In honor of my neighbors, the Man of God and his Lovely Wife...

Ten things I know about babies:

1. Babies are remarkably resilient. You can drop them on their heads and they'll be fine. They're made out of rubber and springs, and can be handled like any other mostly-sleeping animal.

2. Sometimes babies hate breastfeeding. Ur NOT doin it wrong; it's simply a personal preference on the part of the baby. If said baby doesn't like the breast, bottlefeeding does not make you a bad mother. (Corollary: sometimes babies and toddlers are way too fond of boobies. I remember vividly the time an 18-month-old tried to breastfeed on me. Bras, after that, became a non-negotiable item in my wardrobe.)

3. Babies are messy.

4. Occasionally, babies can be surprisingly loud. Luckily, your tolerance for baby-produced noise grows with the lung-strength of said baby.

5. Babies require a lot of *stuff*. Diapers alone take up more space than you ever expected.

6. No baby can stay clean for more than two minutes (max) at a stretch.

7. If you need to, you *can* walk away from a baby, head into another room, and take some time off. Just make sure the baby is on the floor, in the middle of the bed, or in a crib: someplace said baby can't fall off of.

8. If it does fall off of whatever it's in or on, it's not the end of the world. See #1, above.

9. Babies are most easily washed in the kitchen sink, with the spray attachment to your faucet.

10. Babies should be kept far, far away from Auntie Jo, lest she teach them how to say "Dilapidated Motherfucker" at the age of two and give them trumpets and drum sets before they reach grade school.

TMOG and LW's baby is due mid-December. I wondered when I last saw her if she were indeed pregnant; I seem to have an innate Geiger-counter for breeding women. The crazy hippies across the street and I are planning a tie-dye-the-onesies baby shower/party for LW; we'll see how the baby does with eight gazillion people tryin' to raise it right.

The strange case of Bret Michaels

Good heavens.

I'm not talking about the eyeliner, or the hair(piece?), or the inexplicable popularity of Poison in the past. I'm talking about his subarachnoid hemorrhage the other week, the ones that doctors "couldn't determine the cause" of.

News flash: If you have a long history of alcohol and (alleged) drug use, the blood vessels in your body--and your brain especially, since there's more complexity there--are going to be weaker and more dilated than the average bear's.

Also, if you're a diabetic (as Michaels is), you're going to have weak-walled blood vessels.

Add that weakness and dilation to poor pressure regulation and you get an SAH. It was just bad luck that his happened near his brain stem.

As for not being able to find the source of the thing, well, that happens too. A number of times our Brain Boys have gone in with an angio setup and have been totally unable to find the source of a bleed. Sometimes they close up on their own. It doesn't always have to happen that a person has an obvious aneurysm that bleeds; sometimes arteries just do that.

What *I* don't understand, though, is this: Michaels, in his first interview after the hemorrhage, said he heard something "like a gunshot" in his ear right before the headache that sent him to the hospital started. I've never, ever heard a patient with a subarachnoid mention a gunshot noise, or any loud noise, prior to their headache. It's like, they get a headache, it's the worst ever, they vomit a couple of times or pass out, and boom, they wake up to me asking stupid questions about what day it is.

Oh, and that prop hitting him on the head? Or stage-dives gone wrong? More'n likely didn't lead to this.

There. Now I've said something about the Celebrity Brain Injury Du Jour and can ignore Poison's frontman and go back to listening to Faster Pussycat.

Dirty Little Secrets of Nursing, Part Five: We wouldn't do anything else.

No, really. For all the bitching and complaining and wondering why Manglement and patients so often treat us like something the cat dragged in, we wouldn't do anything else.

It's actually pretty simple: we do what nobody else is willing to do. We do what nobody else *can* do, really; the weak ones get left behind and the stupid ones mostly wash out early on in their careers. Being a nurse is challenging, mentally and emotionally. It requires that you understand every system of the body in a way that specialists often don't, and recognize how all those systems interact. It necessitates the ability to reach the person inside the patient.

Sometimes you're the nurse. Sometimes you do nothing but run numbers and replete fluids. Sometimes you're also the lactation consultant, the woman who reassures the teenager that *everybody* gets her period on the day of admission, the person who, though thirty years younger than the patient, tells that patient without blushing or stammering that yes, sex is possible even after neck surgery. You're the person who flies through awful freezing rain in a helicopter, keeping your patient calm, even though you don't know if you're going to be landing in a controlled fashion. You're the person who not only knows the various ways to save somebody else's life, but also how to comfort those left behind.

It's been a tough week for me, personally and professionally. The combination of work-related and personal-life events have left me with nightmares, anxiety coiled like a serpent in the pit of my stomach, and no appetite for anything but beer. I've rerun things I've done over and over, wondering if something different I could've done would've made a difference in outcomes.

Yet, with all of that, I can say honestly that nursing is the one part of my life that I have not fucked up. That dedication to honesty, a clear ethical standard, a measurable good outcome, is what keeps me punching in in the face of Manglement's initiatives and my own personal doubts.

I would not do anything else. It's the last, biggest dirty secret of nursing: I love my job, like we all do, and I cannot imagine saying "I'm a nurse" with anything but a quiet swelling of pride.

In other news, I am beat up.

Max dose of propofol: one hundred micrograms per kilo.

Normal response to max dose of propofol: floppy, rag-doll lack of muscle tone.

Response of last night's patient to max dose of propofol: Attempted de-catheterization, extubation, de-restraint-ization, one kick to the chest that sent me two steps back, and two bruised knuckles (mine). From a teeny-tiny little person.

Lesson learned: Pilates does indeed make you very, very strong. Even with a paralytic.

Dirty Little Secrets of Nursing, Part Four: It's not doctors directing your care.

I got into the same conversation this morning that I do every week, with the guy stocking produce at the local Crazy Grocery Store.

"How you doin'?" he asked.

"Inelegant." I replied.

"You look fiiiiine" he said, grinning and showing his two gold teeth.

We talked today about the time he spent in the hospital a few months ago. "Those doctors saved my life, you know" he said.

I didn't want to tell him this, but it was probably the nurses in the ICU here at Littletown General that saved his life. I know the doctors who cared for him, and I know that they're not around that much.

It's a dirty little secret of nursing: those handmaidens and helpmeets who take a subordinate role to the great Medical Deity are the ones directing your care. Nurses are the ones keeping an eye on your electrolytes, your fluids, your nutritional status, whether or not you're running a fever. Nurses are the ones, often, who decide whether or not you need a central line or a tube running through your nose down to your stomach. We're the ones who push for that indwelling bladder catheter. We're the ones who yell and screech when something goes wrong.

Nurses have more input into a patient's care--even including, sometimes, their surgical course--than most civilians recognize. I had a patient with a belly bleed the other day who was doing okay...but if he hadn't been, it would've been up to me to provide the information and the observation that would've been the deciding vote on whether to take him back to surgery.

If a patient codes, nurses run that code, doing compressions and giving meds, until the code doc shows up. That might be two minutes, or it might be twenty--or it might be never. I've taken part in three codes during which the code doc didn't show up until well after we'd gotten a steady rhythm back and the patient intubated and stable.

This makes sense, if you think about it. I'm there for twelve hours, taking over your care for a colleague who's been there for twelve hours. In the CCU, that means that I've been in your room a minimum of once an hour for that long shift, keeping a watchful eye on your vitals, waking you up regularly (sorry) to make sure nothing's changed with your mentation. The doc will visit for fifteen minutes in the morning before rounds. He'll spend ten of that fifteen minutes with me, five with you--enough to reassure you that all is going well, and to get a clear and comprehensive picture of what's actually going on from me.

In the specific case of my asparagus-stocking buddy, it was the nurse who had him for four nights in the Littletown ICU who noticed his crazy heart rhythms and suggested, not gently, that perhaps an implanted defibrillator was in order. It was because that nurse had pulled and saved EKG strips that the docs realized that yes, the nurse was right: dude was hovering on the edge of a heart attack. I don't know whether that nurse was a guy or a girl, or whether it was somebody with thirty years' experience or someone I graduated with, but the point remains:

It's a dirty little secret of nursing: sometimes we control your care.

Dirty Little Secrets of Nursing, Part Three: We've all killed somebody, except when we haven't.

Every nurse fears killing someone. New nurses fear it the most, because they don't understand the safeguards in place to keep it from happening. Older nurses, if you get 'em liquored up and they trust you enough, will certainly have a story about something that seemed...off, that they didn't catch in time, and that led to a patient's death.

Because we're with those sick and vulnerable people more than anybody else, we tend to take the responsibility for their deaths on ourselves--even when it's doubtful that anything we did or didn't do led to that death.

I have my own story: an older guy, in his eighties, with a blood calcium level that was horrendously low, had a cardiac arrest. He couldn't have gotten calcium IV, because he was already in physical rehab, where peripheral IVs don't exist. Further, because of his history of chemo in peripheral veins (that's how they did it back in the day), he was an impossible stick and refused to consent to a central line. And he wouldn't take the calcium supplements by mouth that I'd been ordered to give.

I rode his chest down to the CCU, doing hundred-per-minute compressions the entire way. He died anyhow. For a time I believed that I, Nurse Jo, had killed the guy. Whenever I had a brand-new nurse under my wing and something went Seriously Wrong, I would consider telling them about That Guy Who Died. Once, I think I did.

Thank God for CCU training. It helped me understand that all the oral calcium supplements in the world wouldn't have brought his blood calcium levels up enough to make a difference.

And thank God for further experience. His decision to forego a central line was his; pushing one on him would've been unethical at best.

Yes, the patient died. I thought I had killed him. Maybe I contributed to his death: maybe I could've been more convincing, or pushier, or more skilled at making him realize that what I wanted him to do was really necessary. At the end of the day, though, he was sound of mind, if not body, and made his own decisions. The fact that he couldn't have known that those decisions would lead to his heart stopping is kind of beside the point: we don't overrule personal autonomy for might-bes.

It's a dirty little secret of nursing: Sometimes, we kill people. Sometimes we only think we do. Sometimes, we're unsure...and that uncertainty is worst of all.

Communicating only through songs: perhaps the first time I've ever liked this one.

From "Glee". Makes me wish I had a TV.

How the hell did they do that? Make an awful song into a fairly decent one?

In honor of my Sainted Mother....

...an accurate representation of raising me.

Thanks, Mom.

Dirty Little Secrets of Nursing, Part Two: Sometimes we hate your guts. And it's your fault.

Everybody bitches about patients. People who are sick can be unlikeable, difficult, whiny, and hard to tolerate. Sometimes, though, we hate your guts. We'll do anything in our power to keep from taking care of you two days in a row, or sometimes for an entire shift, if you're offensive enough. We'll deputize other nurses to deal with you as much as possible and beg the doctor to send you home early. And that, my friends, is entirely your fault. You are an unlikeable person.

If you're an open racist, it's fairly obvious that we're going to have trouble finding people to take care of you. If you throw things, same deal. If you're a sexist piglet, we'll put you with the biggest, ugliest male nurse we can find--or me.

There are some patients that set off warning alarms in a nurse's head. My two personal least-favorites, the people I really and truly dislike, are the Nuts and the Lawyered-Up.

Nuts are reasonably easy to spot. Everybody gets drug allergies, and people with chronic conditions, or who've been treated for cancer, tend to have a lot of them. Nuts, though, come in with four-page, single-spaced lists of things they can't tolerate or are allergic to--and those lists are often annotated with editorial comments about how a surgeon "nearly killed" the patient, or a doctor's mistake harmed them irreparably. Nuts tend to be allergic to everything from tomatoes to polyester, yet are able to eat their favorite foods without harm, even if those foods contain supposed allergens. These are the people who are allergic to oxygen.

Strangely, in all those allergies, two will never pop up: Dilaudid and Phenergan (or Stadol and Zofran). And, because the Nut has been in more hospitals than MRSA, his or her (usually her) tolerance for pain meds is huge.

The Lawyered-Up are a little different. I've had two in the last year. In the first instance, the patient was fine and dandy--it was the family who was Lawyered-Up to the hilt.

They wrote everything down. That does not bother me, actually, and I'll happily write stuff down *for* them--after all, health care is so screwy these days that it's smart to have another set of eyes or three on the patient. What bothered me was that they'd second-guess everything we or the doctors did, call family friends who were doctors in different fields for advice, and question my skills in a particularly insulting fashion.

When I came in to start an IV on the patient, one of his family members looked at me narrowly and asked, "Are you sure you know what you're doing?" A question that silly deserves the response I gave, which was, "Frankly, I haven't a clue." The patient laughed, the family member fumed, and I'm sure wasted more ink on that smartassed nurse.

The second Lawyered-Up patient was, as she announced to me, an auditor for a large national hospital accreditation board. "I" she announced proudly, "make nurses cry."

"Good thing I'm not a nurse, then" I shot back. "I just found this uniform in the Dumpster out back."

Every time I walked into the room, she would regale me with stories of how she's sued this nurse or another, or gotten some nurse's license revoked, or generally destroyed the career of somebody with whom she disagreed. I finally sat down in the chair next to her bed, looked her straight in the eye, and told her this:

"Telling me that you routinely sue people is counterproductive. I will chart more thoroughly than you can imagine, and as a result, I won't be able to be in here every hour, as I'm supposed to be. I won't want to spend the time with you that I should, because you're trying to freak me out. Furthermore, if you continue with this, I won't be your nurse tomorrow, and your continuity of care will suffer. So how 'bout you drop the badass act and let me do my job without attempts at intimidation?"

We got along fine for the rest of her stay in the CCU. I even got a TEAM playa card from her later.

Sometimes it's the patient's fault that they are unlikeable. Nurses are human, and there is only so much we can take in terms of abuse and bullying. It's our dirty little secret: we hate you because you're an asshole.

Dirty Little Secrets of Nursing, Part One: Wasting it in the tubing.

Dude was 330 if he was an ounce, and not all of it was fat. Chita had been wrestling with him for an hour, during which he'd broken two sets of restraints and cold-cocked a respiratory therapist, sending him spinning into the wall.

An agitated, violent patient with vascular dementia is no fun, even if they're not big enough to hurt you. Somebody big enough to hurt you, as this guy was, can break your bones or his own without even realizing it.

Something had to be done. Chita left three of us holding down his arms and legs (I drew the short straw and ended up riding his shins like they were a bucking bronco) while she called the doc. She came back with an order for half a milligram of Ativan IV.

Half a milligram of Ativan will put *me* down, but will do buck-shit-nothing for a patient his size, strength, and craziness. I got the job of retrieving the drug and administering it.

Ativan comes in two-milligram-to-a-cc ampules, and is thick. It's viscous. It's surprisingly hard to push IV, even with fluids going.

It's also, as it turns out, quite difficult to measure accurately when all you have is a ten-cc syringe and the patient it's intended for is screaming and cursing and punching.

"Chita...." I said, not sure of how to phrase it, "uh...that Ativan? I think I measured it wrong."

Chita began to laugh. She doubled over, giggling, then gave me a high-five. "Dear," she said, "We call that wasting it in the tubing."

Everybody does it. Nobody will admit it. People will probably howl now that I've said it out loud: that clinical judgement, exercised by the RN, sometimes means that gosh, it's awfully hard to cut that Valium in half. Y'know, sometimes the whole damn thing just...dissolves in the water before you can rescue it.

It's like my friend James The Towering Inferno said once, "I gave him two Vicodin at midnight-thirty, for boredom."

Let's be straight: I'm not talking about administering rogue medications for the purpose of killing a patient (though a disheartening number of nurses seem to do that, these days). I'm not talking about giving paralytics to patients who aren't vented. Nor am I suggesting that nurses routinely give larger-than-ordered doses of medicines to patients in order to keep them quiet (although I have seen that happen myself, and have gotten into scrums over it with the nurse in question).

Sometimes, though, it really is the better part of valor to knock somebody down for ten minutes or a couple of hours. I've had doctors tell me plainly to give "a generous milligram" of something prior to a procedure, or heard them say, "Half a milligram, one, two--use your best judgement. I'll write to cover it."

Is it ethical? Only if you're more of an ethics contortionist than I am. Is it practical? Sometimes, yes: if a patient is violent or so anxious that they're having trouble, say, breathing, then a generous milligram of something can be useful. Is it widespread? Hell, yeah. Do we admit to it? Hell, no. Is it safe? There's a question, for sure.

The only--*only*--time I'll "waste in the tubing" or "forget to halve a pill" is if the patient has multiple good IV accesses, is truly in extremis, and I know that the dose I'm administering will, in the end, be safer than the dose ordered. If the person doesn't have an IV, or I don't know their tolerance, it's down-the-line, by-the-book time, and I'll use non-drug methods to deal with whatever problem they have. Safety first means it's easier to put ice on my black eye than it is to bag the guy who gave it to me.

I've overdosed patients three times: twice, the patient was being violent. This last was the second of the two violent people; the first bit a tech quite badly and kicked me in the gut. Once, the patient was so anxious, so freaked-out, that nothing would touch her except ten milligrams of Valium. Each time it worked, and each time I felt like I was doing something really, really bad.

Even so, we do it all the time. A patient reports a pain level that, according to orders, justifies one Lortab, but we give him two, because we know it'll work better and longer than just one. A patient has a particular sort of headache with which we're familliar, and we give Fioricet rather than Lortab, because experience has taught us it'll work better, even though Fioricet is ordered as a secondary if Lortab doesn't work. We crank oxygen up a bit (oxygen is a drug, remember) in order to calm the patient who swears she can't breathe. We give a tiny bit extra Dilaudid to the person who's got chronic pain and who takes massive drugs to control it.

It's one of nursing's dirty little secrets. Done right, it can be beneficial to the patient and safer than the alternative. Done wrong, it ends up a story on this blog and a black mark on my record after I yell at another nurse for obtunding a patient.

Don't tell anybody, but sometimes we waste in the tubing. It's our little secret.

Happy Friday!

Yeah, yeah, Nurses' Week. Whatever. Blow me.

It's National Nurses' Week! Everybody get down! Celebrate! Wahooo!

They're celebrating Nurses' Week (an aside: why is it that, after nearly ten years as one, I still type "nurse" as "nruse"? Damn) at Sunnydale right now. Matter of fact, it's being celebrated all over the country, by gum, as the hospital- and clinic- and school-going public bows in honor of our awesomeness.

Mostly, NW at Sunnydale is being celebrated with food. Yep. Potlucks ("Happy Nurses' Week! Bring your own food!"), ice cream socials, breakfasts, snack times. A couple years ago, we celebrated with food. Last year, food. And massages, which were nice.

I propose a different sort of Nurses' Week observation for next year.

For Nurses' Week 2011, let's start paying nursing professors what they're worth. Let's make their wages better than those earned by the most entry-level nurses at the bedside, for starters. When I graduated with a two-year degree and started working at the bedside, I was immediately earning thirty percent more than my highest-paid professor, who had a PhD.

Paying nursing professors fairly would bring people who really want to teach into the field. Right now, they look at the starvation wages, long hours, and piles of paperwork and decide to bag it and stay at the bedside. That's led to the shortage of class space and contributed to the nursing shortage--plus, it shows how little we really value a good nursing education.

For Nurses' Week 2011, I want a commitment that hospitals in particular will be safe, healthy places to work. Too many nurses and ancillary folks are subjected to the sort of abuse from patients and family members that would get you thrown out of the skankiest bar in Bigtown.

I've had problems personally with patient-on-nurse violence, and it raised its head again a couple of weeks ago, when a patient's family member got up in a colleague's face. She did what I'd told her would work: called 911, turned the family member over to the cops, and then filed charges. That made Manglement pay attention and deal with the situation, but it should not have to go that far. I want a commitment from managers all over the country that nurses should not have to make a federal case of violence and threats to get relief.

For Nurses' Week 2011, how 'bout we quit cutting budgets for support staff, too? The patient care techs and housekeepers and lab staff and radiology folks are all vital to the jobs we do. I can't monitor a patient with a bleeding problem if I'm busy cleaning a room for an emergent admit. Likewise, sometimes it's better to have a tech bathing patients than a nurse, because--frankly--not only are the techs better and faster at it than I am, but they're likely to learn something from the patient that the patient won't tell me.

We do incredibly important things, but those important things are dependent on the work that the invisible people in the hospital do. Let's bring those invisible people out into the spotlight for once, and make it clear how much we depend on them.

And finally, for Nurses' Week 2011, let's you and me talk about what we actually do as nurses, and get the word out.

We dare to care, yes. I don't know about you, but I personally also dare to interpret lab values, take calls from pathologists, arrange meetings between family members and doctors, push the occasional dose of epinephrine, hug people, wipe ass (yes), act as a care coordinator, take responsibility for my own and others' fuckups, and generally herd cats.

We're not just warm and fuzzy: we're scientists, we're social workers, we're personal counsellors. If we can give the people we talk to about nursing a complete picture of what it is we do--rather than focusing on things like nurses eating their young, or crappy doctors, or how fulfilling it is to wash a back at three a.m.--we're likely to find many more smart, motivated people who are suddenly interested in becoming nurses.

I wish you all a very happy Nurses' Week 2010: old nurses, new nurses, nursing students, nursing professors, ancillary staff, respiratory techs, radiology guys, the dude who deals with the red-bagged stuff, unit secretaries, transporters, EMTs. I'll bring the queso and chips; the rest of the feast is up to you.

For Nurses' Week 2011, though, let's plan a real celebration and appreciation of nurses. Let's plan something meaningful and push for changes that'll really make a difference for us and for our patients.

And let's all get massages. That was really, really nice.

In which years of neuro nerdery are made worthwhile

So I'm listening to a story on NPR the other day about synesthesia.

Synesthesia is a condition that was originally described sometime in the 1880's, by whom I don't recall, and it's caused by a failure of the cingulate gyrus to de-wire wiring in your brain that's really tight when you're a fetus.

In English, the cingulate gyrus is a part of your brain that runs along the sides of your head, just above your ear. It does all sorts of things, including regulate the perception of various sensory input. In human development, all the different types of sensory input are wired together, but as you mature in utero, that wiring spaces itself out. The result is that you have five senses, and they don't overlap.

Synesthetes experience the world with perceptual overlap, is the best way I can describe it. They taste color, they smell sound, or they see sound, or they attribute personalities to letters and numbers. About one in twenty people is a synesthete according to current reckoning; I suspect the actual proportion of synesthetes is much higher, based partly on what happened the other day.

So I'm listening to NPR. And this woman puts on a techno record, and says, "Now, this is obviously a dark gray background with light gray and white dots." And as I'm chopping poblano peppers, I'm thinking, "Bullshit. This is obviously blue with yellow and silver streaks."

I stopped chopping. I considered what I'd just thought. And I ran to the CD player.

Bach: intricate uncolored geometry. Beethoven: woodgrain in sweeping pastel colors. "Rhapsody in Blue": the clarinet slide is obviously a bright medium-blue, and it tastes like blue besides.

Then I remembered what happened every time Mom played ragtime music as she was cleaning, when I was a kid. All I saw was somewhat chaotic flashes of color, moving with mathematical precision, across my internal film screen. It became so distracting that I began working consciously to ignore it. Later, in college, I would practice piano and build up this gorgeous, fragile matrix of colorless, clear geometric shapes that one mistake would make come crashing down (I hated practicing piano).

I emailed Beloved Sister about this, and her response was, "WOAH. You mean not everybody does this? And there's a name for it?" Turns out she does it too: the number nine tastes like cranberry, while the number seven tastes like tin. Neither she nor I have total saturation (as she puts it); some music evokes no visual response in me at all (thank God; constant visual distraction would drive me bonkers) and some numbers and letters have no taste or smell for her.

Eight, for me, is a fluffy purplish-blue, five is yellow, and seven has the personality of the Tin Man from the Wizard of OZ. The numeral one doesn't get along with anybody. All of which was more interesting still after I talked to Friend Pens the Lotion Slut last night.

She said, "Well, I don't see colors with music, but I do know that certain numbers and letters have personalities." And, "You mean not everybody does this? And there's a name for it?"

Three people with at least partial synesthesia in twenty-four hours. I know the proportion of people who experience the world this way *must* be higher. We just haven't heard about it, since the study of synesthesia fell out of fashion in the 1920's and didn't re-emerge until we got good functional MRI capabilities in the 1990's.

It explains why I love Philip Glass and hate techno and ragtime. It explains why Bach relaxes me and Mahler seems so avant-garde. It also explains why the shouty Katy Perry is a nasty burnt-orange voice, while the dude who sings for The Magnetic Fields is dark charcoal grey with fuzzy edges. It's simply *there*: the film that plays in my head is nothing I can change, and it's the same every time I listen to a particular piece of music. I'm lucky enough not to be one of those people who see the music across their field of vision; I don't have to walk through colored flashes of light when I'm crossing the lobby at work, for instance.

It also explains why so much of my wardrobe is an odd shade of yellow-green: it makes me smell yarrow, one of my favorite Texas-In-Springtime smells, every time I see it.

My sister has the additional gift of being able to switch her visual perception from three dimensions to two at will. It's such a natural part of her being that she can't explain it.

Every day I am amazed at how normal abnormalities are when you really look around. When a friend of mine told me he'd only had synesthesia when he was altered, I was a little shocked. It seems like everybody ought to be able to do this, you know?

And this, friends, is why I love neuro nursing.

i carry your heart with me (i carry it in my heart)

OMG WTF AM I DOING HERE? A guide to your first months as a nurse (with special thanks to Pip)

When I was a new-new nurse, like my first six months on the job, I would show up way early for work every morning and pray in the hospital chapel that I wouldn't kill somebody. I was scared--constantly terrified--of all the mistakes I could make, of how little I knew, of how easy it was to screw up and do damage.

Slowly, those feelings went away. It took about a year and a half before I could say "I'm a nurse" without feeling like a fraud. Watching other new nurses go through orientation after me really helped--it showed me exactly how many people are watching your every move as an RN.

So, and with full thanks to Faithful Minon Pip, who said, "Yo, dude, you need to write a 'surviving as a nurse' post", here are tips for Surviving As A New Nurse, Dude. Yo:

1. Pee.

This is the single most important piece of advice I have for new nurses. Right after report, but before you hit the floor, pee. Emptying your bladder will clear your mind and take one small worry away. With any luck, it'll be hours before you need to pee again (unless you're me) and you'll have a chance to get things done before then.

2. You are not going to kill anybody. No, really, you're not.

There are three reasons for this, so I will subset them under the main point:

A. Humans can take an unbelievable amount of damage before they keel over.

You're unlikely to do the sort of damage it would take to kill somebody yourself; it generally takes a fair number of tiny mistakes that add up. At every stage of the way, there's the chance to ask questions, to catch problems, and to stop bad things from happening. Your job, therefore, is to be The Elephant's Child and ask questions about anything you don't completely understand and feel comfortable with.

B. Everybody is looking over your shoulder.

Yeah, you as the RN have ultimate accountability and responsibility for what happens, but remember: you have other nurses, pharmacists, and docs checking you all the time. Lean on them. See "asking questions", above.

C. Humans can take an unbelievable amount of damage before they keel over.

This is exactly the first point, but I'd like to take a different tack on it: I have had patients with potassium or magnesium or calcium or pH levels that were totally incompatible with life, and those patients weren't even all that sick. I have had patients with blood pressures that would make your eyes bug out and others with pressures that made me wonder if they were perfusing everything. I have had patients missing legs, arms, and (once) half of a body. All of those folks lived, and they all did mostly fine. It's all about what that person is used to. For some people, walking around with a calcium of 5.3 is totally legit.

3. The First Rule Of Nursing Is: If You Have To Fuck With It, It's Wrong*.

There was a story years ago about a new nurse in my orientation class who ran oral contrast through a central line, thus injuring (but not killing) her patient (see, we really can take a lot!). In order to do that, she had to set up a Rube Goldbergian series of tubes and connectors, find a certain type of syringe that would fit the end of it, and then administer the oral contrast bit by bit, because it's very thick stuff.

Think of how much she had to fuck with that to make it work. If you're having to force something to make sense or work, STOP. Look around. Ask if you're doing it right. Medical equipment, med-administration rules, and protocols are so bulletproof these days that it's work to screw them up.

4. Find somebody whose shoulder you can cry on.

This might be a preceptor, a fellow orientee, a more experienced nurse, or your mom. Whoever it is, find that person and use them as a sounding board for when you do something really stoopid. You *will* do stoopid things now and again--all nurses do, all through their careers--and it's important that you find someone who understands and can make you feel like less of a donkey.

5. Remember that things will get easier.

It's hard at first to get your skills and time-management and organization down. You might miss lunch or end up with a bladder infection, but that will change. Eventually, some things will become so second-nature that you'll have to double-check to make sure you did them. Eventually, changing a bed with a patient in it will be simple. And eventually, you'll have time for lunch. Don't despair.

6. Don't be afraid to ask for help.

Delegation is a beautiful thing. Find the people who are willing to help you and lean on them.

7. Don't be afraid to ask questions, even stupid ones.

I ask questions all the time, sometimes the same ones over and over in a shift. Nobody thinks I'm an idiot. Obsessive-compulsive, yes, and perhaps with a little short-term memory deficit, but not stupid. They do it too. Questions are good.

8. Be kind to the techs and the unit secretary, for they will save your ass someday.

This one needs no explanation.

9. Likewise, be kind to the doctors, for mostly they love to teach and are fairly nice people.

If you find one who's a jerk, avoid him or her at all costs until you feel more confident. Nothing will make you fade faster than being yelled at by an asshole with "MD" after his/her name.

10. And do find time to be kind to yourself.

You didn't spring fully-fledged from some god's forehead, and neither did any other nurse currently in existence. Even Cherry Ames screwed up now and then, and she learned things every day of her career. You will, too. Be easy on yourself: you've taken on a very tough job, in a challenging, rapidly-changing profession, and the whole of it is something that nobody but another nurse could really understand.

*Funny story about Jo's First Rule Of Nursing: I had a student precepting with me the other week in the CCU, and I told her as we started, "Remember: the first rule of nursing is, 'if you have to fuck with it, it's wrong'." She immediately said, "Oh, my gosh! You read Head Nurse, too! I love that blog!" I concurred solemnly that the writer was a damn genius, the crafter of elegant and spare prose without equal in the world today, and then we went on with our day.

Yes, yes it is.

Better now.

I tell you, I cannot wait to get back to days. Not only does working nights mess up my life, it apparently messes up my brain.

Stadol for the patient, wine for his wife (yes, the alcohol cabinet is on the same floor as the CCU; what's it to you?), a turn around the basement at a quick clip for me, and I am feeling almost back to normal.

Except that I have a doctor's appointment tomorrow (today) that I have to stay up for, and then I work out at one with Attila.

Ugly. I cannot wait to get back to days.

Conversations with Ginny the Chaplain

Ginny stayed late tonight, ministering to a family whose father was out of his mind both with pain and with the effects of a glioblastoma on his frontal lobes.

We say the worst things to the people we love. We treat enemies better; we treat nurses best of all. Long ago I recognized this, and I try to reassure the wives and sons and daughters of the absolute faith that abuse implies, but sometimes it falls short.

Somehow, having a six-foot-four female Baptist chaplain tell you the same thing has more effect. I can't imagine why (she says, from her five-foot-two height).

They abuse you if they love you. That's a weird, twisted sort of love, and not one I'd like to champion even at the worst of times. Yet it happens, most often when people aren't in their right minds; aren't themselves.

Sometimes, blessedly, we get the chance to say: Do not love me. I cannot be the person you love.

I had that chance this week, both with a patient and with a person who was not a patient. In the first case, I was able to say it out loud; in the second, silence was the best response.

Do not love me. I will hurt you later, by sticking a heparin injection into your belly, or a cold shot of insulin. Do not love me: later, when you are not expecting it, I will not be able to be what you need or want; my brain doesn't work that way.

It's very simple, love, and it makes no difference at all. Sometimes, at 00:41, you're dealing with somebody who loves you simply because they're jacked up on pain meds and crazy from a tumor. Other times, at more reasonable times of day (for those of us who don't work nights), you're dealing with somebody who's totally with it and who has taken time out of a busy day to say, "You know, I do love you."

Either way, it makes no difference at all. Love is a changeable thing. It makes us capable of hurting the people closest to us. It makes us capable of making promises that nobody could ever keep. It makes us capable of acts of cruelty that we'd never consider if we didn't feel that particular way about the person on whom we're dumping.

At the end of the day, love makes no difference at all in the present moment. It's a nice memory, and it's a nice nostalgic thing to look back on, and it's a nice, sentimentally valued emotion, but it allows such violence, and such awfulness.

I am looking forward to the day when I'm not up in the middle of the night, blogging at my workstation, minimizing the page every time another nurse walks by.

I am looking forward to the day when I can live my life like I did in microbiology, all those years ago: without emotion, looking only to the evidence in front of me to tell me whether this thing the professor had shoved at me was TB or gonorrhea. Somebody get me the ethylene blue; I'm jonesin'.

Night nurses are the strongest people I have ever met. Remember this: the person who works with your family member overnight hears things, and sees things, that no other person ever does. And somehow, some way, they have to deal with it.

I have Ginny. She's a day person, and she's as clumsy with words as I am in motion, but she's almost enough.

Because a Faithful Minion asked...

This is what I got the purple patent pumps to go with.

It rocks. With a cropped white cotton cardigan, it will rock even more.

Go Big or Go Home.

Dude had a benign tumor in his midsection that was more than a foot wide at the smallest part.

The day after his surgery, when most people are hitting the hell out of their PCA pump button, he was sitting tranquilly in a chair. When I asked him how he felt, overall, he said, "Better than I've felt in six months." He'd been split both ways from Sunday, had had his entire gut taken out and put back in, and was feeling fine.

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

Another patient had had a teeny-tiny tumor, less than a centimeter wide, at the base of her brain. It was not malignant, but it had caused (for some reason) a hell of a lot of swelling--enough that when she was transferred, the chief surgeon on the case came to me specifically to talk about what he was worried about. (That never happens. This guy walks around with angels announcing his presence, y'know?)

About halfway through the night, she started getting sleepier and more irritable. I hollered at the attending (again, this never happens: guys who walk with choirs of angels don't generally want to be bothered at 2 a.m.) and let him know. He came in and put in a ventriculostomy (see "this never happens", above) because he wanted the resident to get his sleep, and also wanted to monitor the patient himself.

(Woah. I just threw a run of about four PVCs. I think I need more sleep and less caffeine.)

Anyway, about an hour after he'd placed the ventric, while he was still at the bedside (see "this never happens") I went in to check the level of fluid. As I was bending over to see the meniscus, the patient suddenly sat up, said, "Oh, ouch" and about a pint of blood poured into the ventric.

I estimate it was a pint, because the minute it started pouring, I did what had been drilled into me for eight years, though I'd never seen it: yanked the collection tube and bag off the ventric line and let it drain freely.

The surgeon and I stood there, amazed, as the patient laid back down (all the while bleeding freely through the tube in her brain) and said, calmly, "Well, that feels better."

He has north of forty years' experience as a brain surgeon. He told me that he'd never seen a patient have an intraventricular hemorrhage and be feeling fine during and after it.

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

If you have cancer of the penis, it's probably best to have it at the tip of your penis, because, as awful as that is--and it's pretty awful--it's easier to reconstruct. Don't be like my patient who had a large sarcoma on the *base* of his penis.

(Hi, Mom!)

Because the surgeons will take off the part of the penis that is unaffected and attach it to a connected flap on your belly. They will then excise the tumor, and wait for the belly-connected penis to form a really good blood supply to its flap before they reattach it where it belongs.

(Every male reader of this blog, and about half the female readers, just crossed their legs reflexively and shuddered.)

The thing about flaps is this: they're purposefully made much bigger than they need to be, so that the whole area has great blood supply. As they meld to the area where they're transplanted, the excess tissue is cut away by the plastic surgeon and you end up, eventually, with something that looks normal.

What you get in the meantime, though, is a Penis For The Ages. It was fully as thick and as long as my forearm (and I have muscular forearms) and, just back of the mitre, was as thick as my wrist.

He looked down at his belly as the residents took down the dressing. "I'm not sure how my wife will feel about this" was all he said.

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

So I'm down at MRI the other night, with Fred The MRI Dude and Scotty, The Other MRI Dude. The scan we're doing on my patient is scheduled to take something like three hours, and about an hour into it, I start feeling really, really sleepy.

"Dudes," I say, "I need something to do. I'm about to crash out here in this chair."

"What would you do at 3 in the morning if you were at home?" Scotty asks.

"Either drink or lift weights." I reply.

Fred nods once and reaches into a cabinet. He pulls out a set of barbells ranging from twenty to a hundred pounds and lifts an eyebrow at me. "Have at it" he says.

Turns out Fred, when he's not working the MRI in the middle of the night, is a semi-pro powerlifter. A sixty-pound bicep curl is nothing to him. I did a forty-minute heavy workout with him correcting my form and spotting me. Yesterday, during my workout with Attila, I was so sore I could barely do a fifty-pound lat row.

Far from dreading having to go to MRI now, I kinda look forward to it.