Odds & Ends

Firstly, because I am a huge noobnik, the link to the latest Change of Shift. I suck, I know. This is going up late.

Secondly, Mike from Scrubcap sent me a very nice email, asking if I'd link to his site. Sure, Mike! The only thing that bugs me about his caps is that he's only got two patterns for the caps that work for women with short hair. And it's not personal; I rarely wear the things myself. It's just a matter of principle.

The featured cap in that link is for the Oklahoma Sooners, which a quick Google informs me is a college football team. Boomer on, Sooners.

Thirdly, an answer to the nice email correspondent who asked me if I'd ever considered posting pictures of, say, my cat or my workplace. The answer on the cat is this: If ever she did anything interesting, I would be happy to start a Friday Cat Blogging feature. Unfortunately, she tends to lie in one position, either asleep or facing the camera with an "I'm going to rip your throat out, asshole" expression.

As for the workplace, same deal applies: If my coworkers ever did anything interesting, I'd take pictures. As it is, we're all drunk at work, lying around in attitudes of total dissipation while our patients hit the bell, so it's no go.

Fourthly, on a completely boring, girly, personal note, I got a "Well Done!" certificate from my personal trainer. I thought it was sweet, a child young enough to be my daughter giving me a fancy computer-printed certificate. The downside was that there were no gold stars on it. The upside is that she's impressed and a bit mystified by my strength and stability gains. Seems I've blown the top off the curve as far as building muscle mass goes. Wahoo me. Boomer on, Jo.

(You know, I may be snarky, but the fact that she printed up a certificate really touched me. It wasn't one-size-fits-all, as it had brains and cats on it. If she adds pictures of Robert Smith circa 1985 to the next one, I'll know we're getting along.)

Umm...what else? Oh, yes: the latest Change of Shift has an excellent post on "Communicating with the Doctor". I wish somebody had given it to me five years ago, just before I graduated. Instead, I had to figure all that stuff out myself, which led to me making a howling ass of myself on the phone more than once. All new nurses and nursing students should read that one.

Did I just mention the year 1985? Seems I did. Excuse me while I go take some Geritol. (Do kids these days even know what Geritol is/was?)

In other news, I have a product review for those of you who wear mascara. See, I had to replace all my eye makeup after that pinkeye thing, and I ended up buying some Maybelline waterproof Sky-High Curls mascara. Because it was on sale. Waterproof because I have to wear waterproof eye makeup for Beloved Sister's wedding, because I don't want to look like Robert Smith, circa 1985, by the end of the ceremony.

Anyway, it works well. Yes, it is waterproof, which means you'll have to use something oily to take it off. And yes, it does curl your lashes, in a weird process that involves you being able to feel your lashes curling. If I had done major drugs in college, that probably would've provoked a flashback. It does not clump, but it takes forever to dry, so don't sneeze after you've put it on. Overall, I give it a good rating, if you like waterproof mascara.

Ooooh. The best part of that mascara purchase? Was finding out that every-damn-thing at the local Target is on clearance. See, they're building a Super Target down the road, so the Non Super Target is moving. That means that all the cool stuff you never wanted to buy before, because $15 seemed like a lot to pay for a furry Sponge Bob pillow, is now 60% off. So I have all the cool eye makeup I could ever want (thanks, pinkeye!) and some other nifty stuff, as well. Boomer on, Target.

And finally, after swimming and dinner and champagne (ugh) at Friend Teresa's, I've decided that Borzois are my new favorite sighthound breed. She has three of them--one skinny, one fat, one shy. The shy one did the lean/nit/burrow thing that sighthounds are known for, plus she was furry enough to really cuddle. I'll always be a sucker for Greyhounds, but Borzois are now running a close second.

So You're Starting Nursing School...

Tips for student nurses of all ages, drawn from my own limited experience:

1. Put aside inviolable time to study every damn day. Even weekends, even holidays. Don't get into the habit of thinking that you'll do it later, or that you can catch up. Study every day. You'll be glad you did.

2. Put aside inviolable time to think about something other than nursing every damn day. That includes not thinking about nursing blogs, or blogging your own experience. If you don't keep some other interests alive, you'll turn into StudentNurseBot, and you'll go crazy.

3. Yes, you will have no social life. This will not bother you. There's plenty of time for a social life after you've passed the NCLEX; nurses are notoriously hard partiers.

4. Make the effort to look as nicely pressed and crisp and clean and starched as you can during clinicals. Really and truly, it makes a difference. You'll not only feel more confident, but your patients will feel better about having you in the room. And if you have a crappy day, at least you looked good.

5. A word about your patients: on the whole, patients don't mind having student nurses. Some of them love it. Think about it: they get individualized attention from someone who's detail-oriented. They want you to succeed.

6. A word about nurses: on the whole, nurses want you to succeed as well. In four years, I've only seen one group of students that I felt couldn't hack it as even marginal nurses. The other students I've seen I have wanted to help, encourage, and see do well. Yes, there is the occasional wackjob or sadist who hates students. You'll be able to pick that person out of a group in no time and avoid them.

7. Another word about nurses: on the whole, nurses do not eat their young. The ones that do (and I work with one) bite everybody, not just the new nurses. And nobody likes them. Their colleagues avoid them, the doctors try to do end-runs around 'em, and management knows their tricks. Do not let the Nurse From Hell ruin your day.

8. Look around at the class you're in. Two thirds of the people in the introductory courses will probably wash out. Support them, study with them, and lean on them anyway. The relationships you form in nursing school last for about five minutes after pinning, but they're the most important relationships you'll have during school.

9. Some of your professors hate nursing. Some of them will try to discourage you, or will show favoritism to particular students for unfathomable reasons, or will be nasty without cause. Ignore those professors. Cultivate respectful relationships with the instructors who love what they do.

10. Pay attention in A&P. Learn enough skills to pass your skills lab, but don't fret about starting a zillion IVs. Know your drug book backwards, but remember that you'll have a set formulary in your hospital--you won't have to remember everything forever. Care plans suck, but they're useful in figuring out disease processes and really do come in handy sometimes. Never use "Potential For" as a nursing diagnosis more than once in a care plan. Make sure you have good pens. Always carry an extra scrub jacket.

And get out there and kick some ass. Being a nurse is infinitely more pleasant and much, much easier than being a student. Soon you'll be done with school. While you're doing it, remember that those of us who've been there are pulling for you.

Sung to the tune of "Heartbreak Hotel"

*strumming guitar*

I woke up at one this morning
And didn't know what to do
My eyes were welded shut with
This nasty yellow goo

Oh, I've got the pinkeye, baby
Yeah, I've got the pinkeye, baby
And don't'cha know I
Wanna diiiieeeee

I went to see the doctor
And all she said was "Wow...
"You sure 'nuff got the pinkeye
"Go fill this scrip right now"

'Cause I got the pinkeye, baby,
Yeah, I got the pinkeye baby,
And I got this burning
In my eeeeyyyyeeeeessss

I went on to the drugstore
And there the folks all screamed
They'd never seen the pinkeye
Be quite this bad, it seemed

And oh, I say
I got the pinkeye, baby
Yeah, I got the pinkeye, baby
And I am so bummed that I could cry.

Downside: I have to throw away all my eye makeup. Upside: I get to buy new stuff, which means I could conceivably change my image from Competent Nurse to Crazy Punk Rocker.

Downside: I have seven days of truly disgusting eyedrops. Upside: The drops kill even C. perfringens, so I won't get gas gangrene in my eyeballs.

Why I love students and GNs, and why you should too.

This past week, I was at the fifty-seventh minute of the eleventh hour of my shift when a GN I hadn't met before approached me and introduced herself. Turns out she wasn't looking for me, but we had a nice chat anyhow.

I asked her if she was getting a thrill from signing "RN" rather than "GN" after her name, and something amazing happened. I don't think she realized it, but she stood up a little straighter, her face glowed, and she said, "Yes. I'm really proud."

Turns out Dad and Mom had both been working three jobs to put her through school. She did very, very well and passed the NCLEX first shot, and now got to sign "RN" after a name composed mostly of consonants. You bet she was proud. Her whole family is proud of her, and rightly so.

And *that* is why I love new RNs. It's not just that they keep me on my toes during preceptoring with questions I've never thought of. It's not that they're seemingly inexhaustable and willing to work hard, because everything is so fresh and interesting. It's not just that they come up with questions about procedures and policies that make me go, "Buh?" and realize that there's a better way to do things. It's that they are so damn *proud*.

They've worked very, very hard for two or three or four years, often while mastering English as a second language or relearning algebra that they'd gladly forgotten twenty years before. They've busted ass through difficult courses with instructors who were, at best, flaky and at worst, actively discouraging about nursing as a career. Some of them turned their backs on lucrative jobs doing something else in order to answer a calling they'd ignored for too long.

They have every right to be proud. And seeing a new nurse's face light up when you ask about the "RN" thing is marvelous. It reminds me why I do this.

Nursing students do everything that a GN does, but more so.

I remember coming on to the floor on the first day of clinicals my first semester. I was so frightened I thought I'd throw up, and seriously considered running away. As the semesters wore on, I got less nervous, but I got much, much more tired. I see that process now with students.

The nursing students we get are excellent. The one exception that I complained about bitterly last year was just that--an exception. The SNs ask questions about anatomy and physiology that require that you keep your chops up. They cheerfully volunteer for tasks that seasoned nurses hate, because it gives them experience. Inserting a rectal tube is a brand-new, shiny job when you're just starting out, after all.

And they're cheerful. On very little sleep. I had classes Monday through Wednesday, starting at seven in the morning and going until three in the afternoon, after which I would spend at least a couple of hours in the lab or the library. Thursday and Friday, clinicals started at 6 am and often didn't end until after 4 pm.

The students I work with have schedules at least as harrowing, and some of them drive two hours or more to our hospital, but you never hear complaints. Maybe a wan smile or two, or somebody might crash and burn for a day or so toward the end of the semester, and have to be revived with coffee and chocolate, but they show up smiling, work their butts off, learn new stuff every day, and graduate.

What with the shortage of nursing instructors and the lack of places in programs, you have to be exceedingly bright to even get into a nursing school. Where I am, two-year programs produce most of the bedside nurses, and the entrance exams are very, very tough. The programs are competative--perhaps thirty people will finish from a starting group of over a hundred and fifty. The women and men who graduate with an associate's degree should be proud of themselves.

And I'm proud to work with them, both as students and as new graduates. I hope I'm as good to them and for them as they have been for me.

Thanks, guys. I'll see you next semester.

The Conga Line

Today I slept.

It's been a long week. We've had a number of folks with undiagnosable whatevers--things that we either have to wait for the disease to progress to be able to diagnose, or for the patient to die so we can diagnose whatever hit them on autopsy--and that always is hard.

So I got up this evening, after sleeping most of the day, and cooked. I had a bottle of wine, three different kinds of cheeses, and a selection of fun vegetables, so I cooked.

And just after ten o'clock, I was suddenly the head of the conga line.

Every nurse has a conga line. It's made up of the patients who die--the ones whose names you remember, whose various afflictions you remember--the ones you might've known even before you were a nurse.

Unexpectedly, I felt Darlene's hands on my shoulders. I kept washing dishes until I knew that Velva was behind her, kicking in rhythm to whatever four-beat polka they play where she is. Curt joined in, his wool sweater as scratchy as it ever was before herpes took his sight and hearing, and made his sister take over the coffee shop. Last in line came Astin, dead of metastatic breast cancer that we caught too late. She and Darlene kicked in perfect rhythm, while Velva and Curt had a good time making up new steps to the music.

I conga'ed around the apartment, macaroni and cheese and zucchini cakes forgotten.

Some of my patients pray to Saint Therese. I pray to the people that I loved--and who hasn't fallen in love with a patient, wished they had been friends with them before--for help, and guidance, and compassion.

And sometimes we dance with them, in a silent conga, grinning, as the music only we can hear and the hands only we can feel guide us.

An Open Apology to My Filipino Colleagues

Guys, I'm sorry.

I know you do better for my patients overnight than I can during the day. Gerb, I appreciate your attempts to teach me to talk dirty in Tagalog. Michelle, thanks for the custard cakes and the joke about the sausage and bread and fish. Ester, you rock my world when you start IVs for me. Jay, you've pulled more folks back from the brink down in post-op than I can count. None of you complains about the schedule, or about the bigots you have to work with, or about the assholes that pepper your day. Along with the Indian and African immigrants and the occasional Slav or Russian, you make my hospital a fun, interesting place to work. I love you all.

But I cannot, cannot eat pork adobo.

I have tried. I like fried eggplant and little squiddy-squids for breakfast. I rock the lumpia whenever you decide to bring some extra. I'll eat anything that you put in front of me, really.

Except pork adobo.

Kill a chicken, pluck a parakeet, slay a sturgeon. Put it into adobo sauce or dry it and fry it and serve it up cold; I don't care. Just don't put pork in front of me, please, with or without that delicious white rice that I can't seem to cook myself.

I feel *so bad* for not liking what is supposed to be the summit of Filipino cuisine, at least according to my coworkers, who can debate for hours the relative merits of various recipes for it, all the while switching into and out of English at baffling speed.

I had a big bowl of the stuff yesterday for lunch. Don't get me wrong; I love the way it tastes. But after? Oh, my stars and garters, it was like trying to work out with a hangover today.

So no more delicious, soft, tender, perfectly-cooked, meltingly wonderful bits of pork in a tasty sauce for me.

I think I'll go on a four-day juice fast now.

Progress.

The chocolate cake for Thursday is made. For those interested, it's the recipe off the back of the Hershey's cocoa box, which even Chef Boy says is the best he's ever tasted. It stays moist for *days*.

The salad for the next two days is made. Artichoke hearts, cabbage, romaine lettuce, baby corn chopped up, red pepper, cucumber, tomato.

My laundry is mostly done.

The patient with the weird collection of symptoms turns out to have both a demyelinating process of some sort and a bizarre, very rare form of bone tumor. "I've...uh...never heard of that" I said to Doctor Number One. "Neither had we." he replied. Doctor Number Two points out that this is not the time for that patient to be playing the lottery. Patient says that's fine with him, just as long as the state doesn't come after him for the amount of the jackpot next week. Mayo says they're not entirely certain that the tumor is what they say it is, but what they say it is is the closest match. We may have something entirely new here.

After five sessions with Der Trainer, I've encountered a new embarrassing reaction at work. Previously, people used to ask when my baby is due. Now, they say "Oh! You had your baby!" Friend Pens, in her wisdom, told me I should reply, "Yep. And as I get stronger and more fit, I will be able to kick your couthless ass more thoroughly."

More reason to think that Just Because You're A Doctor Doesn't Mean You Know Everything: a patient, a doctor, decided to manage her own Parkinson's medication. No problem there, as most Parki patients prefer to continue the routine that's kept them functional for years. But! If you try to "wean" yourself prior to your brain stimulator being turned on, you will indeed fall over and freeze, and we'll have to pick your rigid body up off the floor. Note to all concerned: This is not as easy as it looks. Six people and a bedsheet later, we got her back to bed.

"House" is on tonight. It'll be the first chance I've had in months to watch an episode. I hope it's a good, snarky one. My record is still good: I've only missed two diagnoses in all the time I've been watching--the first was the pregnant teenager with autoimmune weirdness, and the second was the guy with the stuff that's transmitted through pigeon poop. I even got the nun with the IUD.

On a completely serious note: If you work crazy hours, can't motivate yourself to exercise, and hate your life, please consider dropping the dough to hire a trainer. Yes, it's expensive. Yes, it's embarrassing to realize how out-of-shape you really are. But damn; this is the second-best money I've ever spent on anything (the first being the clams to get away from The Ex Husband). No really noticable changes in my body yet, but my stamina is improving, and I feel wonderful.

And I'm not even tempted by the cake.

Why do you come here when you know I've got trouble enough?

I finally got to say it.

"Are you shitheads gonna do the same thing to me this time that you did last time?" he demanded.

"He told me that nobody would help him with his bath last time. And that the doctor wouldn't come see him. He told me he was in here ten days without a bath." she concurred.

"Ma'am, Sir," I replied, "let me be straight with you. You weren't given bed baths last time because when the aides came in, you would curse and throw things at them.

"Then you'd get up and shower.

"The doctor stopped coming in after you threatened to kill him and his family. You've been fired by every nurse on the floor except me.

"The aides have been instructed, for their own safety, not to enter your room.

"I am the only person here who is willing to take care of you. And if your behavior is anything like it was the last time you were here--any cursing, any throwing things, any threats--I have instructions to discharge you immediately. If you assault anyone, I'm going to call the police."

There was a brief silence.

"Where am I supposed to go if you discharge me?" he asked.

"You may go to any other hospital of your choice. We will assist in your transfer." I said.

"No place else will accept him," his wife said, "They've all got do-not-readmit on his chart."

Another brief silence.

Then I gave him twenty of immediate-release oxycodone, four of dilaudid, and a milligram of Xanax and went away. That was all he really wanted anyhow.

Damn. Mention poutine, and the world beats a path to your blog.

I'm not much in the mood for IMAGE WARZZ today, sorry, SS and Bob, because I had that dadratted physically and verbally abusive patient come back in AGAIN. If he hates us so much, why does he keep coming back?

Anyway. I see your naturalistic images and raise you...

this.

He looks like he would love some poutine.

That's it. I'm effing moving.

I can't stand this any longer. People have a right to their own opinions, of course, but if these crazy, narrow wackjobs keep posting stuff like this where decent people can see it, I'm leaving the country.

This is just offensive. And blasphemous. I suggest you go to the blog and give the "writer" a piece of your mind.

Shrimp, I'm lookin' at *you*.

Back to Life

The paradox of palliative care is that sometimes, when you quit poking somebody, they improve.

She had come to us after a fall in the mall parking lot that resulted in a subdural hematoma. She also had a subarachnoid hemorrhage--probably what caused the fall--and had had a glioblastoma resected three years earlier. It was the nasty sort of glio, multiforme, that has a life expectancy (untreated) of three weeks. After conventional chemo and radiation, she'd gone to a clinic in Texas that, while it's mentioned on QuackWatch, has had some success in treating patients with brain and other cancers.

She was also septic. MRSA sepsis, which means it's tricky to treat. We'd had her on vancomycin and rifampin and she wasn't getting better. When I took over her care on Monday, she was globally aphasic (couldn't speak or understand speech or communicate at all). By Tuesday, she was tachycardic and moaning. On Thursday, her sodium had dropped to an eyebrow-raising 124 (135 is the bottom end of normal) and she was minimally responsive to pain. She was producing almost no urine and was swollen and blotchy all over.

The doctors ordered a nasogastric tube. I'd spoken to her family at length about what she and they wanted, and I was pretty sure an NG tube wasn't part of the plan, so I stalled until her family arrived that morning. They decided, with the doctor, to stop all interventions, put her on palliative care, and let things happen as they'd happen.

I didn't expect she would live through the weekend.

Imagine my surprise, then, when I walked in Monday morning and she sat up in bed, waved, and smiled at me.

*boggle*

The wave was a little messy, as she had a spoonful of mashed potatoes in the waving hand, but I was glad to see it anyhow.

We'd repleted her electrolytes and rehydrated her and dumped dozens of grams of various antibiotics into her. We'd put in a central line, taken it out, put in a different central line, pumped her full of drugs to keep her comfortable, sat her up in a cardiac chair, and generally been as unpleasant as caregivers can be to a patient who just wants to rest.

So, finally, she got a chance to rest.

I explained to her family that, since her sepsis was only about halfway treated, she could go rapidly downhill at any point, and would probably die from that sooner rather than later. Still, as the week progressed, she continued to improve. By the time she left later that week, her edema was gone, her urine output had normalized, and she was talking and (mostly) making sense.

Regardless of what happened in the end--and I'm not sure, even with no tumor regrowth, that she would've survived long--she got a week or two of mostly-compos-mentis-ness to spend with her family. That's enough.

Rule Number Seven Gazillion of Nursing: Sometimes just sitting down and shutting the hell up is enough.

Dear Joey,

I have decided what we need to do.

I'm tired of the South. I'm tired of the pollution and the hundred-degree days, and of the lack of calamari and itty-bitty grilled cephalopods.

So I'm going to learn French. I figure I can do it at the same time I'm losing this 40 pounds with the new trainer.

Then I'll move to Montreal.

While I'm losing 40 pounds and learning French, you'll have to take the art world by storm. I figure that your Spring 2007 show, "Where are you going? Where have you been?", featuring GPS-enabled dresses and blouses that will map out one's progress through any city, will be a big hit. You will make Montreal the center of the art-tech-fashion world and will become a household name. Meanwhile, I will figure out how to become independently wealthy. Maybe the exchange rate will improve.

Shortly after that, you'll buy an Audi TT. White. Six-cylinder, with Quattro all-wheel drive and a stick shift. You can drive a stick, right? Oh, what the hell...if I can lose 40 pounds and learn French, you can learn to drive a damn stick. If we work it right, you can put one tiny box of mine into the back of the white TT and help me move.

I will drive a refurbished Karmann Ghia or a mail truck. An old right-hand drive mail truck, painted with large bright polka dots. You may keep your condominium while I move in to something loft-like in Chinatown (hard to find) or Little Italy (slightly easier). I'll hang a swing from the ceiling like Marguerite has.

You may wear gorgeous old cashmere coats with huge collars. I'll wander around in ball skirts and men's sweatshirts and plastic pop-bead necklaces and collect Balinese dancing masks. We'll never have a bad meal and will eat tofu only by choice.

We will spend our summers on Ile d'Orleans, eating raspberries and drinking champagne and figuring out your next artistic coup. Aside from six weeks of summer, which will be warm and sunny and dry, it will always be either spring or fall in Montreal. Except right around Christmas, when it will snow in a picturesque fashion, but not long enough to get all dirty and awful.

By general decree, the river will not only become safe to swim in, but will become pleasant and just cool enough. We'll buy big straw hats and a parasol or two.

That's what we're going to do. Please get cracking on taking the art world by storm. I'm going out to buy some lottery tickets.

Love,

Jo

Fluff Life

Yeah, yeah, yeah. I have a patient who suddenly improved dramatically after she went on palliative care, and one who has an interesting bacterial infection, and I just saw a patient at the grocery store who was given a 30% chance of living four years ago, but I'm not in the mood to talk about work.

I'm in the mood for fluff, simply because.

So. On to the fluff:

Allure magazine might be the best fluff rag ever. Especially this month's, where they concentrate on hair. Who could do better than hair? I mean, there's a column by a redhead, and one by a blonde, and they go through the evolution of Debbie Harry's and Twiggy's haircuts. Go. Buy it. Get some Mallomars or some Cheetos too, while you're at it.

Being in Montreal during a heat wave left me with an addiction to two things: San Pelligrino mineral water and S. Pelligrino lemonade-in-a-can. The former is good for hydration before a night of bitty baby grilled octopi and endive; the latter is good for the morning after, when you're walking along the canal with a baguette and some triple-cream brie, looking for a place to stop and eat. Unfortunately, you can't get the lemonade within 30 miles of here, which means I'm going to have to make a pilgrimage to the Foncy Food Place on Sunday.

Who thought of the Ben & Jerry's flavor Black & Tan? I mean, really. Cream stout and chocolate? Yick. Vermonty Python, though, is excellent--and since the fudge cows are moisture-resistant, you and your significant other can flick them at one another. You can even make the little cow say, in a squeaky little cow voice, "I don't know!" before you flip it across the table with an "AAAAAAUUUUUGH!!"

I bought a Maybelline two-pencil set of eyebrow color today in the "Auburn" shade. Wish me luck. Review to follow.

Speaking of which, why doesn't anybody make straight brown stinkin' mascara any more? Used to be you could get the stuff, but now the only manufacturers are weird off-shoot brands that smear down to your chin after five seconds.

Burt's Bees Lip Shimmer, continuing the makeup discussion, is the best. Lipcolor. Evah. Get the "Coffee" shade--the others are too pink.

I have hired, wait for it, a personal trainer.

Yes.

Because I am tired of having my back fat rub against my hip fat, and because I don't want to look like a licorice jellybean while wandering down the aisle at Beloved Sister's wedding. More importantly, I'm beginning to fear for my health and my job security because of lack of muscle mass and achy feet. So I've hired a cheerful drill instructor to show up at the house three times a week and kick my butt. My first appointment is on Saturday.

Beer Review: Independence Pale Ale, out of Austin, Texas, is great stuff if you can get it. It's produced by Independence Brewing, which is a small enough company that they use plain bottle caps and (I think) put them on with an antiquated capper. (You can tell these things after dating a guy who brews his own.) Also, if you want to know what Chef Boy's Winter Warmer tastes like, pick up a sixer of Ten Years Alt from Victory Brewing, and increase the abv% to 10.1. It's like a Tootsie Roll with a kick. (Shrimpy, that last was for you. "Small dogs dipped in Maudite", indeed.)

Amusing Montreal Story: as Jennifer and Joey and I were walking through Little Italy at 10:30 pm (things really begin to get started then), we passed a restaurant with a rooftop terrace. There was a man playing accordion amidst the diners--and playing "Volare", believe it or not. Just across the street was another restaurant, this one with awnings over the window and a second-floor apartment with a deck in the back. The deck, therefore, was even with the awnings. A small dog, a Jack Russell terrier mix by the looks of him, had come out to run along the awnings and inspect the restaurant's patrons and bark at them until he was called back by his owner.

It's scenes like that that make me thankful for whomever it is that's writing the soundtrack for my life. There may be nothing better than being full of home-made pasta and ricotta cheese and basil tomato sauce and walking with grocery bags full of nifty things past groups of gazing men in the warm summer evening. Unless it's doing so in the company of two of the coolest, smartest, wisest people you've ever met.

And finally, a note for any north-of-the-border readers I might have: What It's Like When It's Really Hot....

(Trying to explain 42* C to a Canadian is difficult. This is the best I can do.)

1. Everything dies. Even if you water it. Even if it's in the shade.

2. Nobody goes out between 1100 and 1700, or else they'll die, too.

3. Your produce wilts in the car on the way from the grocery. At 6 am.

4. Learning French seems preferable to getting into a car whose steering wheel is so hot your palms will blister if you grab it.

Medical Stuff next time, I promise.

Back in the English-speaking world again...

Montreal was, as always, lovely. Hot, though. It gets to a whopping 90 degrees about a week out of every year, and I was there for five days of it. With 70% humidity. And wind. Quebec's motto is "Je me souviens", which translated from the French, means "Hey, who's the fat sweaty chick with the frizzy hair?"

Joey has a sweet condo just across the canal from the Atwater Market, with brick walls and a soaring ceiling and a loft. It also has the Quebecois version of "central air conditioning"--a Japanese-made widget about one foot by three that somehow cools the air without actually exhausting anything to the outside. It was placed in the stairwell facing the western exposure of the condo, facing the glass doors to the deck. The top two stairs of the stairwell were therefore very cool indeed. I spent most of my time between showers there.

We went to a wedding on Ile d'Orleans, which is a bit east of Quebec City and smack in the center of the St. Lawrence river. It's beautiful. That's all there is to it. Not only was it cool, but there were little stands advertising pick-your-own strawberries and raspberries (heaven), and a really good pub with homemade beer--some of the best I've ever tasted. We partied all night long with the bride and groom, then drove to Quebec City afterward, which was (if this is possible) even hotter and stickier than Montreal.

QC's old portion, where the wall and Parliament and all the old buildings and cannon are, is interesting and lovely and European and hot and sticky and sunny and crammed with tourists from all over the world. It also takes the prize as Most Inconveniently Hilly Place Ever, even worse than San Francisco. There's one SF-style hill, and everything spills down and winds around it, effectively a) blocking any breeze and b) ensuring shinsplints and fractures in the unwary. What vertiginous spiral staircases are to Montreal, That Damn Hill is to Quebec City.

Everyone in Quebec City greets you with a cheery, "Bonjour, Mademoiselles!" which, translated from the French, means "We weren't able to Darwinize you with the staircases, but we'll get you with the hill, by God!" They then charge you two dollars for a soda and laugh hysterically as you immediately turn said soda into sweat.

(I was pretty exhausted and cranky in QC, having stayed up all night for the first time in my life. Don't let my grump dissuade you from visiting.)

It's impossible to get a bad meal in Montreal. Well, I suppose you could if you tried hard enough, but it would take some doing. La Banquise is, of course, the classic poutine shop. Cafe Internationale in Little Italy has some sort of salad that combines grilled calamari and baby octopus with capers and endive and is heavenly. And, of course, Marche Atwater is good for cheese and bread and fruit and veggies and chocolates and fizzy water and San Pelligrino lemonade and meat and oh, my God. And, as always, there's Le Pied De Cochon, for all your piggy needs.

Everyone is fit and beautiful and very, very tan there. They all speak some lovely but unintelligible version of French. The men shake your hand with an "Enchante" which, translated from the French, means "You may be a fat, sweaty American, but I'll be nice to you anyhow and speak English, because I am so much better-looking and cultured than you are." Joey has just won a Maclean's Magazine award for being a person who makes the world a better place to live in, so she was even more impressive than usual. All her friends greeted me with a double-cheek kiss, which, once I got used to it again, made me feel very cosmopolitan and not at all silly.

All in all, a lovely time. Next time, however, I am visiting in the spring.

Saturday night, old meme

Five things nobody knows about me:

1. I'm a total snarky bitch at work, but I cry at "Extreme Makeover: Home Edition." And "Cold Case." Hell, I just watched "The Princess Diaries" and cried at that.

2. I have no clue what to do with my hair.

3. I lived in a commune--and got college credit for it.

4. I know quite a lot about engines.

5. I often fantasize about having a high-precision rifle with a laser sight in order to get rid of people who bother me. The gentleman who garages his car downstairs (that would be a Pontiac with glass packs) is first pick.

Five things in my car:

1. A trash bag.

2. Two silver spoons I used to eat yogurt that I haven't brought in yet.

3. A security card for the hospital parking garage. Ditto the apartment.

4. A jug of laundry detergent.

5. A copy of the book "The Evolution of Useful Things."

Five things on my desk:

1. A small garden gnome with a basket of flowers over one arm and a bouquet of flowers in the other. My friend Jeanie from the 'Net sent him to me. His name is Alan.

2. My passport.

3. A cartoon of two snakes with snaggle teeth, one saying "Where *is* everybody?" and the other saying, "I have the *snacks* all ready!" with the caption "Your typical nest of vipers has an undeserved bad reputation."

4. A pair of speakers I keep turned down.

5. A jar of Carmex.

Just...ew.

***Beloved Sister, Scroll Down.***

An hour and a half into the process, I was getting a little tired of things. Three urology residents were bent over my patient with speculae and a headlamp, trying desperately to find her urethra.

Things had started to go badly when the fourth Foley catheter came out. (For those non-nurses in the audience, a Foley catheter is a long tube that goes into the bladder through the urethra and sits there, held in place with a little balloon filled with sterile water. It drains urine.) The damned thing actually shot out of her urethra and flew to the end of the bed, splattering urine as it went. I'd seen some interesting reactions to Foleys before, but never that.

I couldn't get the thing back in, primarily because I couldn't find her urethral meatus (opening). Normally, with women, this is not a problem--although bodies differ, I can usually manage on the first try. But this time? No go. No go, either, for the second-year resident, who found the ridge of muscle that usually marks the urethra, but whose attempts at inserting a Foley ended when the catheter coiled up time and time again.

So in came the third-year. He didn't have any better luck.

By this time, I had a lumbar drain that needed opening, so I went and did that. I came back to find the fourth-year in my patient's room as well, complete with OR headlamp and a variety of other...stuff.

No go. Still, with three people working away, sweating and cursing under their breath, no go. Things were complicated by the fact that my patient couldn't move her legs at all, and had some pretty amazing contractures.

Finally, the doctors figured out why they couldn't insert a catheter into this poor woman:

She had no urethra. And no neck to her bladder. They'd been worn away after twenty years of wearing an indwelling Foley catheter. The only thing left outside her bladder were three fistulas to the outside.

We put her in a diaper and scheduled her for a suprapubic catheter placement.

***You May Now Resume Reading***

Speaking of things you wish you could forget, I left a lumbar drain open too long the other week. Although my patient drained nearly double what she should've into the drain, her brain did not herniate down through her skull. I got very lucky, and so did she. There is no feeling worse than the feeling that you could've irrevocably fucked somebody up--unless it's the feeling of waiting to see if that's the case.

New nurses, take note: You will make minor mistakes on the average of once a day. Major mistakes might come as often as twice a month. A really huge mistake, like leaving a lumbar drain open for an hour, will happen at least once a year. The first time it happens, you'll be crushed. Later you'll learn to manage the mistake, figure out what caused you to make it, make changes in your practice, and keep going. Have faith.

And speaking of things new nurses should know, I have become a more-than-respectable IV starter. For the first three years, I sucked. There is no other way of putting it. Unless I was presented with a vein the size of a firehose on a comotose patient, I would dig and stick and fumble around and generally cause horrible bruises without getting a blood flash.

That seems to have changed, hopefully permanently. For some reason, over the last few months, I have had The Mojo. Even people with tiny threadlike veins that hide present only a minor challenge. I can't point to any one thing that changed in my technique; the only thing I can come up with is that the process finally got so routine that I was no longer spooked by it.

And finally, go read this. I tried to leave a comment, but was speechless. (The rest of her blog rocks too.)

Random Musings

Gosh, it's nice to have my brain back.

*** *** ***

Buck's traction for a dwarf is not easy.

For those of you who don't know or don't remember, Buck's traction is a type of traction used for femur (thighbone) fractures. You get a one-size-fits-badly foam rubber boot with a metal bar across the bottom and velcro straps across the front, and once you put that on, you attach the traction ropes and weights.

Unfortunately, there are two problems when you're doing that for a person who's smaller and differently-shaped than the creators of the Buck's traction setup anticipated. First, dwarves' legs are shorter and usually a bit bowed. Second, they're short people. Traction depends on a straight run of rope to hold a fractured leg properly; if the person in traction is only about three feet tall, there's a lot of rope that can catch on the bed and in the sheets. Unless you put the person more than halfway down the bed, you're going to have Trouble, with a capital T, and that rhymes with M, and that means I had to be the MacGyver of Traction yesterday.

It works like this: grab the Buck's boot. Note that the metal stabilizer bar comes only halfway up the boot and then runs across the bottom. Good deal. Cut the top part of the boot away with a #11 scalpel. Now we have a shorter boot. Excellent. Grab two catheter leg-bag kits and scavenge the Velcro wraps out of them. Use those to help tighten the boot around the lower leg. Now you've got the boot on.

Remake the bed so that the bottom sheet lies flat and is held in place with a top sheet, folded lengthwise and tucked very tightly, so there are no wrinkles across the bottom third of the bed. Then fold another top sheet crosswise and lay it across the patient. This covers them without smothering them. Do the same with a blanket. One of the patient's feet will necessarily be outside the covers, but oh well.

Snag a fresh coil of traction rope. Measure twice, cut once. Set up traction. In order to keep things clear, use paper flags marked "TRACTION ROPE" to label the, you guessed it, traction rope as it goes down the length of empty bed. Adjust weight to be sure it's hanging freely.

Pat self on back. Collect accolades from co-workers, the patient in question, and the orthopedic surgeon. Eat a bar of chocolate.

*** *** ***

Somebody put a lock cap on a lumbar drain the other day. They disconnected the lumbar drain (which is supposed to be a sterile, closed setup) from the bag, locked off the drain with the cap from a syringe, and sent the patient out to have a smoke. This did not happen on the neuro unit, obviously.

*** *** ***

New squick I never thought about before: watching a doc put in a couple of really deep retention sutures, through skin and subcutaneous fat, with a curved needle and 2.0 vicryl. I felt a little queasy.

*** *** ***

Speaking of squick, this is probably the single most potentially-gross thing I've run across in a while...

I had a patient in a few weeks ago for a shunt. We use them when the pressure of fluid in the brain gets to be too high; the shunt pulls fluid off the brain and sends it into the abdominal cavity. Anyway, this guy had a shunt placed and came to me post-op. I knew he'd been in prison a couple of times and had had some close calls with regards to bullets.

One of his shoulders had a patch about the size of my palm. The skin was thickened and whitish, with what looked like embedded pieces of doveshot or gunpowder in it. The whole thing looked for all the world like Dick Cheney had taken a bead on him. I thought it was a gunshot scar. So, "Did you get shot here?" I asked.

"No," he replied, "That's a big ol' blackhead. Last time I was inside, my cellmate squeezed part of it, and something popped out and hit the wall of the cell."

I managed to warn him against doing that again, as sebaceous cysts like that are sterile as they are, but can get badly infected if you try to pop them. Then I got a wheelbarrow and took my jaw out of the room.

Eugh.

*** *** ***

Wow.

Just...wow.

I opened my email box yesterday afternoon, about an hour and a half after posting "Gee, Officer Krupke!" and found more than two dozen emails. Some were comments on the blog postings about my brain; others were just emails, sent to say "hang in there" or "throwing yourself under a bus is a bad idea" or "look at me; I'm stable and healthy and have been doing this for thirty years".

I can't thank you all enough. It's a relief to know, of course, that you're not alone, but it's also a relief to know that there are people in the world who are nutjobs like me but who can also use paragraph breaks and spell correctly.

A couple of points I need to clear up: I am not going to toss myself off a high building, or even a low one. Suicide is not attractive in the least.

Also, I'm feeling better. Either I have the fastest chemical-reaction time known to man or this is the placebo effect; either way, I'm not arguing. This happened the first time I upped my dosage of Effexor, from 37.5 to 75, even though "everybody says" that it takes a week or two. I'm a little speedy yet, but feeling much better.

Too, I think I figured out what Doc Pedro meant by "rapid cycling". The last time I saw him was March of 2005, and he didn't get the date right. He thought I'd gone from peachy to miserable in three months, not in fourteen. Regardless, I'm still going to find a shrink. I got a little grumpy when I realized Pedro hadn't read my chart right, for Chrissake, but that just reinforces my next two points:

Doctors are human and can screw up, especially in minor ways, especially when they're stressed out; and,

It's never a bad idea to hold up a hand and say "Wait. Stop. I don't understand." If *I* can fail to do that, as somebody who's used to dealing with doctors all the time, *anybody* can.

Still, shrink it is. Brain chemistry is a specialty, and I have some questions about my med that Pedro couldn't answer.

Thank you all again for your emails and comments. It was really and truly like being borne up on a huge wave.

Cue "Gee, Officer Krupke!"

"You--take him to a headshrinker!"

So I saw my pal Pedro, also known as Doc Pedro, PCP, today.

Doc Pedro wasn't having the best of days. Somebody's grandchild was trying to systematically dismantle his waiting room as somebody's grandchild's grandmother made a big stink about nothing, and in walks his primo, pure-dee, brass-plated Headcase Du Jour.

Poor Doc Pedro. He's sending me to a headshrinker. On accounta, she says, channelling Action and Riff, I'm depraved. And on account of the "cyclical nature of my depression." Yes, he really talks like that.

Never mind that four years of good control on Effexor is the longest damn cycle I've ever seen, Jack, and maybe he got me mixed up with somebody else; I'm headed off to find a psychiatrist.

All joking aside, there's a definite period of adjustment when you come to terms with the fact that you need medication to function like a normal person. Then your medication gets doubled on the same day that your PCP tells you he can't really manage your care any more, and you're forced to look at yourself in the sunshade mirror of your car and say,

I am mentally ill.

I have a chronic condition that is not curable, but is manageable with lifestyle changes and medication.

I will be doing this the rest of my life.

Whereupon, driving up the street, it suddenly made sense to me why some people actually kill themselves.

I, of course, not wanting to deprive the Reading Public of my thoughts, did not drive my car under a bus. Instead, I went out and got an order of nachos with extra guacamole and drank a beer. Then I considered my plight.

I am mentally ill. I will be doing this the rest of my life. I will be managing, with any luck, my illness with lifestyle changes and medication. Forever.

Then I swallowed another Effexor. Doc Pedro doubled my dosage today, given that all my symptoms are those of somebody whose body has grown accustomed to Effexor. He wasn't willing to change my meds, fearing that that would merely confuse any other practitioner I consulted.

So, here I am. I'm depraved, not on account of I'm deprived (unless it's some intrinsic genetic failing), but I'm depraved. Just knowing that I have some problem that he can't help me fix makes me feel better. You know those questionnaires that you take, where the max score is 21? I got 18. I think anything over 15, for him, merits a referral.

I swear to Frog I'll find the silver lining in this. (See? My mood's improving already.) It might take a while, but I'll find it.

Meanwhile, I have to find a shrink I can handle. Good thing I work on the Brain Unit, eh?

Reflections of a Nutjob

It has come to my attention that I am a nutjob. Not a hard-core nutjob (meaning, I take only one medication, and the lowest effective dosage of that one), nor an unmedicated nutjob, but a nutjob nonetheless.

Please. I am not "depressed" or "differently serotonined". Euphemisms are for the differently brained. I am nutso. A whackjob, if you prefer that terminology. A crazy. Whoo-whoo-whoo, a la Moe of the Three Stooges. I have a shopping list of things that gets me through the day, most of them mind-altering substances of varying availability (Caffeine, Effexor, Caffeine, Simple Carbohydrates, Norepinephrine, Effexor, Scotch, and venlafexine for dessert). I have been known to have anxiety attacks for no particular reason, and in fact had one today.

So. In the spirit of past Things To Do lists, here's:

What To Do If You Know A Whackjob, Version One-point-Zero

1. Do not, under any circumstances, indulge their desire to talk about nuclear holocaust or other forms of apolcalypse. See, whackjobs get anxiety in weird ways, and this is one of them. Steer them away from the David Brin and onto the Spider Robinson, where everything turns out okay.

2. Do indulge their desires for simple carbohydrates and alcohol, within reason. Carbs raise serotonin levels while alcohol in moderation can keep the garden-variety nutcase from jumping off a bridge. Make sure it tastes good, and you'll have accomplished another goal: showing the loonie in question that tomorrow is indeed another day.

4. Crazymeds dot org (thanks, Anon, for the correction!) is an excellent resource website for both the interestingly-brained and their friends and relations. True, there are some postings on the site what will make you say "Wooo. Buh?", but overall, it's a nutjob presenting what it's like to be a candidate for the whackshack with grace and humor.

5. If your crazy pal needs a warm body around, be that warm body. I cannot tell you what a difference it makes from the loonie perspective to have somebody around who can quote Bloom County and make coffee. It's invaluable.

6. If you work with even one other person, do not make denigrating comments about crazy folk at work. That one other person might be me, and I might be on a short leash due to my antidepressants not working all that well, and then there might be a lot of mess to clean up. Crazy people *are* different from you, yes: we're often smarter and more creative. We're certainly posessed of a well of nastiness that you can't even conceive of. So be nice.

7. Answer the phone at 3 am.

8. Don't pressure the nutcase in question to go out in public with you. Often, nutcases such as myself can't muster the energy to go to the bar or a restaurant. It's simply too overwhelming. Bring by a clamshell of Chinese instead if you really want to see me.

9. Make sure the nutcase keeps their doctor's appointments. This is not such a problem with the minorly-medicated, but can be a real issue with those of the brotherhood who take multiple meds or meds in major doses.

10. If in doubt, call 911. I am not saying here that this has ever been an issue for me. I have been blessed up to this point with having not had any serious thoughts of self harm....but I can certainly see how some people might.

If you work with, live with, or love a moderately- to severely-depressed person, or a person who deals with bipolar disorder, keep in mind that calling the fuzz in might someday be necessary. This does not mean that you or the other person has failed; it's a modern response to an age-old problem that used to drag the median lifespan down. Think of it as your way of boosting our national life expectancy.

Tomorrow I see my Muppet-like doctor. We'll talk about how to regulate this pinkish lump of neural tissue behind my eyes. I'll certainly, since everything is fair game here, keep things updated.