her to bed and stuck the chart in the rack, and went on with the day. 

(You can see where this is going, right?)

Lab samples have to be labeled in a particularly tricky way. For that reason, it's up to the nurse to label the samples on the floor, in the patient's presence, while looking at the armband on the patient's wrist. If you have a sample that's been drawn somewhere else, there are a couple of unique identifiers that are slapped onto the sample tubes, but the rest of the labeling and sending the samples to the lab are the floor nurse's responsibility.

(Now it's all coming clear, isn't it?)

The CSF that had been drawn, with great difficulty under X-ray, and with the patient heavily sedated, sat in the chart in a plastic bag for seven hours.

Seven hours.

And it was my fault. Yeah, yeah, the floor nurse should've checked the chart, but *I* was charge and had had the chart in my hands multiple times in that seven hours. I never once double-checked, as I was supposed to, that the samples had actually been sent. So, when the lab called to ask where in blazes those samples were, I was flummoxed.

Until I opened the chart. Then I was queasy.

(See what I mean about Learning Experience, Nuclear-Grade?)

I did what I had to do: I called the doc. The conversation went something like this:

Doc on phone, returning page: "This is Scott."

Me, shuddering internally: "Hey, Scotty. You wanna yell at me now, or yell at me after you find out how bad I fucked up?"

Doc: ".... ..... ......shit. Jo, what happened?"

Me: "That CSF didn't get sent. It's still in the bag on my desk."

Doc: "Oh, that's fine. We just need it for (insert name of obscure test here), and it doesn't have to be fresh for that."

Me, weak with relief: "Oh, thank God. Okay, then; sorry to scare you."

Doc: "No problem. Boy, am I glad it wasn't something important."

Me: "Meee tooo, Scotty. Me too."

I got really lucky. More importantly, our patient got really lucky: she didn't have to be exposed to ionizing radiation again, didn't have to get tapped again, and the thing that was wrong with her wasn't going to get worse with a seven-hour delay in test results.

Nevertheless, the point here is that I Fucked Up. Royally. I have been doing this, as I've pointed out in other places, for seven years. I *know* what the drill is with lab samples. I *know* how to take care of them. And yet, with the stress of the day, all of that went out the window and I made a huge, potentially damaging mistake.

Next time I'll be more paranoid. I won't assume that the patient's nurse has checked the chart; she might be too busy, or might forget. I won't relax until I see that the samples have been received by the lab and entered into the computer. I'll hand-carry the damn things down myself, charge nurse or not. 

So don't feel bad if you screw up. It happens to all of us. The best you can do is try to fix the mistake, recognize where the mistake started--because it's never just one thing; it's always a chain of events that leads to a mistake--and make plans to avoid it next time.

Everybody has it that bad. I promise.

A colleague-shaped blur went past me this week and resolved itself, once I caught up to it, as Marcia, one of the new nurses on our floor. She just got out of her internship and has been looking a bit white around the eyeballs lately.

"What's up?" I asked. "D'you need any help with anything?" 

"No..." she replied, "It's just one of those learning experience kind of days."

Ooooohhhh yeah. I remember those days. Sometimes (meaning about three shifts out of five) I still have them. There is nothing worse than being a new nurse and having Learning Experiences every. damn. day. you work.

Because, no matter how hard you try, you still feel like either an asshole or an idiot (or both) by about noon. This is common, and it's caused by the fact that you think you've actually learned something in nursing school. 

Not that I'm bagging on nursing school. It's like this: You learn all this very useful information, and all these valuable facts, but you don't--you *can't*--learn how to put them into practice until you've been, well, *practicing* for a while. Coming out of nursing school and expecting to have a handle on being a nurse is a lot like taking driver's ed without ever getting into a car, then expecting to be able to handle rush-hour traffic. On a different planet. With totally different physical laws.

Part of the problem, I think, is that you're trying to put things that you learned in a static fashion into practice in motion. I know that's a weird way to look at it, but bear with me. When you're in nursing school, you get a case study or a scenario to work with, and you can go through it step by step in a logical fashion.  You're sitting down, what you're working on is the only thing you have to deal with. Once you get out onto the floor, though, you have that scenario *and* about fourteen other things--literally--happening at the same time, and you have to keep track of all of them, and call bells are going off, and people are falling over in the bathroom, and you're running down the hall. 

Not only does your brain have to get good at sorting, discarding, and shoving things into medium-term memory, but you have to do it all on the run and while paranoid. 

This is why new nurses have breakdowns, start drinking, and think about going back to banking.

The good news is that things do get better. I don't know how it happens, but somehow your brain gets good at remembering five or six things for an hour or two, ranking those things in order of importance automatically, and then (most important) discarding them once you've dealt with whatever they are. Thinking back, it took about six months for that to start happening for me, and another year for it to get really good. Now I can go to the grocery store without a list and not forget anything. It's a good skill to have.

Also, you get used to thinking on your feet. It'll get to the point eventually that it'll be hard for you to really grasp a new concept without being in motion as you learn it. There's some neurological basis for that, but I'm down two Hop Head Reds at the moment and can't remember what it is. Anyway, you'll get so used to learning and coping while on the fly that it'll seem weird to discuss a problem with a doc if you're standing still.

And finally, you'll lose your pride. I don't mean that in a negative way: you don't turn into some sort of snivelling creature who winces any time anybody corrects you. I mean that you realize that mistakes happen multiple times a day, and catching and correcting them before they do harm is the important thing. You'll also learn that nobody knows everything, and even experienced nurses screw up in impressive, mind-boggling ways. Your ego learns to lie down and take a nap while you're at work, and mistakes quit seeming so damn personal.

Listen: I screw up at least six times in a shift, every shift. Most of the time, thanks to experience, I catch those screwups before they head out the door. Sometimes, I manage something so amazing that it qualifies as a Learning Experience, Nuclear Grade--and I've been doing this full-time, in one specialty, since 2002. Thankfully, my pride doesn't take a hit (or not much of one) every time that happens, because I've learned that I'm not the only one.

There are also things that I still do not know. Some of them are very basic; others are kind of arcane. I ask a lot of questions (one of the docs has nicknamed me the Elephant's Child) and do a lot of reading and try to get in on cool bedside procedures when I can. Those habits are among the most valuable you can develop as a new nurse. Not only do they mean you'll never stop learning, but an honest curiosity about things will put you in good stead with doctors and other nurses who like to teach and learn themselves.

Eventually it will all come together. You'll look up one day and realize you've filled out your chart's checkboxes in three minutes, your patients are all medicated and comfortable, and you actually have time to pee. Six months later you'll have time for lunch. Two years later you'll have enough downtime to fill in a couple of boxes on a crossword. More than that, you'll be able to form a synthesis with speed and accuracy and keep a dozen metaphorical balls in the air without flipping out.

Getting there sucks. The nightmares suck, the fear that you're going to hurt somebody really sucks, and the anxiety is awful. But it all does ease out over time. 

New nurses, listen up: Cut yourself some slack. Be easy on yourself when you look stupid, as you most certainly will. Don't expect to be an instant expert, or even instantly competent at everything. Recognize that you have strengths and play to those. Recognize your weaknesses, too, and learn how to hedge around them and how to compensate.

And for God's sake, don't go back to banking. We need you here with us. I am glad and proud and tickled to death to be working with you, because you teach me so much. You also remind me why the heck I got into this business. So thank you.

And if you need some help, don't hesitate to ask. We've got twelve hours, after all.

I spent all day screwing, and boy am I sore...

...but the deck is DONE.

It's 12' x 12', built out of pressure-treated lumber, and is solid. It's not *quite* square--there's about an inch of weirdness going on at the far corner--but I don't think it's going to fall down in a heap the minute people start stepping on it.

Friend Suz The Critter Whisperer is going to email me pictures that I can then put up here.

Next up: Will Nurse Jo survive the Deck-oration process? Tune in to find out!

Yes, yes, I know. I am a romantic fool.

But this really got me.