Make me a Saturday-night drunk, please.

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

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

Two out of three ain't bad.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cost/Benefit

Benefits of narcotics:

1. Freedom from pain.

2. Ability to hurple around house without cursing.

Drawbacks of narcotics:

1. Itch.

2. Weird sleeping patterns.

3. Inability to concentrate. Look! A chicken!

4. Itch.

5. Dizziness.

6. Apathy.

7. Short-term memory deficit.

8. Itch.

9. Strange dreams.

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

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

Product Review: tramadol!

Ultram: the bomb of all bombs.

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

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

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

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

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

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

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

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

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

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

But instead, I find myself musing on feeling stabby.

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

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

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

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

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

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

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

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

I Pity The Fool: A Team versus B Team

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Change O' Shift is up!

Here.

'Twas the day after Xmas; all over the yard

A lone dog was chewing his prime rib bone hard.

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

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

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

A Chrissolstikah Story

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

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

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

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

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

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

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

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

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

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

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

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

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

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



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

Blue

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

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

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

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

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

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

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

Umpteeen trails of barbed wire around biceps.

A dragon over a mastectomy scar.

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

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

I wish I could take a camera to work.

When it hurts, I cuss.

Prodigally. Fluently. Creatively.

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

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

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

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

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

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

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

Everybody's a comedian.

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

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

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

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

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

Things I have learned on my winter vacation:

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

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

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

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

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

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

7. I don't miss having a TV.

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

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

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

11. But I still have two more days!

(Insert clever title here)

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

Announcement:

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

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

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

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

You must immediately click the following link...

To Digital Cuttlefish.

Immediately.

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

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

Woo doggies.

I do brains. Brains and spines. It's what I do. It's why I titled my blog "Head Nurse." Because I do brains. And spines.

Except lately I've been doing a lot more than brains and spines. Kidneys, for instance, and intestines. And weird plastic surgery dealios that involve, like, seven incisions in somebody's head, all intended to rebuild bits that have been lost to gunshots or cancer or accident.

So I've found myself having to do things that I'm not exactly comfortable with lately, and I've come up with some new tips and tricks. They're old news for those of you who handle a lot of bizarre surgery patients ("bizarre" in this case modifying "surgery"), but they're new to me.

Tip the First: Label IV drips in more than two places.

The rule is to label your pump and your IV line if you're running, say, chemotherapy or total parenteral nutrition, two things that should not be combined with anything else. Normally those lines are labelled on the IV pump itself and then below the IV pump in one spot, using fabric tape and permanent marker or a pre-printed label in yellow or red.

I've found over the last couple of months that that is not enough labelling for somebody like me. I now label TPN and Weird NonMixable Drips in four or five places, running those labels straight down the line. It's not such a big deal if you're infusing, say, normal saline and IV immunoglobulin, but if you've got a four-channel pump with four fluids plus piggybacks, it helps.

Tip the Second: Label the drains coming out of your patient.

Again, I'm used to three or four drains at the most, and those well-spaced: maybe one at the head, one in the belly, and one coming out of the person's lumbar spine. I was confronted late last month with a patient who had ten (10) drains coming out of her belly alone. I'm not counting the ones coming out of her back, or the ones attached to the Wound-Vac.

None of the drains were labelled, yet there was an order that said, "Flush PAD with 30 ccs NS q 8 hrs, dwell for one hr, drain." Um. Lessee...three PADs there and no clue which one to flush. Flush 'em all? Flush one every eight hours? Or ask the resident? I went with door number three, then labelled the drain we were supposed to be flushing. I also labelled the lines with where they went (JP, Jvac, Hemovac, Wound-Vac) so there'd be less tracing back. It also helped differentiate the two drains that had exactly the same tubing but different uses when the only distinguishing marks were covered by tape and connectors.

Tip the Third: Warn the next shift about that abscess.

If you know your opposite number on the night shift will have to irrigate and re-dress an abscess or undermining decubitus, have the Vicks Vaporub right there at the door when they walk in. This is one of those "do unto others" things I wish somebody had done for me. There's nothing quite like encountering a fist-sized hole in somebody's belly or a stage IV undermining bedsore without proper preparation.

Tip the Fourth: Warn the next shift about that resident.

We have our residents trained well. The same can't be said for the residents who are, for our unit, off-service. It's only politic to warn the oncoming shift about the resident who's paranoid, suspicious, and has a God complex. I was the first person to encounter him and thought he was being ironic. Wups.

And, finally, Tip the Fifth: Iodoform, Aquacel, and various other specialty dressings never go as far as you think they will.

Let's say you've got a wound that's just about big enough to swing a cat in. Let's further assume you have to pack that sucker with some sort of wound-packing material. If you already have three containers of that packing in the room, take in a fourth. If there are already four in there, take in a fifth. Have an extra in your pocket just in case. This is especially important if your patient has a live flap from, say, their shoulder to where an ear used to be that has to be wrapped with petrolatum gauze, as that stuff's a beast to work with.

It's been an interesting couple of months. Things'll probably start getting back to normal soon, as the construction that's sent Bizarre Surgery Patients to our unit is almost done. I'll miss the variety. I think I've grown a third hand through dealing with all this new stuff, and I'm hoping that sticks around. What I *won't* miss is seeing patients with half a face, or faces that are attached to arms or shoulders or chests.

Who knew that a subtotal lobotomy patient could seem so peaceful and normal?

With regards to Jill Sobule

I once saw a photo of a poster, somewhere online, that showed a large Malamute and the words "LOOK AT THIS DOG."

The text below read like your typical Lost Dog advertisement, except that it consisted of things like "Isn't this a MAGNIFICENT FUCKING DOG?? I love this dog. He is so damn cool. Last seen being COOL in my huge-ass backyard, which is what he does EVERY DAY."

I am totes in love with my dog.

He grumbles. He dances. He makes "hmmmMMMMmmmrrrgh" noises when I rub his ears. Sometimes he invites me outside to play by bringing every single damn chew toy and rubber ball and bone and bull penis (dried) and stick and rock in the back yard up to the door and dropping it, then looking hopeful. "Herd Ball? Can we play Herd Ball, please? Pleeeeeeez?" (Thanks to Kris for the name of that game.)

He has enormous shoulders, big brown eyes, and blond hair. What more could I want in a male that takes up most of my bed? Yeah, he's got a hairy back, but hey. He only eats once a day and that's dry kibble, so I know he won't drink the last beer.

And he likes me to scratch his belly. There's nothing better after a long day than coming home and letting him in and having him roll over with one paw up, asking for Belly Rubs. Rub Mah Belly, Human!

He has a magnificent bark. I love to hear him bark, unless it's at 2 am. And we're having a problem with the "bark when people come to the door" thing, as he normally barks as they're driving away. Yeah, the Mansons could come in and he wouldn't mind, provided he got Belly Rubs, but he's learning.

He doesn't chase the cat. He doesn't chase squirrels. So far, he has not peed once in the house (we'll see how that goes once I get a Christmas tree). He's nice to strangers, unless they're skeevy. If they're skeevy, he stares at them with his ears pricked. If they're not skeevy, or if they're friends, he lets his right ear flop over or to the side. He's completely smitten with the pug next door. He licks my face when I'm feeling bad.

I am totally, *totally* in love with my dog.

LOOK at my dog. Isn't he magnificent? He is. Yes, he is.

Holiday recipe #1: Stuffing for Residents

Chop two white onions and five stalks of celery. Sweat in half a stick of butter until soft.

Dump into a large bowl. Refill the saute pan with a pound of chopped mushrooms and melt them into a stick of unsalted butter.

Boil six cups of chicken stock. Add one stick of unsalted butter.

Toast one pound of chopped pecans at the same time you cook one pound of lean bacon in the oven.

Open two of the largest bags of Pepperidge Farm stuffing mix you can find. Use the homestyle stuff, not the cornbread stuffing, which is too sweet.

Dump them into the bowl on top of the onions and celery.

When the bacon is crisp, drain it. Add bacon, mushrooms, and pecans to the bowl of stuffing. Be glad you got the largest mixing bowl Target sells.

Pour chicken broth mixture over your stuffing and mix well. Bake for an hour or so in a casserole pan or six, until the top is crispy and the house smells marvelous.

Will feed sixteen nurses, twenty normal people, or three and a half residents.

Burnt. Out.

It's that time of year again. I'm feeling burned out about my job.

What do you do when you feel burned out?

The eleventh hour of the eleventh day of the eleventh month.

Wilfred Owen

Dulce Et Decorum Est

Bent double, like old beggars under sacks,
Knock-kneed, coughing like hags, we cursed through sludge,
Till on the haunting flares we turned our backs
And towards our distant rest began to trudge.
Men marched asleep. Many had lost their boots
But limped on, blood-shod. All went lame; all blind;
Drunk with fatigue; deaf even to the hoots
Of disappointed shells that dropped behind.

GAS! Gas! Quick, boys!-- An ecstasy of fumbling,
Fitting the clumsy helmets just in time;
But someone still was yelling out and stumbling
And floundering like a man in fire or lime.--
Dim, through the misty panes and thick green light
As under a green sea, I saw him drowning.

In all my dreams, before my helpless sight,
He plunges at me, guttering, choking, drowning.

If in some smothering dreams you too could pace
Behind the wagon that we flung him in,
And watch the white eyes writhing in his face,
His hanging face, like a devil's sick of sin;
If you could hear, at every jolt, the blood
Come gargling from the froth-corrupted lungs,
Obscene as cancer, bitter as the cud
Of vile, incurable sores on innocent tongues,--
My friend, you would not tell with such high zest
To children ardent for some desperate glory,
The old Lie: Dulce et decorum est
Pro patria mori.

White girl, white rice, white wine edition: I threw away my TV, so...

...I can't watch Grey's Anatomy any more. Therefore, a list of things I do when I'm sick and tired of being a nurse.

Surf YouTube for Harry Potter tribute videos. Love that song. Love it.

My jeans are falling off of me, thanks to weeks of getting the yard in shape, so I might not qualify for Manolo for the Big Girl any more...but it's still a good read. You might see someone you know in the postings.

Gala Darling. Still my 3 a.m. fix for things to make me cheerful.

I own one bag for work, one for not-work, and one for play. Why, then, do I read Bag Snob? For the writing, friends.

No, you can't wear most of the makeup to work, and the latest mailer is silly beyond belief. Still, Sephora has the best deals on good soap guaranteed to get the smell of formalin/blood/poop off'a ya.

No, you can't wear these clothes to work, but when is a girl's life ever all work? StyleBites.

Dumb Little Man is not.

Canned goods are always a good investment: the story of my life! Frugal Fag has the lowdown. Or the down-low.

Food. Or not. The Food Whore is always a good read.

She's like me. Except she's a doctor, and all.

And this is what I do when I'm not at work. Or walking Max, or washing the car, or making salmon with cream-garlic sauce.