Why I love my job, part umpty-umpty-ump:

1. Standing around on rounds with the chairman of the department and the United Nations of Neurology (aka the residents), trying to figure out what the hell is wrong with a particular person. "He can't read out loud, but he can read silently and give you a good summary of what he's read." "Do you suppose that guy has edge-sensing and blindsight? That would be really cool. I've never seen a case of blindsight before." "How the heck are we supposed to get her to eat all of her food if she has total extinction of the left side?" (Me, having read Oliver Sacks: "Just tell her to turn her plate to the right until more food appears." Neurologists, not having read Oliver Sacks: *gaping in amazement*) "What about that one dude who sees only in black-and-white? Is that any better?"

2. Seeing function come back after TPA administration. Normally we don't do MRIs prior to TPA, just CTs. The MRI suite is always so busy that holding TPA until we have a solid MR image would push most of our patients out of the window (in terms of time, not literal defenestration). That means it's always kind of a crapshoot in terms of what we'll see, depending on whether the embolus was a clot or plaque or whatever.

3. Learning even tinier details of brain anatomy every single day. Just when I think I've got a good handle on things, some genius comes up with a theory that a patient's symptoms are due to a minor derangement of Whargarrbl's Foci of Bolognese's Range of the Straits of Inglewhazzit. It all starts to sound like Terry Pratchett, and I'm off to the textbooks again.

4. Learning really gross things about gross anatomy. Turns out there's a nasty situation that can happen inside an artery that causes a big snotlike glob of fat and plaque to detach partway and hang there in the blood streaming from the artery. Except that it's attached at one end to the wall of the artery, so it just goes "hrrbl hrrbl hrrbl" and blops around, occasionally causing TIAs. I can't remember the name of it, but if I see it again, I'll know it.

5. Knowing enough to explain what's going on when somebody in a different department starts freaking out about the YouTube video with that octopus? That's dead, and in soup, but then somebody pours vinegar over it? And I can explain how the acid in the vinegar stimulates the sodium channels and makes the octopus-food-corpse-guy want to crawl out of the bowl. That's really cool. I like that part.

In which Nurse Jo performs an assessment:

Nobody died over the last four days: good.

TPA given to two people who needed it: good.

TPA given to one person who has a factitious/psychological disorder: well, no harm done.

Intubation of one patient: very, very good call.

Extubation of another patient: good. I'm glad her daughters got to be there.

Lotioning of a patient: Jeebus grits, why did this woman have to use Johnson's Baby Lotion? I hadn't smelled that smell in better than twenty years. It took me back to watching my grandmother get ready in the morning, in her alcove lined with mirrored closets, and her vanity mirror with Johnson's on the table.

I think I might have to go buy some Johnson's Baby Lotion just for the helluvit.

Self:

Oh, dear.

Noticeable right nasolabial flattening. Left neck musculature overcompensates for right on swallow. Left and right shoulder shrug equal. Right facial and neck dermatomes non-compensatory; total extinction of buccal and mandibular distributions. Compensation adequate.

Crooked smile: my new trademark.

So, yeah. Hey. How you doin'?

Well, we're moved.

We have a spandy clean new unit with seven (!!!) beds, monitors, a central monitoring station, computers that work, (oh, crap, I just realized I have to call them about the call light system) and beds and so on that actually function and don't have bits broken off of them.

So that's what I've been doing for the last couple of weeks. That, and the usual keeping people from falling out of their chairs or having larger strokes or otherwise having complications that would keep them in the hospital for weeks and weeks.

The first thing I did in the Spandy New Unit was stretch my arms out from my sides and turn in a complete circle. That did not used to be possible. The second thing I did was walk from one end of the floor to the other, giggling, and saying "wahoo!" softly. Then I got my poop in a group and got the patient we had to move to her new room.

It feels a bit like a shakedown cruise. There's still a lot of stuff that doesn't work, and things that could be neater or more convenient, but we'll work those out in time. Right now, I'm just grateful to have a place to put people where I can be relatively sure that the walls won't catch fire and I can get them into and out of the rooms through doors wide enough to admit hospital beds.

While you're waiting for a real new post, kd lang.

Things They never tell you about having had cancer:

1. While cancer might be simultaneously boring and terrifying, it beats waiting for the surveillance scans. There's an up-and-down rhythm to getting your lymph nodes biopsied (ow!) that just isn't matched by the four-month drag that is waiting for your first chest CT.

2. Growing your hair out after having had cancer sucks just as much as it does when you're well. You still have weird flippy pieces and flat bits, and you still look like hell, but at least nobody says anything snarky. They just look at you and say, "You lookin' good. Whassup with yo' 'fro?" (credit: Friend Lisa from work.)

3. Every beer, every french fry, every night out on the town is larded with guilt that This Might Be The Thing that tips you over the edge into another horrible diagnosis.

4. Your blood pressure will always be a source of concern for the nurses at your surgeon's office, and they'll waste lots of paperwork on you before you say, through gritted teeth, "MY PRESSURES ARE HIGH BECAUSE I DON'T WANT ANOTHER BIT CUT OUT OF MY HEAD, THANK YOU VERY MUCH."

5. Your foresight in putting all your favorite colognes at the back of the closet during the first week of treatment will be rewarded when a patient in the chemotherapy unit says you smell good.

Redemption rips through the surface of time

(Bruce Cockburn, Lou Reed, and Roseanne Cash)

"...and guess what? I felt the baby kick today."

Merry Christmas, y'all.

Question From A Young Nurse: But What About The Feelings?

A Young Nurse asked Auntie Jo for advice this week. Poor, deluded Young Nurse.

Our correspondent asked this: "What do I do when a doctor or older nurse snickers at an answer I give to a question, or takes me aside later and tells me that I should've done something different? I have six patients, and I'm new to the night shift. I can't keep everything straight all the time. I want to kill them. What should I do?"

Dear Young Nurse,

We were all there, once. Those of us who got over it became the sort of nurse that your Auntie Jo is. Right now, I have a cat rubbing on my shoulder, a cold beer to the right of the keyboard, a happy dog frolicking in the back yard, and a list of men who want to be seen with me.

Those of us who didn't get over it became the doctor and nurse you're working with.

Practically, what you can do is this: Do what residents do. At the start of your shift, make out index cards that have each patient's name on them in big, bold lettering, so you can't miss it. On those cards, write the essential lab results and neuro/cardio/gastric/renal changes the patients have during the shift. Update them as you need to. That way, if you're ever caught out by a question, you can yank your index cards out of your pocket (be sure to wear scrubs with pockets at the waist) and answer the question quickly.

Doctors *love* it when you do things that they did as residents. It makes them feel very smart, and they will treat you better as a result.

As for the nurse: be humble. Shrug things off with a "Well, I'm still learning. Someday I'll have all that stuff on the tip of my tongue, like you do!" Make sure your back is turned when you roll your eyes. Mean nurses love that sort of thing, even as it makes them wonder if they're really *that* decent of people (answer: No, you're not, and you're going straight to a flaming-hot Hell when you die).

But what about the feelings?

It is hard, and I acknowledge that it's hard, not to reach out gently and wrap your scrawny little hands around somebody's neck. As The Bloggess once said, "A hug is just a strangle you haven't finished yet." I would suggest that you find a nice, private place to feel those feelings.

Feeling something like rage or disappointment doesn't mean you have to act on it. It just means that you've opened the door marked "RAGE" or "DISAPPOINTMENT" and have gone in and browsed through the goods on offer. It's best to do it in private so you're not interrupted. Rage, rage, against the asshole nurse or doctor who decided to get his or her rocks off by humiliating you. Then set it aside.

Resolve that next time you'll be so bulletproof that you'll embarrass them without meaning to. Resolve that next time you'll have the perfect l'esprit d'escalier and won't forget to say something like "up yours, motherfucker" when it's warranted.

Resolve--and this is both the most difficult and most important thing--that you won't let this make you think less of yourself or your practice. Some people are just assholes. Instead of bundling the urge to finish the hug up inside yourself, practice letting it out in the car.

All you can do is the best you can do. Be prepared, be on point, and if things don't go your way, don't fret: you've done your best. Believe it or not, your best doesn't have to be perfect. This is a twenty-four hour a day job. Self-doubt is a killer, because the minute you doubt yourself, you start doubting that little voice in your gut that tells you something ain't right.

If all else fails, Talisker. It's a good Scotch for beginners.

Am I old yet?

A coworker of mine reminded me recently that 2012 will mark my tenth year at Sunnydale General (Healthcare for the Hellmouth). Reader's Digest called me a "long-time" nurse. Doctors refer to me as "experienced."

So am I an Old Nurse?

I would argue not, and this is why: Old Nurses are people who still know how to work stuff you only heard about in nursing school, and who remember techniques and tricks (and are willing to teach them to you!) that you've never even considered.

Take Wendy, one of the nurses I work with. She's not an old nurse, having been a nurse for only slightly longer than I have--but she's an Old Nurse. She can count drip rates and work them out to milliliters per hour, having worked in rural hospitals. She can make a mean hot pack. She knows how to access the really bizarre permanent catheters that we sometimes see. She doesn't remember the days when pneumocephalus was induced as a diagnostic tool, but she's done stuff--like reducing dislocated shoulders--that I've only read about. In fiction.

On the opposite side of the coin, I was a New Nurse with eight years' experience under my belt when I went to the CCU. No matter how good you are at one thing, if you move to another, you're automatically a novice. That's not a particularly comfortable role to inhabit, but it does do wonders for an overblown ego and a sense of entitlement. At the same time you're being humbled, however, you're being encouraged to ask "Why?" (That is, if you don't work in a bad environment.) "Why?" is one of the most important questions we can ask on a daily basis; it's the only one that leads to changes and improvements in care.

So, no, I'm not an Old Nurse. Not yet. At this rate, I may never *be* an Old Nurse. Although, I will say--my willingness to get post-op patients up out of bed without waiting for physical therapy has gotten shocked, admiring reactions from CCU nurses.

If I ever do get to Old Nurse status, I want to be asking "Why?" still. Those are the best sort of Old Nurses to have around.

HA.

And a Huge Shock:

Teddy Bear the Fretful Porpentine is from My Home Town!

I might have to ask to meet him (and bring him erk-erk-eeenh-eeenh-gitback! noms) next time I'm up there.

Updates, of a sort.

I saw Dr. Elf today for the last time until April. The New Bug is performing beautifully; I'm even able to lie on my stomach for a massage without any nasal regurgitation (aka saliva running out my nose). He thanked me for being such a happy patient; I thanked *him* for being kind on the days when I was not happy. There were plenty of those.

So, April: I go for a chest CT. That's scary as hell. Apparently, polymorphous adenocarcinoma rarely metastasizes, but when it does, two things happen: it goes to the lung or brain, and it's incredibly virulent. My brain, so far, is clear. (My coworkers would say that it's not just clear of cancer, it's clear of thought and reason as well.) My neck is clear. I'm very happy that the lymph nodes in my neck are clear, by the way: the radiologist who read this last CT was the same dude who read the last one, and he said something like, "I note that the lymph node in the right neck, swollen in the pre-surgery CT scan, has returned to a normal diameter and density." I'm hoping nothing nasty shows up in April.

ANYway, the same day I see the CT guys and Dr. Crane, I see Dr. Elf for a follow-up. As he said, this is a dynamic process. As I age, as I lose or gain weight, as I sing more or less, the prosthetic will need to be modified. We'll let it float until April unless something major happens.

Speaking of major, two things happened this past week: BCBSTX denied my appeal and simultaneously refunded me about a tenth of the money that they ought to admit they owe me. What this means in real terms is that I now have to appeal to the Office of Employee Benefits at Giganto Research and Education Corp. Beloved Sister is helping me set up the most impressive packet of information ever, including slightly nauseating pictures of The Deficit, in order to do that. So, more of that.

Enough about me. In work news. . .

It's getting harder and harder to get one of the cross-covers to call me back. She's a nice girl, if a bit scatterbrained and inclined to panic. I'm thinking that I ought to just page her in haiku:

Your patient's IC

P is rising. Perhaps

You should come see him.

or

Wind through falling leaves

Like gas in patient's bowels.

Please order senna.

In sadder news, one of my coworkers simply didn't wake up last week. He was thirty. As is usual for this sort of unexpected death, there'll be an autopsy; likely he had sudden cardiac arrest or a PE. And, as is usual for this sort of death, nobody had a bad thing to say about the man. He was, as a friend of his said, a "good hand"--coming from a deep East Texas country boy, that's high praise.

I know I'm not supposed to wish death on anybody, but wasn't there somebody out there who set kittens afire that could've died, rather than the nice young guy with four kids? I liked working with him, knew I could trust him, was glad to see him in the mornings. Greater praise no nurse hath for any man.

Aaaand in less-sad news, we have a new place for the NCCU: we're taking over a unit on the floor above where we currently are. We'll have real doors that close or not, as we choose, and real monitors, and real beds, and real pumps! Just the luxury of more than four square feet of desk space (and half of that taken up with a sink) is more than I can think about without giggling. We should be there by the end of next month.

Finally, read this by Xeni Jardin. She captures better than I ever could the feeling of being out there, beyond reach of the people you depend on most, stuck in a new place.

"When I finally got through, someone else's voice was coming out of my mouth, and it was taking forever for the stuttery radio transmissions to beam through space, from the cold planet I was lost on, way out here, far from home."

Two and a half minutes of nomming Teddy Bear.

This is. . .amazing.

Real posts a bit later, after I get back from buying new blades for my reciprocating saw.

In case you've had an especially bad day. . .

I present the Strontium-90 of cute animal videos.

This is not a title I bestow lightly. Until today, the best-ever cute animal video was that of a porcupine who thought he was a puppy. He's been dethroned by a greedy porcupine. At least they kept it in the species.

Behold: Teddy the Selfish Porcupine!

Man. That is one fretful porpentine.

The Evolution of a Bug.

The scans were clear. I have a flowery turbinate that bears watching, but that apparently can be a normal variation. Next flip-out comes in April, with CTs of my chest and belleh.

I also got the new obturator fitted yesterday. It works. It works wonderfully, in fact. So, in honor of the New Bug, a retrospective:

The obturator on the far left is the first one I had, the surgical one. The speech bulb was added later, and they had to change the position of the wire on its right side, hence the weird plastic outpouching. I broke off the wire on the top right by biting on it.

The obturator in the middle is the interim one. Note the thumb-sized snot channel, meant to drain away what doctors euphemistically call "secretions." You'll notice that it's narrower and longer than the surgical bug, as a result of my head healing and changing shape.

The obturator on the far right is the one I'm currently wearing. It's made of chromium nanowhatsit, some nonferrous material that's only found in conjunction with unobtanium. It's hollow to cut down on weight, and no, that hollow doesn't fill up with crap. I was amazed.

See how the shapes have changed as I've healed? You can't really tell from this picture, but the first Bug is so large I can't close my hand over it, and I wear a size 7 glove. The newest one is so petite and light that it feels like nothing. Plus, since it doesn't cover the backs of my front upper teeth, I can do things like bite into an apple.

Notamus loves the fabric I laid out as a background. He started milk-treading it just after I took this picture. Weirdo.

First obturator, alone. Damn, that was huge.

Second obturator, alone. That loop of metal inside the plastic speech bulb is meant to stabilize things. Look how tiny the obturator part is, and how fat the speech bulb is in contrast to the first one!

It's like I'm watching my own baby grow up, she says, clasping her hands to her breast.

Well. Enough of that. I've got sausage and potatoes and sauerkraut to eat. With my new obturator.

BIG DRAMA today at Bigton's Scanning Centre!

Call out the Marines! Get the helicopters going! Phone the Prezznit!

Or, at least, call the security guys and have them come and scratch their heads.

There was an Opossum (from the Proto-Algonquin aposum, or white beast) in one of the trash bins this morning at Scanning Central. The security guys, the maintenance guys, the housekeeping folks, and the animal control peeps were all alerted. Everybody ran about and waved their hands.

Until one of the valet parking dudes rolled the trash bin (with aposum inside) carefully over to a landscaped bit of ground with plenty of bushes and tipped it over. The white beast made its way (trundle trundle trundle, wide-butt-ily) to the far side of the landscaping and disappeared.

Possums got big teefs.

And so do I. Scans were today; results of scans and possibly an Evolution of the Bug, tomorrow.

Black Friday Relief. (not that I went anywhere, mind)

It's like I put a quarter in the scumball machine.

No, I will not hide you from the cops who have come to investigate your lousy ass for leaving the scene of an accident in which you hit a pedestrian while cracked off your noodle.

No, that minor forearm injury will not qualify you for disability.

No, you may not leave the critical care unit to smoke one with your buddies.

Yes, I do intend to start this IV on you. You can threaten to hit me all you want; it's still going in.

Yes, we enforce visiting rules. No, conjugal visits are not an option.

Get your child out of the CCU. Now. I have already explained this to you twice. You cannot smuggle a toddler in under your coat and not get found out.

You do indeed have gonorrhea. Sorry. Now roll over and take this shot.

And you do indeed have syphillis. All the shouting in the world won't change that; besides, it's annoying the Clampetts on the other side of the curtain.

You may not see your "clients" in my unit.

Telling me that you'll sue me if I do one thing you don't like is not the way to build a therapeutic relationship. Neither is having your lawyer call me to demand details of your care. There is such a thing as confidentiality.

Yes, I am a fat bitch. Pointing that out neither hurts my fee-fees nor makes me more inclined to be cheerful.

Thank God for little grannies who come in with their unfailingly polite, helpful family ranged around them. Grandma can hold court from her bed as long as she likes, and you guys can stay as long as you like, bandanas and weird droopy-ass pants and all. You may be scary looking, but you're obviously good to her. You're also very nice to me. Thanks for the chicken pot pie.

Had a bad day? Have some ducks and a cop.

Here.

H/t to Friend Pens for this!

One thing about being single

. . .is that you learn how to do things on your own. You get used to doing things on your own, and even begin to like it.

Today, for example, I hung wallboard and panelling (not that I like panelling, but I had to match the stuff that was already on the walls). Last weekend, I took down an eight-by-eight-by-two built-out closet that was messin' with the feng shui of the bedroom where I type. Tomorrow I'll bake a couple of pies (home-made crust, thanks) and tape and mud the wallboard in the utility room. I did all of this on my own, except for loading the stuff into the bed of my neighbor's truck today. I'm used to doing stuff on my own. I'm good at it.

Which is how I came to be lying atop a fighting, screaming, thrashing man, holding his wrists with one hand to keep him from punching me and threading an NG tube down his nose with the other hand. I figured I could do it on my own.

After all, I reasoned, with six of Ativan and God only knows how much of Haldol already in his system, he's well sedated. He withdrew to pain thirty seconds before I busted out the KY and the NG tube, so I figured I was good to go.

I was wrong.

As he felt the bed starting to rise, both of his legs went over the bedrail and he started screaming. It was a full-blown, woman-like scream that went on and on and on. Dude could've made a killing in opera, I tell you. I figured that he, like most patients with encephalitis, would stick to the screaming and maybe make a small gesture here and there with one arm.

Again, I was wrong.

He scooted all the way to the end of the bed, got his legs out, and proceeded to try to buck his way out of the situation. Which is why I laid atop a person who had a history of projectile-vomiting blood and punching unsuspecting phlebotomists.

I was very glad to see Figgy, the stocky and strong intensivist, come through the door at a run. Figgy and I managed to get the guy back into the bed and tied down, then ran him down to CT.

It was a long day. I'd give my kingdom (with new wallboard!) for a thousand milligrams of methocarbomol right now.

What we talk about on slow days.

Is there an animal which, in its baby form, is not cute?

I assert that there is, though I don't know which one(s) that might be. The Mankiller swears that all baby animals are adorabubbles. We went on a Google search to see what might, in the baby-critter world, be uncute.

Llamas are cute as babies. So are goats. So are Tasmanian devils. Even Chinese Crested puppies are cute, which I was not expecting. Baby parrots are about the furthest thing from cute ever made, but even they, with their oversized beaks and button eyes, have a certain charm. Baby reptiles are cute because something scary in a large form is cute when it's wee.

We are still looking for the baby animal that won't make us squee and want to snuggle it.

The Mankiller and I also discussed the concept of Intrinsic Funniness, which I mentioned here a couple of days ago. Elephants, pennyfarthing bicycles, large moustaches, tweed blazers with leather elbow patches, and half-grown puppies are intrinsically funny. We agreed on those things. Possibly intrinsically funny things (those things which need more study) are mice, any consumable good that has a name like "Ho-Ho" or "Ding-Dong," certain shoes (white bucks and those loafers with tasseled tongues), balloons (opinion is divided between funny and scary), people in drum circles (funny or tiresome?), and bologna. Personally, I incline to the idea that bologna is funny. The Mankiller isn't so sure. She thinks bowling shoes are funny, but I find them overdone. I find pit bulls hilarious, especially when you rub their bellies and make them banjo, and she says they're too politicized.

We agree that although they are the butt of many jokes, the following things are not intrinsically funny: Jews/Poles/Irishmen/Your Best Friend (whatever ethnicity he is), the Wicked Witch of the West, the suburbs (more depressing than funny), anything Scots, garbage disposals, utility companies, and the Works Progress Administration. That last came out of a conversation with Richard the Respiratory Guy, who asked, "What can you never imagine anybody telling a joke about?" I came up with "the WPA;" The Mankiller came up with something I can't talk about on a family blog.

Suggestions? Disputations? We can't spend all day hacking our coworkers' Facebook pages; we need some help.