Odds and Ends

Things not to do:

Show up tanked on the day of surgery.

No matter how nervous you are about having brain surgery, it's probably best not to appear at the hospital at 6 am completely schnockered. It'll require a delay in the start time. 

Yank the spike out of a REALLY big bag of fluid.

You all know that I am Genius Incarnate when it comes to being clumsy in new and creative ways. In the past, I've spilled most of the contents of the pharmacy on myself...but I reached a new high recently when I accidentally yanked the spike out of a three-liter bag of saline that was hanging at about head-level.

No, I don't want to talk about it any further. Thank you.

Sell drugs out of your hospital room.

Calling security is a pain in the ass. Could you not wait until you got home to make some extra bank?

Attempt to mug one of our employees in the parking garage.

Because, though she looks tired and vulnerable, she might actually end up being a second-degree black belt and wind up kicking your lousy ass. The cops who responded to the yanked emergency phone arrived to find one mugger, in a bruised lump on the concrete, and one rather pissed-off, medium-sized woman who just wanted to go home to bed.

Have two dogs, each well over a hundred pounds, and only a Honda Accord to move them around in.

I could solve this problem in one of two ways, I guess: 1) Buy a new car, like an xB or a Versa, that has room enough for two guys who each stand more than 25" at the shoulder. Or, alternatively, I could 2) Cobble together a lightweight cart and train them to pull it. That way I'd save the money on gas, give the boys some exercise, and look cool doing it.

The only problem would occur if Strider were to see a snack on one side of the street and Max a potential belly-rub on the other. 

Roll a loaded linen cart over your toes.

No, surprisingly, this did not happen to me. Owie, though.

Eat like, fourteen cups of blueberries at once because, you know, they taste soooo good.

I did this. It was actually more like three cups. That's still enough, though, for Interesting Things to Happen.

Ah, the glamorous life. I livez it.

Two questions:

First, which one of you smart-alecks sent me the subscription to Glamour?

It was in my mailbox today. Ha, ha, ha. Very funny. (*golf clap*)

Second, who has recommendations for dog training books? Strider is apparently even younger than his rescue foster thought and is a total doofus. He needs training before he puts on that 20 lbs. he needs. Sheesh.

Daily Strider Tidbit: He has what I'm now calling the Strider Boing: It's a move where he leaps straight up in the air, all four paws off the ground at once with his spine parallel to the ground (so he's not on his hind legs, if you see what I mean). He gets a good 30 inches of vertical air under those paws. This move is usually accompanied by a basso profundo BOOF! and can be seen in moments of great excitement, like when Brownian motion occurs or the planet is circling the sun.

Max is exhausted but happy. I need to go rub his belly now and reassure him that he's the best boy EVER. I never thought I'd see the day when a 110+ lb. German Shepherd mix looked small, but here we are.

Strider, day two

Scene: The back yard, morning

STRIDER: Dude. What *is* that thing?

MAX, yawning: Lawnmower.

STRIDER: What's it do?

MAX: Shortens the grass so we get better back-skritches.

STRIDER, examining lawnmower from all angles: Is it dangerous?

MAX, rolling on back: Just stay away; you'll be fine.

STRIDER: ....Okay. I guess I can't herd it. *sigh*

Scene: The living room,  afternoon

MAX: Don't go there, man. I'm warning you. I've tried it.

STRIDER: Aw, c'mon. It's cute and fuzzy! What harm could it do?

KITTY-CAT: I'll kill ya! I'll kill ya! I'll taste blood! Murder! DIE! DIE!! DIE DIE DIEDIEDIE!!!

(KITTY-CAT swipes at STRIDER with claws out.)

STRIDER: Holy shit, dude! She's got needle-paws!

MAX: Told you. You can't win with that one. It's crazy.

Scene: The back yard, nightfall

MAX: Doh dee doh doh dum dee dah dum dee dah....

STRIDER: Laa laaaa laaaa *roll roll roll* *scratch scratch* daaa deee hummm hummm...

MAX: Dah doh dee la la doh dum diddly dum....

STRIDER: Laaaa laaaa laaaa li loooo...wait. GO AWAY!!! GO AWAY!!! GO AWAY!!!

MAX, running after: Yeah! What he said! 

STRIDER: What was that?

MAX: Uh...it was The Hooman. But no worries. She's used to it when she comes home.

Meet Strider.

No, not that one.

I picked up a very sweet, very very very large dog yesterday from a very very very kind woman who fosters Pyrenees and other large dogs.

Strider is a close-to if not pure-bred Anatolian shepherd. I wanted a dog who was calm, athletic, not inclined to hysterics, and large enough for Max, the German/Anatolian cross who rules the back yard, to play with. Strider met all of those qualifications, plus he has a very sweet face.

So off I went in the Honda, not knowing what to expect. Strider had been picked up in Houston and had spent some time in a really awful kill-shelter there. He had mange, pneumonia, heartworms, had been underfed, and generally wasn't in the best of shape when he got rescued. The woman who fostered him has done an amazing job: he's healthy, healing, and not the least bit shy or timid. He still needs some more poundage, and his face is a mess (from healing mange and being chewed on by other dogs), but I expect he'll be in tip-top shape in six weeks or so.

His ad on Petfinder said he wasn't a big barker, didn't jump on people, and was generally well-behaved and low-maintenance. 

I think he's blooming already. He remodeled the outside utility room last night (it was almost empty anyhow, and there was nothing in there I wanted), then announced his presence to the dogs next door this morning. He barks like a Great Dane. When I went outside to greet him and Max, he *plopped* both front paws on my shoulders and licked my face.

Good boy. Gooooood boy. Nice doggie.

Max is amazed that there's another dog large enough for him to wrestle with. Strider, thank Frogs, is following Max's lead when it comes to playing and wrestling: 230 combined pounds of tooth and muscle in a dominance struggle is not what I want to deal with on my own. 

Let me say a word here about rescuing animals:

If you want a dog, cat, pig, donkey, guinea pig, chicken, or goat, please consider rescuing an animal from a shelter or rescue group before you consider buying one from a breeder. If you're really wanting a purebred animal, there are rescue groups for practically every breed out there.

The benefits to rescuing an animal are huge. First and most importantly, every dog that's rescued from a shelter or placed by a foster human is one dog that doesn't get euthanized. Animal overpopulation is a huge problem; most shelters have to euthanize not because the animals are unhealthy or vicious, but because the shelter has no more room. 

Second, if you get a dog or cat or whatever from a rescue group, you have backup that you don't get from the guys who sell puppies on the side of the road. Somebody has lived with the animal for some time and can tell you about its personality and quirks. Many times, the foster family will crate- and housetrain the animal, take it to obedience classes, and generally do all the dirty work of socializing the animal for you.

And third, you know what you're getting into with a rescue animal. They're mostly adult, someone has their medical history all there for you, and the dog/cat/donkey has already got a vet. If there's a problem, you can call the foster or rescue group for advice.

Yes, adopting an animal from a rescue or shelter is expensive--the group has to cover expenses at least partially, and everybody there is volunteer or badly paid. Every bit of cash goes to the critters. Yes, it's a tough process--home visits and vet interviews are the norm, because the folks who adopt out critters want to be sure they all get good homes. But think of it like this: these are animals who've already been labeled "unwanted" by some other human, so it's natural that their caretakers would want to prevent that happening again.

I now have three rescue critters: Max, Strider, and Evvie the Cat. I would not trade any of them for the world; rescued critters are the best ever.

And now, since that particular sermon is over, I have to go shower and run out and get some larger dog toys.

My family, problem-solvers extraordinaire.

So, my uncle. Nice man. Hunts and fishes, but eats what he kills. Raises good dogs and raised two good kids. The sort of grandfather you'd want for your child, you dig? Goes to baseball games, can fry a mean catfish, has a good sense of humor. Sober, steady, church-going. I've never heard him raise his voice and have only heard of one time (and this was hearsay) when he used a naughty word, and that was "hell". Or "damn"; I don't really recall which.

My uncle. My Beloved Mother's baby brother, the one who loves Chefboy and is never in a bad mood? That one?

Sent a cosh.

A real, live, spring-handled, lead-ended, leather-wrapped cosh. As in, I'm not entirely certain this is legal within city limits cosh. Eight inches long, weighs about two pounds, makes a satisfying and painful thwap when you whack it into your palm, would easily fracture somebody's frontal skull. No lead pellets dropped into eelskins here; this is a serious weapon in an itty bitty package.

Apparently he read (sweet hopscotching Jesus, if he's reading this, I'd better clean up my fucking language) or heard about the patient taking a swing at me. And he got a little irritated on my behalf.

"She can put it" he told Beloved Mother, "in her pocket. Nurses have big pockets."

It has quite the loop strap on it, too. If I don't want to get too close to somebody and still land them in ICU overnight for observation, I could conceivably swing the thing at arm's length.

My methods of self-defense have been limited, these last twenty years, to ducking and running and imagining how, exactly, I would get to the fire extinguisher and loose it into some bad guy's face before Max ripped out his throat (always assuming Max would do that; it's not been put to the test, knock wood). I've never hit anybody with a cosh. I've never carried a cosh in my pocket. I've never even SEEN a cosh, for cryin' out loud; my naming it thus is informed by my taste for good and not-so-good detective fiction.

Nonetheless, I am now the proud posessor of an eight-inch-long (fourteen with handle), spring loaded, lead-tipped widget that's wrapped in braided black leather and looks like something either Bettie Page or your local pr0n store would carry.

And I can keep it in my pocket. My big nurse's pocket.

I can't wait to see the docs' expressions when I pull it out instead of a penlight. 

Gracious snakes.

I post, I go to bed. I wake up earlier than God, and bang! Six comments in six hours.

Strike a nerve, much?

Some study I Googled last night said that 430,000 nurses report that they're victims of violence or intimidation on the job every year, and that that number is likely low due to under-reporting. Seems that a lot of nurses think that getting clocked or yelled at is just part of the business of being a nurse, and that some managers think it's whiny if you report being a victim of violence.

Hm.

You know, what pisses me off most about last night, is this: (well, two things, actually)

First, that the first-line person, my manager, did not automatically go to bat for me. Instead of laying out ground rules, he attempted to perform some weird magical act of conflict resolution that would somehow make it all okay. 

That has two results. The first is that the person who swang/swung/swinged at me has no incentive to change that behavior. "Act badly, get coddled" is the message.

The second result is that I know, now, that if I attempt to set firm boundaries with a person, like "Do not try to hit me. That behavior is unacceptable" I have absolutely nothing with which to back that up. I am really and truly on my own as a caregiver. If the person then complains, or tries to rough somebody up, we're back to Conflict Resolution and Good Customer Service.

And this makes me sit back and scratch my head and slurp my coffee thoughtfully.

The majority of comments left after yesterday's post talked about lawsuits and criminal charges, which tells me this: That I am not alone in working for a facility that has no plan in place for dealing with patient-on-caregiver or family-on-caregiver violence. I'll bet doghair to donuts that all of you guys have codes for civil disturbances or codes for when some nut comes onto the floor waving a gun, but that there's no code to call when a patient tries to cold-cock you.

So. Sunnydale has no plan. Sunnydale's Corporate Manglement has no plan. It's nursing, Three-Stooges style, except the pratfalls are real. So what will I do the next time this happens?

That's a hell of a question. If I'm feeling tough, I might well file charges and insist upon a root-cause analysis of the problem. (RCA's are when all the mucketies get together and go, seriously and with intent, over the entire history of something that has gone Very Wrong.) I might make noises about lawsuits and editorials for nursing magazines. I might even be serious.

Because, as I said before, the only way to get the folks on the carpet to listen is to threaten either their bottom line or their good public image. 

Now: one thing to get straight this second is that I would not, unless Manglement or the hospital were way, way in the wrong, sue anybody for money. I'm not really interested in that sort of drawn-out, pain-in-the-ass process, and it wouldn't end up solving a damned thing, as the facility (if somebody *were* to get hurt) would settle in return for a non-disclosure agreement.

What I *would* do is insist on new standards of behavior for patients, family members, and visitors. What I want is a policy in place that says, If you do X, then Y will happen. What would make me happy about working where I work is a recognition on the part of all the managers that The Customer Is Not Always Right, and that there are some things that are beyond the pale. 

Right now, all of us, whether we're in the ER or on the floor, are subject to threats that would never fly in any other business. If you holler abuse in a bar or try to start a fight, you get thrown out. If you throw a temper tantrum in a restaurant, you'll get thrown out. If you try to injure somebody in public, you're gonna have to talk to the police. But swing at or holler at a nurse? It's all part of the game.

Why are we less safe at work than we are in a bar? Why are the standards of behavior so much lower for the consumers of our product? Because, quite frankly, if the patient is going to be treated as a consumer of healthcare, they need to be subject to the same standards of behavior that consumers of alcohol, groceries, or cut flowers take for granted.

The answer to the problem of violence against nurses is simple: People who are violent or threatening need to be refused care. The way to get that policy implemented is much, much more difficult.

I think I'm going to lean back, furrow my brow, and slurp some more coffee while I think about it.

This "Customer Service" bullshit has got to stop.

Normally, I never post immediately on coming home from work. I'm too frazzled, too scattered, and unable to complete a spoken sentence, let alone a written one.

Today, though, it's different. Today, for the fourth or fifth time in as many years, I had a patient take a swing at me. What's different about today is that this particular patient was alert, oriented, knew where he was and what he was doing, and was trying to hurt me.

This patient was the typical Sunnydale Hospital* frequent-flier: pages and pages of old charts, all of them with extra pages attached from nurses who'd had run ins with him. The documentation was complete and careful and clear: this particular person was a nutjob. No way 'round it; he had enough baggage for the Rolling Stones on tour.

His course was also typical: noncompliance with the simplest of instructions, obscenities screamed at nurses, pharmacists, and doctors, and the final lovely touch of hiding narcotics in his room. That was just recent visits. It didn't take him long to get a file this (holds fingers apart at arms' length) thick.

So he took a swing at me. And screamed obscenities. And I reported it, as I was supposed to, to my boss, one of the Manglement Trifecta on the floor. (Winky, Blinky, and Nod, as I call them, do the work of one person, and do it.... Anyway.) Winky went on into the room, and there....

...Practiced Good Customer Service and Conflict Resolution.

The upshot? I got told the patient didn't like me--big shock, as he didn't like anybody--and was told not to do whatever it was I did to get him upset again.

Managers, read this, if you read nothing else:

Customer Service Does Not Mean Putting Your Nurses In Harm's Way.

This was a patient who'd already threatened to kill two surgeons. He had come up on out of the bed with a pharmacist and had caused three of the toughest nurses I know to refuse to take him on as a patient. Now, I am not the shrinkingest violet on the block, but one thing here ought to be perfectly clear: The only way to deal with a problem like this is to get rid of the source.

Patients like this ought not to be readmitted to the hospital. They ought not to be "counselled" about their behavior. There ought to be no quarter given: if you swing at a nurse, or scream obscenities, you should be told briefly and bluntly that that behavior is unacceptable, and if necessary, you should have a security guard posted outside your room.

The fact that this guy wasn't ditched from the hospital admit list tells me that Sunnydale doesn't give a good goddamn about their nurses' safety. The fact that my charge nurse, Winky, didn't lay down the law tells me that he cares more about our floor's customer satisfaction scores than about *my* safety.

And that tells me this: Managers, listen up: the only way you guys will ever pay attention is if we, the people on the front lines, start making a stink. 

Next time some direct descendent of Einstein swings at me, I am not going to get out of the way. I'm going to let them hit me.

And then I'm going to file battery charges.

And then I'll talk to your board of directors, Sunnydale, about the whole situation, and how much compensation I ought to get for mental anguish. Because the only way to get large groups of carpeted-area manglement types to pay attention is to talk about negative publicity and dollar amounts.

I'm not fucking kidding. There is no reason in the world that I ought to have to put up with somebody who's actively violent still being in the hospital after he's behaved like a beast. There's no reason that the charge nurse or house supervisor or whatever shouldn't march into the room and tell the person who's a nutjob that nutjobbiness is unacceptable and *will* stop, NOW, or the patient can go home. 

There is, in short, no reason for me to feel less safe working at Sunnydale than I did working at an abortion clinic. And I do. 

*w00t Buffy.

Butt Tufts and Other Hazards of Southern Life

Or, what I do on my day off.

Max is shedding. Among those of us with double-coated dogs, there's a less-polite, more-descriptive term: "Blowing the coat". Max is blowing his coat.

Yesterday it was close to 100* here. In one day, Maximus Doggitude went from looking like a gentleman, albeit a shaggy one, to looking like he'd earned the nickname "Banjo" by living under a bridge for six months. My neighbors, who live with a good-natured pug and a corgi who never ventures outside except under duress, were amazed to see me pulling handfuls of hair out of Max's coat, especially on his hindquarters. Anatolian shepherds, being a mountain breed, tend toward large poofs of fur to keep their hrbls warm in the winter. Max's hrbl frbls were out of control.

Doggie dreadlocks, only six days after his last intensive grooming session. Every sparrow and mockingbird on the block is wearing comical mustaches of Max Fur, soon to be lining their nests.

Speaking of sparrow nests, I had a heartbreaking moment the other day when I noticed that a piece of decorative trim had come off the side of the house, just around the soffit. It had exposed a long empty space, and in that empty space were shreds of grass and other material. That spells "sparrow nest", which in turn spells "rodents looking for prey" and "rotting wood", so I climbed up on the world's shakiest hand-me-down ladder to have a look. I got out the entire nest (why does a small bird need a nest as long as my arm?) and dropped it to the ground before noticing it contained unhatched eggs. Two were broken. Three were intact. The parent sparrows were flipping out.

I put the nest, as close to whole as I could manage it, in the crook of a tree nearby. Given that the only bird with a sense of smell is the vulture, I figured the parents would adopt the nest again with no problem. They did...until the next big thunderstorm. *sigh* I feel like a baby bird murderer.

In gardening news, things are mixed. The dill and lavender are doing well (though Max chewed up half the lavender plant today; why I do not know) and the tomatoes are fruiting. The Romas are behind time, having gotten munched by some unknown bug, but the cherry tomatoes and heirlooms are already setting tiny green fruit. The cilantro got as high as my shoulder before seeding out. I pulled it yesterday morning and tossed it on top of the compost pile, intending to dig it in later on, once I'd bought a pitchfork. Before I was able to do that, I saw Max, head and shoulders into the compost pile, delicately yanking strands of seeded cilantro out and eating them. 

I had wondered why, for weeks on end, the cilantro seemed to be self-pruning. I know now that the Weirdest Dog In The World had been chewing bits of it, perhaps to freshen his breath for the pug next door. Fortunately he doesn't seem to have the same taste for basil as he does for cilantro and lavender. The dill and basil are safe, which is good for him. If he were endangering my future pesto binges, we'd have to have a talk.

I'm already planning the garden for next year. I want to build four raised beds, two square and two long, with cedar poles and plenty of fencing to keep the dog and the neighborhood tomcat, who sleeps in my lettuce, out. One bed will be for perennial plantings, asparagus and strawberries. The other will be for things like carrots and tomatoes and radishes and bush beans. Lettuces and cabbages (fall crop), brussels sprouts (ditto), and pole beans will go into the long beds, along with cucumbers melons perhaps kiwis peppers herbs etcetera.

In the front beds, which I have yet to till and de-grass (dammit, sigh), will go perennial herbs like rosemary and lavender and dittany and oregano.

There's a lot to do when you have a house. I'm just now learning this. I've not even mentioned the difficulty of finding a black toilet seat (better in keeping with the theme of the bathroom and its historical roots) or an affordable vented oven hood. Or what it takes to find a really good screen door, or the spasms I'm having over whether to save the original, Art-Deco doorknob and plate from the back door when I replace it with something that's not mostly glass.

Even with the sleep I lose over such things as whether the wallpaper for the kitchen ought to be 1950's vintage repro or 1940's, it still makes a nice change from primary leptomeningeal melanoma and Ted Kennedy's brain tumor.

Today I got yelled at 4.3 times in twelve hours.

And it didn't bother me a bit.

I've grown inured to the yelling-at that some doctors, pharmacists, other nurses, house supervisors, patients, and facility management specialists (read: Janitors) do.

I used to bristle. I used to take offense. Occasionally I would vent.

Now, if the person doing the yelling is doing it face-to-face, I imagine that person covered with banana pudding. If the person doing the yelling is doing it over the phone, I giggle. Audibly.

Because, you see, *everybody* yells at nurses. We get caught between the proverbial rock and steel plate, and we are the recipients of everybody's frustrations. Toilet broken? Yell at the nurse. Did payroll fuck up your overtime again? Yell at the nurse. Can the pharmacist in Alabama not read your handwriting? Inform the nurse stuffily that that's the same DEA number you've used for the last five years. 

Then listen to the nurse (well, *this* nurse, at any rate) giggle helplessly at your stuffiness.

This is the time of year when I face both burnout and brilliant ideas simultaneously. The time I don't spend updating the blog is time I spend out weeding the garden and grooming the dog. This time of year, I'd like nothing better than to get fired for smarting off to somebody, just so I could work for triple or quadruple what I'm making now, with plenty of time off to weed and groom and just lie in the sun. I know I won't feel that way come January, though, when things are cold and rainy, so I mostly hold my tongue.

And giggle. Audibly. Audibly, but not offensively. Because, honestly? Not one damn thing I got yelled at today had anything to do with me or my nursing. One was a doc who was pissed at a pharmacist; the next was the pharmacist who was pissed at the doc. The third was a patient who had an entirely different nurse. The fourth was a manager who got annoyed that I actually followed hospital policy (and they wonder why I'm such a loose cannon) and did what I was supposed to do.

Keep your yellow "Live Strong" wristbands. You can have your pink ribbons and red dresses and grey ribbons and God knows what else. I am wearing, from here on out, a smiley face. Giggling is my new cause.

You may be next.

Take *that*, work frustrations.

This post was going to be titled "When Morons Attack".

But I ran a mile.

Then I lifted weights.

Then I stretched. And did some yoga.

And now I'm cheerful and warm and relaxed and no longer concerned with morons. Instead, I think I'll go buy some doggie nail-clippers and then hang out with Max for the rest of the day.

Spring. Sprang. Sprung.

This is the time of year when it's hard to go to work. The weather is beautiful, the birds are singing (did you know male mockingbirds will sing all night long in search of a mate? They will. Especially the ones in my back yard), Max is wanting belly-rubs, there are music festivals and art shows outside in the sun, and I'm stuck inside with patients with disseminated vasculitis and brain stem tumors and stupid, stupid families.

The past few weeks have been a sojurn in the Land of the Tiny-Brained.

For instance, if you have a family member with a fistula that communicates between esophagus and trachea, and that person is unable to swallow in the first place, and has a tracheostomy to make it possible for them to breathe without choking, and the nurse has said six times in the last three hours that you are NOT to FEED that person, why on earth would you try to make them eat oatmeal?

I spent ten minutes deep-suctioning oatmeal out of the guy's lung.

Likewise, if you have the nastiest chest wound in the history of ever, and you're going for your fifth surgery to debride it, and you've been told over and over not to eat or drink anything preparatory to surgery, why would you tell the anesthesiology resident who comes to consent you that, by damn, you *are* going to drink this Dr. Pepper, and he's not going to be around if and when you get aspiration pneumonia, so he shouldn't worry his pretty head?

 Just because you had an LPN license for six months twenty-five years ago does not mean you necessarily know more about anesthesia than the guy who does it for a living.

And, finally, if you have the nastiest stomach wound in the history of ever, one so bad that you had to stuff washcloths in it to keep the pus from pouring out and getting all over your clothing, why would you undo the work of two surgeons, a wound-care nurse, and an hour of OR time to undo your wound-vac dressing and stuff the wound with washcloths again?

"It needs air to heal" is not an acceptable explanation.

I'm not even going to tell you about the disseminated vasculitis patient who screamed. Constantly. And cried and whined and hollered. Not their fault; vasculitis in the brain makes you completely crazy. But still, it's difficult (note ironic use of understatement!) to deal with a screaming, crying, whining, abusive patient for twelve hours straight when the other three people you're caring for hit the call bell Every. Twenty. Minutes. Without. Fail. All. Shift. Long.

And this was, comparatively, a good assignment. The other patients on the floor were worse.

Nobody wants to go to the hospital. No sane person wants to spend any more time than necessary indoors during the six weeks of the year when the weather here isn't actively trying to kill you. That, unfortunately, means that the only people in the hospital right now are both very, very sick and completely nuts. And, according to a newly-delineated Universal Law, the amount of shit you get from a family is inversely proportional to the total number of teeth in the room.

I was considering throwing up my hands and becoming a bank robber yesterday. Or a train robber. On a pink Vespa scooter. With pink leathers and a white full-coverage Bell helmet with a reflective faceplate. And saddlebags with fringes. 

The pharmacist on call looked at me thoughtfully and said, "I'm a little concerned that you seem to have thought this out so thoroughly."

Well, yeah. The one thing that's stopping me is the knowledge that if you get caught robbing trains, your time inside doesn't end at 7 pm. 

A Day In The Life

Getting Better All The Time

There's been an outbreak of what I'm convinced is norovirus at work. Norovirus is That Nasty Stomach Bug family of viruses--the sort of bug that incubates in a day or so and takes a day or two to resolve. Since all nurses work some degree of sick most or all of the time, it makes sense that something that could only be eradicated by bleach and scrubbing might be lurking in the viral soup that is our hospital.

My turn was yesterday. I was pretty damned puny, but Chef Boy brought over bread and ginger ale, and I ate soup and laid on the couch, making noises like the cartoon woman in the introduction to "Mystery!" Today I am better, though not enough better to, say, climb the Matterhorn or work out. I shall (she says, determinedly) finish the laundry and nap.

Sky of Blue, and Brain of Green

What makes your brain the color and consistency of pea soup in about three days?

I wish that were a riddle. Instead, it's something that happened to one of my patients (now dead). Mayo took their sweet time over the biopsies and sent back a detailed pathology report that said, in essence, "We have no fucking clue. Try Hopkins."

It's been about five years since we had a patient who had a true God Only Knows diagnosis. That last one garnered laurels for a couple of fellows in neurology who presented a paper on the patient's decline. What it did not get anybody was a name for that person's condition, a cause, or a cure. 

Dr. Dink, the psychiatrist who writes my prescriptions for Happy Brain Pills, said, "Well, those are the interesting cases, you know." Yeah. Interesting. Because it's never any fun at all when somebody gets better. That gave me an insight into the shrink personality.

Fixing A Hole

Finally, a non-neuroscience happy ending. 

A couple years ago we had a patient with a big hole. I mean a *big* hole, the sort of thing you could easily put your head in. Mediastinitis, it's called, and it's an infection in your chest that's usually caused by rupture of one of the organs there. In this person's case, it was the result of surgical infection. The hole went from the middle of the breastbone down into the belly and tunnelled every which way. It was so badly infected, necrotic, and generally nasty that it took weeks and weeks to heal, and we had to repaint the room after the patient was gone--it smelled that bad.

He's fine. Two weeks ago, he came breezing in, more than a hundred pounds lighter and quite fit, totally recovered, and with only a half-dollar-sized, puckered white scar on his chest to show for his ten weeks of hell. That was nice.

Run For Your Life If You Can, Little Girl

In non-nursey news, I bought a treadmill. I am totally, totally in love with my treadmill, to the extent that I get up a bit earlier every day than I used to and hurple along for a few minutes before I get ready for work. It's quite fine. The cat has no opinion on it, while the dog looks at it with deep suspicion and loathing, but does not actually run off when I start it up. 

The damned thing weighs 300 pounds and has a control panel that looks like it belongs on the bridge of the Enterprise. I haven't yet discovered how to make it do laundry, but it does nearly everything else. It took two guys with experience in the process an hour and much multilingual cursing to put it together and get it working. Man, I love my treadmill.

You Like Me Too Much

I've finally had--and gotten rid of--my first patient-stalker.

It happens to everybody at some point: you take care of a patient who decides for some reason that you're the be-all, end-all, and that (to add to the weirdness) they simply must hang out with you outside of work and be your babydoll. This probably happens much more often to people in the brain business (be it psych or neuro), but hadn't as yet happened to me. 

Well, now it has. A traumatic brain injury will make a person think anything's possible. Thankfully, a combination of carefully-timed hiding in utility rooms and non-diplomatic "go aways" has made that patient, well, go *away*. 

If this ever happens to you, be aware: It's not always something you can predict or prevent. Especially with brain-injured patients, there's not going to be a way to control their reactions to your actions. The simple act of changing a dressing can, for them, become a declaration of your undying devotion. The best way to handle it is the way you'd handle a recalcitrant child: with firm repetition and without panic.

The End.

How to have a good stay in the hospital, or:

Driving your nurse crazy, in three hundred eighty four thousand, six hundred forty-two easy steps.*

Adopt a lofty tone. Nobody here will remember how important you are. Therefore, it's crucial that you remind them at every possible opportunity. Condescend as often as possible. Refer to your nurse as "The Girl". Refer to every female doctor as "Nurse"--they love that. If you can, work in a shadow of doubt about your nurse's or doctor's competence. Ask repeatedly if they've "ever done this before."

Don't forget to bring your four-page, single-spaced list of demands. Make certain that you've listed all of your drug allergies, even if they're not actually allergies, on the first page in bold type. List all of your previous surgeries on the second page, with editorial comments such as "spent six weeks in hospital--doctor's fault". On the third page, specify that you be transferred to the "VIP floor" only. The fourth page will have plenty of room for you to note your food preferences, the fact that you don't want to be served on plasticware, and that, regardless of your latest test results, you refuse to be put in isolation.

Refuse to have an IV placed in a spot where it is least painful and most convenient for all involved. If necessary, lie about previous surgeries to that extremity in order to manage this. Nobody reads your history, right?

Be noncompliant with treatments. If you can't turn off or change the settings on the IV pump because it's locked, the next best thing is to unplug it and leave it unplugged until the battery runs down. If you've been ordered to remain on flat bedrest because of a cerebrospinal fluid leak, by all means sit up as often as possible. Conversely, if you've been ordered to walk at least three times a day, make as dramatic a production as you can of getting out of bed. Moaning and groaning is required; sagging to the floor whimpering is optional but effective, especially when done in front of your family.

One very important note about treatment noncompliance: If you are diabetic, ensure that your family brings you huge amounts of sugary food. Hide it in your room. Hide it in your bed. Hide it on your person. The Girl needs exercise, which she will certainly get when your blood sugar comes back at 1300 mg/dl.

Work the occasional old-fashioned derogatory term for racial minorities into your conversation. Those People have to be reminded where they stand, after all. The Girl and the other nurses will be glad you're reinforcing the social order, even if they don't act like they are.

Invite all your friends, fellow gang members, remote family connections, and strangers on the street to come visit at all hours. Instruct them to talk loudly on cell phones in the hallways. Send whatever small children they bring into other patients' rooms. The pre-teens should be told to ask for ice cream and sodas, repeatedly, at the nurses' station.

If you can't get what you want, call your doctor at home. This is particularly effective if done at 3 am, and if your doctor doesn't have admitting privileges at the hospital where you are. Bonus points if you have a doctor who'll call the nurses' station and bluster.

Speaking of bluster, if you have a family member who's a doctor, use that person the way God intended: To attempt to bully the staff of the hospital into changing treatment protocols.

(Special note for those with medical family members: Be sure that if your son-in-law is a staff physician at the hospital, he is the primary physician on your case. It's been too long since the last ethics course refresher; the staff could use the training.)

Remember that medical people, nurses in particular and neuroscience nurses in especial particular, are too dumb to know if you're faking a seizure. A well-timed fake seizure will get you two extra days of Ativan and Dilaudid.

Instruct each and every one of your family members to call the nurses' station every sixteen minutes throughout the day for updates on your condition. Phone trees are for the hoi polloi. Extra points if you can arrange to have several family members call at once during shift change.

If all else fails, barrage the director of nursing, chief medical officer, and police with phone calls. People in management will have a better idea of your treatment needs and activity restrictions, your diet orders and medication regimen, your physical therapy schedule and dressing changes, than your nurse or doctor. 

*I wish I were capable of making this shit up. 

Things they don't tell you in nursing school

There are plenty of books and articles out there about how to survive your first year or two as a nurse. Most of 'em are pretty useful; they cover things like confidence and time management and self-examination, all of which are important. There's always a "transitions" class in nursing school that attempts to cover the same things.

Nobody, though, gives you the real dirt on being a nurse. Here, then, are ten things you didn't learn in school and which will become obvious soon:

1. Constipation: Your own, not the patient's.

Everybody poops, yes, but some of us have to learn to poop less often. If you're working three or four days in a row, your first day off will be spent pooping and sleeping. Accept this and do not attempt to buck the trend. The downside to not getting to poop when you'd like is hemorrhoids. The upside is stronger sphincters and the ability to work through a case of food poisoning.

2. Did something die, or did you just take off your shoes?

If you wear decent shoes (ie, supportive closed-toe-and-heel shoes made of leather), your feet will stink. If you work a full shift in them, your feet will stink to high heaven. Again, acceptance of your plight is key. Soap and water before bed do a lot to prevent both athlete's foot and the death of your bed partner.

3. Bleach is your friend.

The likelihood of getting something nasty splashed on your scrubs is directly proportional to the amount of white you wear. If, like me, you *have* to wear a white coat as part of your uniform, you should buy stock in bleach companies now. It'll subsidize your retirement.

4. You will become more cynical than you ever thought possible.

Look: It's impossible for a human being with a heart to do what nurses do on a daily basis and not become cynical, both about other people and about the universe we live in. Cynical doesn't mean evil; it just means that you're coping with the stresses of your job. I used to feel bad about the sort of whistling in the dark we do until I realized that it's the only way to keep from crying in the face of three patients dropping dead unexpectedly in one day.

5. You will become capable of both more tenderness and toughness than you ever thought possible.

Nurses soothe people. We ease their fears. The number-one thing that we do is educate our patients about what's going on, and knowledge is power. The number-two thing we do is stop pain. Those two things, taken together, will make you more tender and gentle than you ever imagined. Even turning a comatose patient can be done with gentleness, and you'll find yourself doing it. 

Nurses also have to hurt people. It's part of the job. Shots hurt. Dressing changes hurt. (Cue "Cruel To Be Kind", please.) When you're changing the dressing on a deep, awful wound that hurts, you'll find yourself wincing in sympathy--the first few times. Later on, you'll get tougher, but never to the point of cruelty. Change the dressing, get it over, and go on. This is not a bad thing.

6. Coping mechanisms can be good or bad.

I'm not talking about the people who sneak narcotics out of locked drawers. I'm talking about what I've heard other nurses say: "I never drank this much before I was a nurse."

There are good ways and not-so-good ways of dealing with the stress of the job. If you're coming home and pouring six shots of tequila down your throat, either you need a new coping mechanism or a new job. One glass of wine/liquor/beer, though, done properly and with ritual, can ease the transition from Nurse to Real Person. Do not be ashamed. 

If you *are* ashamed, then get a different way to cope. Buy a treadmill and go for a run after work. Get a puppy. Buy some Mister Bubble and use it. Adopt a new ritual.

7. Doctors are (mostly) people, too.

There are some doctors who came here from Planet Asshole. The same can be said of some chefs, some office bosses, and some bowling-alley customers. The majority of doctors, though, are nice, normal people with nice, normal needs and reactions to things. The same doctor who writes insane orders and demands that crazy things be charted does the in-car butt-dance every time she hears "Girlfriend" come on the radio. Remember that.

8. Dating somebody from the same facility is always, ALWAYS a bad idea.

No matter how discreet you think you're being, somebody's figured it out. 

9. Nurses are nice, normal (mostly) people, too.

All but two of my nursing instructors in school went on and on and on about how dysfunctional and co-dependent nurses are. I figured out pretty quickly that the instructors who were down on nurses were no longer working as nurses because they hated the job and couldn't cut it on the floor of even a moderately busy facility. The two instructors who still worked full-time as nurses had a much better, more realistic attitude. 

Yes, there are bitches and bastards. Yes, you'll run into the occasional young-munching nurse. But they're as rare in this field as they are in others, and you'll learn to avoid them the same way everybody else does. For the most part, nurses become smarter/faster/less inclined to bullshit the longer they work. This makes them good people to work and relax with, both.

If one or more of your instructors is pathological about hating nursing and nurses, ignore them.

10. If you hate it, you can always do something else.

Nursing school has a weird vibe: like this is the be-all, end-all, most important and worthy thing you've ever done. It's incredibly, indescribably stressful--more so than medical school, according to several people I know who've done both. It's also wrapped 'round with the whole Ethos Of Nurse. That makes it hard to admit that you've chosen wrong or that maybe you hate being a nurse.

Let me make this totally clear: If you don't feel like you're a fish finally dropped into water, you don't need to be doing this for a living. It's too hard, and the money's not *that* good. At any point in school or in your career, you are certainly allowed to back out and go be a banker. You haven't wasted your own or anybody else's time; remember all that great stuff you learned?

Don't let one bad day or one bad month or semester or year (whatever) make your decision for you, though. If you have a gut feeling you shouldn't be doing this, then for God's sake back out as soon as you can. If your gut is happy, though, and it's your brain or ego that's bruised, keep on. Things will improve.

Change of Shift!

It's here.

(Clever Title)

If you have to get one bizarre disease in your life, one that defies diagnosis and makes doctors scratch their heads, one that'd land you on a not-happy ending episode of "Medical Mysteries", one that would make Hugh Laurie sit outside your room with his chin resting on his cane, don't pick the one bizarre disease with the word "encephalopathy" in the name, okay?

'Cause it would suck. Hard.

"Encephalopathy" means "brain disease". It can be caused by a number of things: everything from kidney failure to liver failure to mitochondrial failure to viruses, bacteria, and fungi have been implicated in the different forms of encephalopathy. "Encephalopathy" is also used as a catch-all term for the "God Only Knows" diseases--the things we can't diagnose except on autopsy.

This has been Encephalopathy Fest Month. Every third person and his brother has some form of brain swelling, sterile meningitis, or GOK disease. What that means for us, practically, is that there are a lot of people with balance and cognition problems getting lumbar taps and having to be babysat so they don't wander naked down the halls.

Taking care of people is a weird business to be in. It's never weirder than when you're split in two (so to speak)--watching somebody go down the drain with astonishing speed and feeling bad about that, while at the same time being pissed off because their drain-circling is accompanied by annoying, time-consuming symptoms and problems. 

Taking care of people on a neuroscience ward is particularly pissing. There's so much that we do in hospitals that's routine--like giving pain medicine or various electrolyte solutions--that can cause symptoms that mimic the progression of disease. I've spent a lot of time over the last three weeks trying to figure out if the person who can't remember her own first name is suffering from a narcotic overdose or simply losing neurons at an ever-increasing pace.

I had a patient go down in a big, scary way. Not in a heart-stopped, start-compressions sort of way, but in a neuroscience nurse scary way: she forgot who her brother was. She forgot her name. She forgot what year it was. She couldn't repeat a phrase I said to her, and kept word-salading everything. She stopped making sense and started making trouble over the course of a shift.

So we stopped her drugs. I reversed the narcotics and benzos. We started one thing after another, tried to get an MRI (no go; as she got mentally less with-it, she became physically more active), tried to get a CT (ditto, even with me in a lead dress holding her hand), got an EEG, did neuro checks every hour, managed a lumbar tap somehow...I finally cracked in a quiet, professional way, after I'd spent two hours dodging punches and kicks while trying to keep her down after the lumbar tap.

And you know what? Every. Damn. Test. Came back negative. There's *something* wrong; there's *something* in her brain that's making it light up like Christmas in New York on an MRI film. But we don't know what it is. Meanwhile, her family is flipping out because she's obviously not right, I'm flipping out because she's a danger to herself and others, and the docs are flipping out because they don't know what's going on.

I've worked with one of our neurology residents now for better than six years. I've never had reason to doubt his competence or his intelligence. I've also never heard him say what he said that evening: "I don't know. I've never seen anything like this before."

So. Don't get a generic encephalopathy, okay? At least get something diagnosable. You'll save everybody, including yourself, a lot of trouble.

Fun Medical Words for the Non-Medical Type: A game the whole family can play!

Ever wish you had a really good excuse for not going to work? Ever wish you had a hellacious conversation starter for that cocktail party? Ever want to drop random words into conversation?

Well this, my friend, is your post.

Observe the wonders of medical terminology and pharmaceutical brand names! To wit:

Mucomyst: No, it's not a faerie land where everyone has bad sinus problems. It's the brand name of a drug (acetylcysteine) that thins and loosens inspissated phlegm. It's also used in cases of Tylenol overdose.

Inspissated: What a lovely word. It means to be hardened due to lack of moisture. Why say your hands are chapped, when you can say they're inspissated?

Whipple procedure: About the furthest thing from squeezing the Charmin you can imagine. In a Whipple procedure, the head (thick part) of the pancreas, the bile ducts, the gallbladder, and the duodenum are all taken out, along with (sometimes) a bit of the stomach. It's not something you necessarily want to undergo. It should be differentiated from...

Whipple's disease: Caused by bacteria, its signs and symptoms include joint pain, diarrhea, and malabsorption. 

Duodenum: Go ahead. Say it over and over: doo-WAH-duh-num. Doo-WAH-duh-num. Your duodenum connects your stomach to your....

Jejunum: That's the central part of your small intestine. The Doo-WAH-duh-num is the first bit and the ileum (which sounds like a town in Greece) is the last.

Zyvox: I wish, I wish this were the name of a Galactic Emperor. Unfortunately, it's not: it's the name of an IV antibiotic. Oh, well.

Melanoma: Sounds like a pretty girl's name, but is actually a nasty, invasive, scarily common form of skin cancer. Do. Not. Want.

Glioblastoma: Another pretty word for an ugly thing: in this case, it's invasive, incurable brain cancer. 

Frenulum: I love this word. It's the name of that little bit of tissue under your tongue (there's another under your upper lip, and several more here and there) that connects your tongue (etcetera) to the bottom of your mouth (and so on). 

Cachexia: Pronounced with a hard "K" sound rather than a "ch" sound. It means "starvation."

Stapes: AKA the "stirrup" bone in your ear. Technically, this bone is an...

Ossicle: a bonelet. No, I'm not making that last term up. "Ossicle" equals "small bone". If you have icicles on your ossicles, you're in deep trouble.

Buboe: Save this one for when you really need it: a buboe is the swollen lymph gland that accompanies bubonic plague.

The laws of Nature have been temporarily suspended. Please do not adjust your set.

It snowed yesterday.

March in central Texas is not a time when you'd expect snow, but sure enough, there it was. As I passed through the little nothing towns betweeen work and home, the snow fell harder and thicker and wetter, making for a bad case of CSS (Can't See Shit).

Max was outside when I got home. He hates rain and goes all Sarah Bernhardt on me when it thunders ("I can has snuggles? KTHNX.") but loves the snow. He was zipping (well, as much as a 100+-pound dog can zip) around the yard, making like a snowplow with his schnozz. If it hadn't been so dark, I would've gotten a picture.

In other news, I can hurt myself creatively. I know this will come as no surprise to those of you who are regular readers.

I fell the other day at work. I mean dropped to the floor without warning, without the chance to even *try* to catch myself, without even the barest hint of grace. 

It was a clean, non-slippery floor. I found the one thing within sixty square feet that would've caused me to fall over, and promptly stepped on it. And fell over. Like a short tree made out of sandbags, I toppled.

If the bruise on my leg weren't enough, I now have a nasty sneezy head cold. I don't feel bad, exactly; just disinclined to move fast. I'm sneezing, did I mention? And did you know that it is entirely possible--I have just proved this to myself--to bruise your own soft palate by sneezing convulsively several times in a row? I think I might've bruised my right tonsil as well, strange as that sounds. It didn't hurt, I sneezed a bunch, and now it hurts.

Then there's the bruise on my shoulder. I got that one in an interesting way, by lifting a patient who can't use her legs. We'd tried to get her back to bed with a two-person lift, but whatever bizarre thing she has going on in her brain (not my patient, so I don't know details) has taken both her legs and her sense of balance, so the two-person lift was a no-go. She swayed and buckled and the gait belt wasn't doing the job. Being safety-minded, I did a squat-lift to pivot her from her chair to the bed.

I didn't realize that her neck was as weak as her legs. Her forehead hit my left shoulder with an audible thud. Now I have a nice egg-shaped-and-sized bruise there, right above my collarbone. The patient is fine.

Finally, this news flash: Some Doctors Can Be Assholes. 

I don't know what it is about this particular guy, but every time I deal with him, things go from being normal to being a total clusterfuck in about five seconds. I'm not the only one with this problem, so I figure if the only common denominator is him, it's him. We'd had a run-in about a year ago involving his inability to follow directions in order to reach another physician and then being insulting about it, so I was primed.

What he wanted this time was a series of genetic tests so obscure that it took our lab manager the better part of a day just to figure out where to send the blood. I mean, when *Mayo* doesn't do a test, you know you're looking at something weird. Specialty Lab Of Fredsville faxed us the proper requisition, which contained lots of numbers and capital letters in strings next to check boxes somebody was supposed to tick off. The resident didn't know what to make of it, and I was totally flummoxed, never having heard of the genetic condition the attending wanted to test for, let alone the test for it.

So, when Attending With An Attitude showed up on the floor, I (waited until he wasn't busy and then) asked him to (pretty please) fill out this form so I could send it to Specialty Lab.

Whereupon he threw up his hands, sighed heavily, and made a comment about nurses being stupid. I stood there like a bump on a lump while he ticked boxes and scribbled his name at the bottom of the requisition, considering whether beating him to death with a chair was something I had the energy for. I decided against assault and battery and for simply ignoring his comment.

And you know what? With inveterate assholes, ignoring their comments is the best way to piss 'em off. He got a few more jabs in before he left the floor, some of them personal and not related to any clinical situation, and I just...pretended not to hear. At all. He was both annoyed and deflated when he left. I don't think we'll have any more trouble from him for a while.

God, that was fun.

An apology.

Dear Nursing Students Who Were On Our Floor Two Weeks Ago:

I'm really sorry about your last rotation with us. If I'd known my coworker Peevie McGripersons would be there, I would've taken each and every last one of you on, like a string of ducklings, to save you from McGripersons.

I probably should've realized there would be problems when I heard McGripersons berating a student about how Medication Sheets Are A Legal Document, Like Charts Are. I mean, yeah, you copy down all the meds your patient has and you learn all about 'em before you come in the next day, right? It's probably still not a good idea to go with your hand-copied notes when you start to pull meds, because something might've changed--but there's no reason for you to get excoriated about Legality and License and So On because you're inexperienced. 

It would've been better if McGripersons had said something like, "Oh, you copied everything? Damn, you're dedicated. Snag the med sheet out of the chart, willya, and let's go yank some pills out of the machine, eh?"

I *knew* there were problems when I watched one of you pull up a couple of different meds into the same syringe--something we do all the time--and watched your face change when it became obvious that the meds weren't compatible. Not one of us hasn't cursed inwardly when we've seen incompatible solutions crystallize in a syringe. Not one of us hasn't grumbled our way back to the med cart to grab two more syringes and re-up the meds. It happens all the time. We just don't give the crystallized solution, y'know?

But to hear McGripersons, you'd've thought the world came to an end. 

Seems to me that a better way to have done it would've either been to have warned you that Solution A isn't compatible with Solution B *before* you pulled 'em up, or to have sympathized and explained after it turned out they weren't. I don't see that you needed to be subjected to a pharmacological lesson *after* you'd screwed up, which does nothing to help you figure out what the hell is going on and a lot to make you feel an inch tall.

And, finally, I apologize for not stuffing Peevie's limp body down the laundry chute after he told one of you that you weren't to do *anything* without him there, because A Chart Is A Legal Document.

Yeah, Peevie, we know. There are better reasons, though, both to follow a nursing student pretty closely and to chart completely and correctly. Legality is a very minor concern.

First of all, your average student is scared to death of your average patients. They're not people to the nursing student; they're huge bundles of foreign problems who are likely to die suddenly while gasping out that it was all the student's fault. Having an experienced nurse at your side makes you a much less scared student (unless the nurse is Peevie McGripersons, that is).

Second of all, other nurses--and the occasional doctor, alors!-- read your charting every day. They do so to figure out what's been going on with the patient and to make sure they don't reinvent the wheel. Charting completely and correctly is about *safety* and *information* more than it is about legality. Yes, good charting will save your license in the event you're sued--but it's much more likely that it'll save your patient some trouble. Other people need to be able to read an informative, intelligent chart to decide if that numbness warrants reassurance or a call to the doc.

Guys, on behalf of my other coworkers and decent, humane nurses everywhere, I apologize for Peevie and his ilk. Please don't be scared away by one jerky nurse. I promise that I'll steer you away from him in the future if you'll just come back. 

And I promise, too, that you are not the idiot McGripersons made you out to be. You're inexperienced, yes, but that does not in any way equal stupid. You've gotta be smart and hardworking to have made it this far, okay? What remains is more hard work and a little more time with sick people and their pills, and you'll have it made. You may not feel confident until you've been a nurse for a couple of years (I didn't, and I don't know many people who did), but it'll come. Just avoid the McGripersons of the world in the meantime. 

Sorry, guys. I really am. Come find Auntie Jo next week and she will set you up, okay?

This was my day.