Hey, I just met you, and this is crazy,

. . .but I have the sudden urge to smack you over and over and over with a shovel across the back of the head, so could you sit down?

Thanks.

I am like Grumpy Cat: my life is empty without someone to hate.

After a rough period in December, when it seemed every nurse in Texas had disappeared without leaving so much as a shoelace behind, things are good in the CCU. We're staffed well. There's Kitty, who has sold her soul to the Devil in exchange for the ability to do a razor-sharp wing with liquid eyeliner *every* *time*. There's Marcie, who is good and beautiful and brilliant and so sweet I dread having to tell her that there is no Easter Bunny. And she's been a nurse for ten years, too, so this is not something that's going away. There's the night crew, who refer to themselves collectively as Team Awesome, and who are not overstating things. And there's Keith.

Keith (not his real name; if they pick me up for murder, they can't prove it) is the smartest nurse ever. He already has a master's under his belt at the age of 30, he's working on his DNP in adult acute care? Or critical care? Or something? He knows every policy and procedure in the manual. HIPAA is an open book. He can, he assured me on day one, run a code by himself. He is a fucking genius. He has been a nurse for five years.

He does not know how to set up a suction rig. He does not know what angioedema looks like. He does not understand how swallowing works, and that silent aspiration is a thing. He does not, in fact, know how to run a code at all, let alone by himself.

Now, I'm willing to excuse all of that and more in a new nurse. Contrary to how I might sound on here, I am the preceptor you want. I'll entertain any question without making you feel like a moron, because even supposedly stupid questions usually have logical backing. I'll show you cool shit and get you into the transplant OR and pull strings so you, too, can hold a heart as it beats outside somebody's body. You can practice IVs on me.

However. If you're a supposedly experienced nurse, who's worked four places in five years (wtf is up with that it's not like the economy has been great why did that not trigger anybody's warning bells oh my GOD), and you make a critical medication error, giving five times the dose of an opiate to an opiate-naive patient, and then turn your back on them in order to futz with the computer, and *then* try to blame the error on *me,* I will cut you.

If you try to pin something on Marcie that she did not do, then boy, your life as you know it just got a whole lot worse.

Keith's head and me, May 2015

Can I get an A-men.

For the time being, we have appealed to Wonderful Boss as a group, and Keith is going down to the bowels of Holy Kamole in order to train with Betty in Interventional Radiology. Betty is sixty. Betty is a dedicated Crossfitter and member of a motorcycle club. Betty runs a six-minute mile, faster than she did when she was an Army nurse. Betty is two years away from retirement and takes even less shit than she used to.

Keith will know, if he knows nothing else, how to dose people for conscious sedation. And what to do if he fucks up. And he'll know exactly why it's a bad idea to try to bully the people he works with.

I feel alive again. I feel like I'm no longer wasting my time, if there's an ego to destroy and dreams to crush.

Or maybe that's the double-bacon cheeseburger I ate for lunch talking.

Thoughts, various.

I would really like to be in Seattle right now. From now until mid-October sounds about right; that means I would miss tornado season here. Tornados, strong thunderstorms, hail--it all sends me, shaking and swigging whatever alcohol is in the house, into my safe closet for hours, usually a couple times a week. I hate heavy weather. Call it a remnant of my days in Kansas, including living through the infamous Wichita/Haysville/Andover tornado of 1991.

Failing that, I would like to be up in the Blue River or over in the Comal for the next few days, not going back to work.

*** *** ***

An email arrived today from a woman who had a palatectomy on Friday.

This is comparable to a dodo sighting. In four years, with God only knows how many hits to this blog for "palatectomy," "obturator," and "palate cancer," I have only heard from one other person who'd had a palatectomy before now, and she was introduced to me by my uncle. Given how quickly oral cancer is becoming The Latest Thing, you'd think I'd have a coterie of fellow bionic-mouth wearers, but I don't. It seems that most oral CA people get nasty stuff at the base of their collective tongues, or on their tonsils, not in their minor salivary glands.

The emailer asked how long it would be before the hole closed up.

Honey, I said, that hole is never gonna close up. That's gonna be with you for life. How did nobody tell her that before? WTF?

Which took me back to the months after surgery, when my obturator was equal parts problem and blessing. I searched all over the Innerwebs for palatal reconstruction, eventually finding somebody in Alberta? Saskatchewan? Someplace in Canada, who would do palatal reconstruction in adults, with only poor-to-fair results.

It took a good three months before I accepted that I would indeed be wearing this Thing in my mouth until the day I keeled over. After that period of adjustment, I started experimenting. I discovered that having a removable mouth was actually superior, in many ways, to stock equipment.

For instance: I rarely have to pop my ears on an airplane, and almost never have pressure and pain with a sinus infection. (Of course, I can't wear my obturator when my sinuses are really inflamed, but you take what you can get. At least I can sleep without sitting up.) I am proof against pizza burns, Dorito stabs, and all but the most aggressive Cap'n Crunch bits. I have something cool to show the medical students and nurse interns, and I have won several bets on how much I can fit in my mouth at once. (The trick is breathing carefully, so as not to send stuff down your airway.) Nothing but poppyseed muffins cause me any trouble any more, and I never liked poppyseed muffins anyhow, so no great loss.

It's weird, how a simple email from a person can bring it all back. It's like I haven't come all that far after all. Then I remember: I saw Maricel, the tech at The Prosthodontic Elf's office, wax like the moon during her first pregnancy. The second pregnancy, I only knew about during the eighth month. I've missed the third one altogether. So that's something.

*** *** ***

Mongo comes home tomorrow. I have to bail him out first thing. I will be setting my alarm. I've had trouble sleeping without him curled up on my feet, or in the small of my back. The cats have been strangely needy this week; I think they miss him, though they'd never admit it. A seventy-pound dog leaves a huge hole when he's not where he's supposed to be.

*** *** ***

Can we please stop pillorying people for shit they tweeted five years ago? Tweets I would've made five years ago would've had me strung up by six or eight groups of people with whom I now identify. Jeez, people: personal growth. Look it up. It's a thing.

My Dog Is A Fugitive From Justice.

My dog is on the lam.

My dog is living under an assumed identity.

My dog is being shielded by others at great cost to themselves.

My dog is an asshole.

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

While Boyfiend (formerly Brother In Beer) and I were spending a nice few days in the Pacific Northwest, watching Der Alter Jo get hitched, Mongo The Magnificent (aka ThugDog) was being dogsat by a very nice woman who keeps pups in her home and charges very reasonable rates.

He had a lovely time. I have more than sixty photographs of him running through the woods, swimming in the lake, chasing ducks (aka Water Squirrels), and sleeping on the nice woman's couch. In most of those pictures, he's side by side with her foster dog. Her foster dog is sweet, ancient, and tolerant.

The last day he was there, on his last outing, he got upset with Dogsitter's Dog and snapped at him. Dogsitter's Dog of course retaliated, because even at ninety years older than dirt, he still has some self-respect. Dogsitter tried to break up the fight. Using her hands. Near the dogs' heads.

And got bitten. Not intentionally, not badly, not in a mean-spirited way, but she had to go to the ED when her hands started to swell. And the ED, following the law, called the cops. All dog bites in this county have to be reported.

(Which brings up the following conundrum: if a burglar breaks into my house and Mongo bites him/her, and then said burglar is taken to the ED for treatment by the cops, does that count as a reportable incident? Or do the cops simply wave their hands and say "Eh"?)

Anyway, things started going Keystone Kops in the ED. The salient point in all of this is that I live in one city, the dogsitter lives in another, and the bite took place in a third, very small, city, just inside the city limits. The first cop--one from my town--showed up, decided it wasn't his jurisdiction, and left. The second cop showed up, the dogsitter refused to give him any information about me (more on this in a minute), and he left.

And the next day, in succession, the dogsitter had the police from four different cities show up at her door with animal control trucks, ropes, lassos, dart guns, and various other implements of distruction. They pounded, she said, on the door. In succession. And she refused to answer the door. (Here I have to credit her heart and cut her some slack for being flustered. If cops were pounding on my door, I would hesitate to answer it as well, for fear that the dogs in my care would be taken away in the paddy wagon, with nobody sorting the good dogs from the bad ones.) Anyway, she said squat until they showed up with a warrant.

(I don't know what the police from the fourth city were doing. Maybe it was a mistake? Maybe a show of moral support? Maybe they had to run to the store for a few things and just dropped in on their way? I dunno.)

When they showed up with a warrant, she called me. I had known she had gotten bitten, but had figured things would work themselves out in the noiseless-tenor way that they normally do. I mean, I had no idea she had bucked the police.

I had to get on the horn with three successive animal control and sheriff's divisions before I found the person who could deal with my problem, only she had left the office about ten minutes before.

So tomorrow, I am staying home from work. I will call my vet, explain the problem, and ask for a quarantine cage. It's the law here that any dog who bites a human has to, if its vaccinations are up to date, be quarantined for ten days. I can't quarantine Mongo at home, since it wasn't a family member who got bitten.

Then I will call the third city sheriff's office and say, "My dog is a fugitive from the law, and I am calling to turn him in." And we will go from there.

No, it doesn't feel quite fair that Mongo has to be quarantined because somebody got in the way of his teeth. On the other hand, I can see the dogsitter's problem: when you see two dogs going at it, the immediate instinct is to shut that shit down, any way any how.

And while it was accidental, I can see the reason for any-skin-break-is-reported. If I asked for an exception, they'd have to make exceptions for every blockhead with a truly dangerous asshole dog, and then where would we be?

So, the upshot is, Mongo gets another vacation. Not as much fun, and not as heavy on lakes and ducks, but another vacation.

And I have to figure out whether to outfit him in a striped outfit, an orange jumpsuit, or just put an ankle bracelet on him and write "LOVE" and "HATE" on his paws.

Things got a little busy.

There was an ice storm. And Friend Abilene Rob and his lovely bride-to-be Alice moved closer (hooray!). And The Boyfiend started physical therapy, and finished it, and now doesn't think he had a failed back surgery. Which I had been telling him, but when does any Boyfiend ever listen? Never.

We're also ramping up for That Yearly Festival That Makes My Commute Hellish, aka South By Fuck You. And our supplies manager's son died of septicemia, which is something you really wouldn't imagine happens any more, but apparently it does, so we were out of supples for about six weeks. Like, no insulin syringes for two weeks out of supplies. Which is horrible, but not as horrible by a long shot as watching your only child die of septicemia.

Also Friend Lisa's husband died, which was scary. He's my age, and he had a sudden heart attack. Just. . .went to sleep, as my mother says, and woke up dead. I assured her, when she asked the other day, that he felt nothing. Just went to sleep and woke up saying "Dafuq?" at the Pearly Gates.

Then another bout of bad weather, although not as bad as the first. I got the stomach bug that was going around and lost nine pounds in six hours, all fluid. Then I got better.

And through all of that, I felt really burned out. Not just burned out on blogging, but burned out on nursing in general. I was looking for jobs outside of nursing. I was considering learning to code, even though dealing with computer scientists is the last thing on my list of Things I'll Do Someday Before I Die, and last on my list of Things I'd Do If The Alternative Were Being Stuck In The Eye With A Bamboo Sliver.

See, we've had some changes at Sunnydale. As a result, we've lost probably thirty-some nurses, the same number of nurses' aides, half a dozen doctors, and not enough Manglement. We've been so short lately that people are calling safe harbor every shift. Manglement's focus has been on getting us new monitors, new isolation gear, and new urine-sampling devices, so it's been. . .well, it's been a recipe for burnout.

It's bad when critical-care nurses call safe harbor. It's really bad when rehab nurses call safe harbor.

It's been really bad.

I started thinking: I deal with people every day who are in extremis. Most days, I can't go home and leave my job behind. Part of that has to do with the job itself; part of it is the fact that I've become the de facto manager of my unit and the de facto mentor for several new nurses. I took a couple of days off--literally two--and came back to people with their hair on fire, asking where I'd been, a stack of paperwork six inches high on a desk that I don't have, and a new nurse having a crisis of confidence.

And I thought, where is the benefit to me? What on earth am I getting from this, aside from a steady, if variable, paycheck? I used to feel a sense of accomplishment at the end of the day. No matter how bad things had been, I knew that there had been one person, at least, who felt less pain at the end of my shift than they had at the beginning. Now, it seemed like, I had so many people yanking me so many different directions that I couldn't even be sure of that one simple thing.

I went in stressed, I worked for twelve hours frazzled, and I left feeling guilty and like I simply wasn't enough.

Most people go to work, get a paycheck, get insurance, get vacation time, and that's enough. Those things are the benefits that they look for. Their work is a thing they do, not the thing that they are. They turn off at the end of the day, shuck the coder/garbage man/shoe salesman/flight attendant skin and reveal their Real Person skin.

It's not that way for nurses. It's not that way, I suspect, for teachers or ministers or doctors or God only knows what other professions. Maybe if you're born to be a garbage man, you never take off that skin. Who'm I to say? Point being, if you're one of those people who's in one of those professions, it's bound up in you to the extent that being a Good Whatever is the main benefit of your job.

So, for about a month and a half, I was burned. the fuck. OUT. Not only was I not wanting to be a nurse, I was not a nurse. I had no curiousity about nursing stuff. I didn't care about medicine. All I wanted to do, and all I did, was explore the wonderful world of Amazon Prime Bad Movies and rearrange my closet. I went to work depressed, left more depressed, and didn't sleep well that night.

Then something changed. I don't know what it was. I knew, going into the period of burnout, or brownout, or whatever you call it, that it was temporary: this has happened every year or two for as long as I've been nursing. Still, the thing that pulls my head out of Burnsville is always a mystery.

This time, it was maybe palliative care for a Mohawk woman. There are lots of tricky technical, cultural details to be aware of when somebody from the Confederation dies. Maybe it was the kid with Ehlers-Danlos type 4, who reminded me of another bright, driven person with the same disorder and the same prognosis. Maybe it was the birthday card my pal Abbs made for me. I don't know.

Six weeks ago I left my job feeling like I wasn't enough. It was a gaping wound. Yesterday I left my job knowing for sure that I hadn't been enough, but that I had done my best, and that I would be enough for some other person some other time. And that was okay.

Yeah. . . .no. I'm having some thoughts about BSNs.

I'm an ADN-prepared nurse. Those of you who've been here for a while know that I often refer to those two years (three, actually, counting prerequisites) as the Hardest Work I Ever Put In For An Extended Period of Time. It was like drinking from a firehose, like trying to cross a raging river while wearing combat boots, like riding a bull with no previous experience. And the instructors I had hammered one thing home over and over: that we, as front-line nurses, had the right and the responsibility to consider ourselves colleagues of our BSN or MD or PA coworkers, not as helpers or assistants.

Of course, that was in the days of The Nursing Shortage. ADNs like me were being fought over by multiple hospitals. Nobody in my class started work at a nursing home; we all got acute-care or better jobs right off the bat.

Now my facility is going for Magnet status, which means BSNs are the basic standard of nursing education. And I have some problems with that.

First, I've seen a massive drop-off in terms of the diversity of our nursing staff. Used to be, Manglement would hire people with ADNs, provided they had either a bachelor's degree in something--anything--or equivalent experience not related to nursing. As a result, I got hired with a man who'd worked as a hospital chaplain for ten years, a woman who'd been in the Navy for a decade, three people from three different African countries, and a guy who'd been a medic in the first Gulf War (1990's) and had worked as a mechanical engineer afterwards.

Now they hire BSNs. And since they hire only people with BSNs from colleges here in the US, we have a crop of new hires who are all white, middle-class, and in their twenties. All of them are native-born, all of them are young, and for all of them, this is their first job outside of, say, Sonic. They're also all female.

This is a problem. This utterly fails to reflect our patient population. Not that that's a necessity, but for Heaven's sake: you ought to have at least some employees who can connect on some level with the people they're caring for.

Second, the BSN programs in Texas seem to focus mainly on management and leadership. Which is all well and good, but you're getting folks who, at the end of their senior year, have absorbed a ton of nursing theory and still have no time-management skills. As a result, we've lengthened the preceptor period for new grads to sixteen weeks. The preceptor period for ADNs was twelve weeks. Why? Because, at the end of our last semester, we were providing care for five patients. The BSN-prepared nurses provide care for two.

And they don't catch up. I'm seeing BSNs who, after two years on the floor, are still having time-management issues severe enough to attract Manglement's attention. They're schooled in critical thinking, they're schooled in history, but they simply don't have the chops to handle more than two post-op admissions in a shift. (Oh, Lord, how I wish I were exaggerating.)

Third and finally, I'm working with a lot of new grads who don't have a good fund of general knowledge (to use the MD's term). I'mma be a snob here and suggest that a working knowledge of, say, how to Google effectively, or American history, or politics, might all be good things to have on a day-to-day basis while you're living your life and doing your job. I'm not getting that from the new grads I work with. I have the reputation of knowing everything there is to know about everything simply because I know how to look shit up. I can assess sources, decide which ones are bunk and which ones are decent, and move on from there in a winnowing process. The new nurses I work with (and by "new" I mean "anybody who's graduated in the last three years") do not have that ability. I don't know if it's a liberal arts education or maturity or what, but unless it comes to them from a textbook, they do not know how to analyze information.

Maybe it's a lack of curiosity. When I get a patient from Backobeyondistan, I try to find out everything I can about their culture and belief systems. I'm the only one who does that. *sigh*

ANYWAY. There is a place for BSNs, no doubt. I'm planning to start mine this year, so's I can continue to work somewhere other than assisted-living facilities. Some BSN degrees (though not the ones here, from what I can tell) give graduates an excellent foundation in pathophysiology, assessment, and basic sciences. (Ours tend to require two semesters of state history and a couple of classes on theory.) Some actually prepare students to be nurses, not just research-bots or management candidates.

Overall, though? I'd rather see more diversity in the graduates we get. I want to see middle-aged, fat women like myself who are on their second or third career. I'd like to get into a conversation about Buxtehude with a dude who got his BA in organ music, then went back to school when his carpal tunnel got too bad. I'd like to see the occasional Indian nurse, or Filipino/a nurse, who took the exact same courses for her or his degree but has been denied a job because his/her  diploma didn't have "US" on it.

I'd be interested to hear what you guys have to say.

Christmas by myself this year!

How I learned to stop worrying and stopped giving a shit--and became a better nurse.

It's the classic nursing moment: after you've spent uncounted minutes putting a gorgeously neat, clean dressing on a wound, a doctor walks in, takes the dressing down, and wanders off without a word.

(Which makes me wonder about the nurses who reference this moment: are their doctors that unpredictable? I always catch mine in the morning and ask when they plan to round; it's easier to work in a dressing change after six neurosurgery residents have looked at it. Maybe they don't have easily-cowed residents.)

That, at the very least, prompts an eye-roll and the exhalation of breath through gritted teeth. That's the bottom of the nurse-exasperation scale: the top is the shouted "What the FUCK do you think you're doing??" Somewhere in the middle is the terse conversation, either with a doctor or a family member, in the hallway, with a candlestick and Colonel Mustard.

Y'know what? I no longer have those conversations. Or, rather, I do, but they're not nearly as terse.

I no longer sigh heavily when a patient has explosive diarrhea right after I've rolled out a new pad.

I no longer roll my eyes when I hear that Manglement has opened a new critical-care unit and hasn't hired anybody to staff it.

I no longer, in short, give a shit. And it's made me a much better nurse.

See, there are things worth getting upset about. If I have a post-aneurysm-clipping patient whose blood pressure won't stay down, even with all the drips I can throw at them, *that's* worth flipping out about. If I have an acute ischemic stroke patient whose pressures won't stay up, even with ditto, *that's* worth a phone call or two. If the pharmacy forgets to send the super-special tubing with that bag of potassium phosphate, then yeah, I'mma get on the line to them.

But the usual, boring, irritating stuff, like dressings hurled flang-dang all over the bed? Not worth giving a shit over.

Likewise, every single corner must not be exactly perfect on the top sheet when the patient's up in a chair. I'll have a chance to fix it once they get back in the bed. Every single label doesn't have to be printed out on the in-room label printer if doing so means my labs will be delayed by twenty minutes; I can always send 'em down with a plain, pre-printed label. I can, if necessary, deal with too many patients in one assignment, because I have learned how not to give a shit. I have, in short, learned to prioritize.

More than prioritization, though, the art of Not Giving a Shit has helped preserve my mental health. I have a colleague who is brilliant, talented, very-very-very smart--the sort of nurse who walks around with a halo of golden light because she is just. So. Good.

She loses sleep over minor stuff: whether or not somebody will get mad at her because she missed charting the KVO rate on an IV for three hours, or didn't match the P&P exactly when she ran hot salt on somebody. It affects her personal life, it sometimes comes close to paralyzing her professionally, and it makes her miserable. She needs to learn not to give a shit.

I would say to her: First, is the patient safe? If so, excellent. Is the patient comfortable? Even better. Is the patient clean, fed, and neat-looking? You get a gold star. Is the patient calm in their mind about what's going on? Then you can sleep easy.

The fact that you might not've checked blood return every two hours on an IV, instead letting it go to two-and-a-quarter or two-and-a-half hours, is not worth worrying about. You'd kept a weather eye on that IV, you knew it was good; fifteen or twenty minutes will not make the world catch fire. Five cc's an hour is not a huge deal.

My Not-Give-A-Shit list goes something like this, in order of Not-Givingest to Most-Givingest:

1. Emails from anybody with extensive lettering after his or her name. If it comes from the president of the university, it gets deleted right away.

2. Emails from management that go out to everybody. Those get deleted, usually, without being read. If it's important, they'll cover it in a staff meeting.

3.  Emails from management that go out to my unit. I'll glance over them.

4. Orders from doctors that say things like "be sure patient is fed dinner" or "turn Q2 hours." Well, DUH.

5. Saline locks that don't work on patients with multiple saline locks. I'll take them out and may or may not start a new one, provided that person has at least one other working IV.

6. KVO orders that don't conform to unit policy. I'll run your IV at 5cc/hour; I may or may not get around to rewriting the order that the doc placed for "KVO fluids." (In my head is the Grecian chorus of They Ought To Know How To Order It By Now.)

7. No orders for Tylenol when the docs have already ordered Norco. They're cool about me stepping a patient down.

8. Patients not getting turned or fed appropriately. This raises my hackles.

9. OT or PT skiving off a patient who they feel is too much trouble. In truth, I only have one occupational therapist that I have to watch closely; he looks for reasons to shorten his patient list. Dude, "patient already up in chair" does not mean you don't have to see them. The PTs and OTs where I work are spectacular. Except for that one dude.

10. Not breathing. That will get me full-on, hair-on-fire, running down the hall, giving a shit.

And I will have time to care, because I have learned how not to, for lesser stuff.

This is not Thug Kitchen.

However, I have a roll recipe for your motherfuckers that you are gonna love.

This is what I bring to every holiday gathering, and have brought since forever. It's a soft, white, not-too-sweet, not-too-salty, buttery bread that you can make into loaves, or into rolls, or into a braid. It is incredibly easy, even if you've never made bread before. It's also high in fat, totally devoid of nutritional value, and should therefore be eaten only once or twice a year.

Check it out: you will need. . .

one package of regular yeast, or quick-rise/bread-machine yeast, or a cake of yeast, if you roll that way. (For newbies: these packets come in threes in the US. You will need only one. It's about two US teaspoons of yeast.)

two and one-half cups (590 ml) of lukewarm milk. I use whole milk and zap it in the microwave for a minute, just to get the chill off.

one tablespoon (~15 grams) white sugar

one teaspoon (eyeball it) salt

one stick (half a cup, or 4 ounces, or 120 ml) of unsalted (very important!!) butter, melted and cooled slightly. (Salted butter will make the dough both too salty and make it brown unevenly.)

Mix all that stuff up. It'll make a nasty, semi-lumpy, unpromising mess.

Now stir in, about a cup at a time. . .

six (more or less) cups (~150 grams per cup) of plain white all-porpoise flour (not bread or cake or semolina flour)

. . . until you get a sort of sticky, shreddy dough.

Now dump some flour onto a clean surface. It doesn't matter if it's a bread board or a counter or what, as long as it's clean.

Begin to knead. If you've never kneaded bread before, this is a treat: the dough is such that it's not hard to manipulate, and you'll know when it's done by a foolproof method I'll lay on you in a minute.

To knead, take your lump of unpromising flour-goop in the middle of your floured surface. Grab the top edge and bring it toward you. Using the heels of your hands, shove the top edge gently into the middle of the lump. Give the whole shebang a quarter-turn and repeat.

It's not hard, I promise. The trick is to stretch, rather than tear, and tuck, rather than hammer, the dough. Although you really can't go wrong. Add more flour if you need to; it's really hard to fuck up.

The dough has been kneaded enough when it's smooth, relatively elastic, no longer lumpy, and --here's the secret trick-- no longer sticks to the surface, even without extra flour.

Now. Take that dough, butter it well all over (I soften a lump of butter in my hands) and stick it into a buttered bowl. Cover it with a damp dishtowel and stick it in a warm, out-of-the-way place, like the top of the fridge, and forget about it for an hour or so (less if you're using rapid-rise yeast).

Make a mental note of the volume of the dough when you pop it into the bowl, so you'll know when it's roughly doubled in size. When it's at that point, put it back on to your clean surface and shape it into whatever form you like. I make two-bite rolls, about an ounce to an ounce and a half each, and I think I got three dozen? today.

Once you've shaped your dough, stuff it into whatever container you'll bake it in. Strangely, butter will not work for greasing your baking pan. Use solid vegetable shortening instead, okay? Throw your damp towel back over the container(s) and stick it/them back into that warm place you used earlier.

Nota bene for first-time bakers: give your dough some room. You want it to be able to grow and expand and breathe, so use a pan a smidge bigger, or leave a bit more space than you'd expect between pieces of dough. Crowded dough can't rise properly and will make heavy, unhappy rolls that don't fulfill their potential.

Allow that shit to rise until it's doubled in size again. The beauty of this step is this: if you want to take a long nap, like I did today, you can leave the dough in a relatively-cool place to slow its rising. Hell, you could even stick it in the fridge overnight! The possibilities are endless. You do you.

When the dough is nice and puffy, preheat your oven to 425F/220C/gas mark7. If you're making rolls, they'll bake for about 20 minutes. If you're doing a loaf, you might want to turn the oven down to, say, 400F, and give it forty minutes or so.

The bread/rolls/carbohydrate portrait of Nathan Fillion is/are done when they're that golden brown that you only see on TV commercials about bread, and when it/they smell done. At that point, remove your product from the oven and turn it out onto a cooling rack. This is important. No cooling rack = sad soggy bread and disappointed eaters.

Americans love these. Canadians love these. Indians and Filipinos love these. Mexican-Americans from Laredo practically fucking riot over these rolls, since they're very close, apparently, to something served in the Laredo school system in the 1970's. Italians love these, but only for dessert. Nigerians love them, as do all the Egyptians and Lebanese and Moroccan people I've tried them on. I have yet, in short, to meet a single person who does not like these rolls. Even skinny white girls like them.

Starch: the Universal language of Peace. Do your part for understanding and tolerance today!

This was my week:

On Monday, my Sonicare toothbrush bit the dust. I'd been limping it along for months, and it finally coded and couldn't be revived.

Today, I had a decision to make: I had money in the budget either for a new Sonicare or a bottle of Laphroiag.

I chose Scotch. Oral care, I am not up in you right now.

And this is why:

On Tuesday, I was minding my own business when I saw a coworker hurpling cheerfully down the hall with what looked like a liter suction container full of bile. I shook my head and blinked twice, and damned if it wasn't a liter suction container full of bile.

Now, normally when one is faced with a quart or more of straight-up digestive fluid that has to be removed from, say, a patient's room, one gets a bottle of this nifty fluid-solidifying stuff and takes it in to the room where the straight-up digestive fluid is. One then dumps the solidifying stuff into the container of SUDF, waits until it solidifies, and tosses it into a biohazard bag.

One does not bop down the hall, hugging the still-liquid, suctioned-out contents of a stranger's stomach.

So I stopped the coworker, and took her into the storage room, and grabbed a bottle of solidifying stuff. And then told her how to handle the liter of green corrosive goo, and what to wipe down, and where to throw it all away.

And she argued with me. She wanted to take it into the nurses' breakroom and deal with it there, because you can't deal with that stuff at the sink in the clean utility room. She argued, and continued arguing, until my hero the unit secretary came in and laid down the law.

Wednesday was a blur. I think it had something to do with more than one bottle of wine, consumed such that I maintained a happy glow throughout vacuuming and napping and cooking dinner. I know there was some Doctor Who involved. (Does anybody else get a creepy vibe from Danny Pink? I sure do.)

Today that same coworker, who is a nurse (well, a nurse who hasn't been a nurse in, like, twenty years) but who has a non-nursing job, approached me with a sunny smile. Here is what she said, verbatim, with no prelude:

"As soon as the car arrives, they can go to rehab!"

What car? I asked. And who, and where, and how?

Turns out she was talking about a patient she'd been rounding on and case-managing for *for a week.*

Dude has a dense hemiplegia and is globally aphasic. He's also incontinent, has no truncal control, and requires frequent suctioning. He's a max assist with two people to sit edge of bed and can't tolerate an hour in a geri-chair.

And she wanted to send him to a rehab four hours away in the family car, with only his wife and son (no suction, no help) to watch him.

And she argued when I said we needed an ambulance.

Unfortunately, the Hero Unit Secretary wasn't working today. I was forced to say, "You are out of your effing MIND" before she would stop arguing and call the ambulance company.

Why is bile green, anyhow? What, chemically, causes that to happen? I never learned that in school.

Anyway, tonight it's Scotch and muscle relaxants (don't try this at home, kids!) because I also threw my back out this week, and then bed. I'm hoping I don't get awakened by Playful Mongo at some ungodly hour of the morning.

We need our own goddamned poster.

Recently, the unit I work in won an award. It was one of those not-Press-Ganey awards; the kind of award that has to do with things that are nursing quality indicators. You know, the "you haven't had a central-line infection in two years; here's a cookie" kind, but bigger.

Much bigger.

And it was nurse-driven, nurse-implemented, and exacting. And national. So, kind of a big deal.

During the hootenanny surrounding the award, we were shown a slide of everybody (so said the CEO of the hospital) who'd had a hand in making Such A Great Thing possible.

There, front and center, was the CEO. Next to him was the director of nursing operations, a man who's been actively obstructionist and slashed staffing and resources, and who has visited our unit maaaaybe three times in as many years. Next to him was a woman I didn't recognize but who, I was told, was instrumental in something statistical.

Arranged behind those people were dozens--maybe as many as a hundred?--people, all in varying degrees of business attire.

No scrubs.

Not one nurse.

Not. One.

Especially not one from the unit, the unit I work on with some of the best nurses I've ever worked with, that won the award.

So, I'm thinking we need our own. Goddamned. Poster.

Yeah.

So, finally, my patient died.

Once in a very long while you get somebody under your hands who ought to have been let go months before.

We had somebody like that the other month: multiple surgeries for a brain tumor that was not going to go away (grade IV glioblastoma), multiple rounds of chemo and radiation, and in the middle of all of that, a surgery for an abscess that led to wound-vac sponges all down one side of the poor sot's body.

The spouse didn't want to let them go. The mother didn't want to let them go. The brother didn't particularly say one way or the other.

Ever smell a person who is, quite literally, rotting from the inside out? It's not fun.

Because, see, a glioblastoma (that's the most common form of malignant brain tumor and is, thankfully, still very rare) slowly takes away your ability to think, speak, walk, control your bodily functions. Then it starts to take away your ability to breathe. And your brain's ability to control things like its temperature and blood pressure. And, eventually, it will invade the areas of your brain that register pain. At that point, you will be in pain all the time every day forever for as long as you last.

Yeah.

It sucked. For us, as well as for the patient.

The only reason I can think of that this person was kept alive was that they had a significant pension that would've ended upon their death.

So their spouse, the person who was supposed to keep their best interests in mind, kept them alive for two entire months in order to get money.

I very rarely get *existentially* angry at work. I get angry at the administration, or at Manglement's bad decisions. There's one house supervisor in particular that I suspect was put on this earth to make sure my lungs get a workout every three weeks or so. But I generally don't get to the point that I go in search of things to punch. Ask my coworkers: they'll tell you that I'm the sweetest-tempered, most cheerful, helpful person they work with.

Seriously. And I haven't drugged a one of 'em.

Anyway. When this person came to us (and I'm carefully not using gendered terms here, because it would probably surprise you), they were reasonably compos mentis. By "reasonably" I mean that they knew their name, they knew where they were and why, and they'd mostly follow simple commands.

Within two weeks, the leftover tumor in their brain had doubled in size. Glios do that. The things that cancer loves are space and glucose and a good blood supply, and the brain has all three. What makes glioblastoma particularly nasty is that it's a tumor of the structural cells of the brain, so it sends out little undetectable filaments all around the original site. You can never get rid of it entirely.

But you can resect, and irradiate, and chemotherapize, and that's what happened. And when the patient developed an abscess on the right side of the abdomen, it didn't heal. It kept filling up with pus and tissue kept dying, because all the things we were doing to kill their brain tumor kept the rest of their body from fixing itself.

So at the end of the day we had a patient who was not a DNR, who was not on palliative care, who could not have a feeding tube inserted into their stomach courtesy of the twenty-five centimeter wide wound in their belly that would not heal; who had been intubated and extubated and who, finally, had to be four-point restrained because the tumor had hit the pain centers in their brain.

The family didn't want continuous pain control because they felt the patient was still able to communicate. This, when the MRI showed that three-quarters of this person's brain was tumor.

All of this made me vent uncontrollably to my buddy Mark, the neurointensivist. It made me vent to Ginny The Inappropriate Chaplain, and to my coworkers, and once to the patient's spouse (in a controlled and therapeutic manner). Ethics came in, ethics bowed out, case management was crushed under the wheels of the Sustain Life At All Costs juggernaut, and we all started to have a bit of twitchy post-traumatic stress.

Finally we discharged the patient to an acute-care, long-term setting. And there they died, after multiple codes, a day ago.

.*** *** *** *** ***    *** *** *** *** ***   *** *** *** *** ***

What nobody tells you about nursing is how cases like this can haunt you. I've dreamed about that poor person at least once a week for two months, now; the news that they'd died has turned the nightmares into milder anxiety dreams.

There's something about changing and bathing and turning a person who begs to be left alone to die that scars you. I am supposed to be alleviating pain, not causing it. I have a personal rule to touch every patient in my care at least once a shift *without gloves,* no matter what they've got, in a way that doesn't cause pain. Because, frankly, a lot of people in the hospital don't get touched without at least discomfort, and that fucks a body up.

But what do you do when there's nothing you *can* do? We were barred from starting a morphine drip or giving IV pain meds. The poor patient's brain was working against them. Everything hurt. Everything was futile.

And through most of it, the patient asked, then begged, to be allowed to go home with Dad. Dad had been dead for some fifty years, but showed up at the bedside on a daily basis, trying to get our patient to go with him.

I do not often have to get angry about injustice and cruelty. I don't often cry over my patients any more.

This one, I'll do both.

An excellent op-ed from a Minion in lovely EnZedd. . .

This is what we all should be worried about.

Conclusions.**

Thanks to the Virally-Knowledgable Minion who pointed out that I made an error by referring to Ebola as EBV. That is Epstein-Barr virus, not Ebola. As you can see from her/his comment below, Ebola is referred to as EVD or EHF. That error's now been fixed. Thanks very much for that correction, VKM! I knew there was something off about my abbreviation, but I couldn't think of what and (of course) didn't bother to check. Der.

The whole EbolaPocalypse is wearing on everybody's nerves.

I have friends who work in Dallas. A couple work at Presbyterian there. And holy shit, are things bad there. Last I heard, surgeries had been cancelled and the ED was turning away ambulances. I don't know what's happened in the last twenty-four hours, but that's what I heard on Monday.

Here's what's happened at the hospital so far, for those of you who have either been under a rock, across the uncharted oceans, or simply hiding under the covers:

A symptomatic patient, Thomas Eric Duncan, showed up at Texas Health Presbyterian Hospital (Presby) in late September. He had a fever and abdominal cramps, and told the intake nurse that he'd come from Liberia, but was sent home with antibiotics. He was later readmitted with bloody diarrhea and projectile vomiting and put in isolation.

At first, Presby officials said that he had lied on his intake form; that he'd said he hadn't been in Liberia. That turned out not to be true.

Then, Presby officials said that the intake nurse had not communicated Mr. Duncan's travel history to anybody else on the health care team. That story stood for a couple of days until some bright person pointed out that travel history is right there in the electronic medical record for anybody to see, and obviously warn't nobody checkin' nohow.

Then they said that he'd been isolated immediately. That story stood until today, when a nurse at the Presby ER said no, he'd actually (during his second admission) been sitting in a common area for as long as seven hours.

Then he died. But not until after getting dialysis and being intubated, both of which the WHO says won't do shit to prolong life and *will* do a lot to spread aerosolized virus or increase the risk of bodily fluid exposure.

And, as it turns out, the nurses at Presby who cared for him spent two days in standard isolation gear (flimsy plastic gown to the knee, goggles and mask if you're lucky, gloves, booties if you can scrounge some up) and also had other patient assignments during the time that they cared for him.

Of course, the CDC said the minute the first nurse came down with the virus, that there must've been a breach in isolation protocol on her part.

But then it turned out that holy crap, the hospital had waited until final results of viral testing from the CDC had come back to get their workers into proper gear and limit their patient-care assignments. The preliminary positives apparently weren't enough, combined with the poor man's travel history, to alarm the administration. So it wasn't so much a breach of protocol on the RNs part as it was sending a nurse into a forest fire with a bladder full of piss and no backup. Nurses were cobbling together whatever they could in an attempt to replicate proper isolation gear. They were borrowing from other departments and MacGyvering stuff for two days.

Now a *second* nurse has come down with Ebola, and she travelled from Dallas to Cleveland and back in a state of as-yet-undetermined contagiousness. I got nothin' to say about that except holy shit what a . . . .wait, no. I can't judge. Because if she'd been told she wasn't contagious without symptoms, and her movements weren't restricted, then. . . .? I don't know what to think about this part of the story, because, if it's like the rest of the story, there's more and different facts to come.

So. What conclusions can we draw from this?

Conclusion the first: The first reaction on the part of everydamnbody has been to blame the nurses. From the first inkling that Mr. Duncan's diagnosis was missed to the news that a second nurse was infected, the director of the CDC and the administration of Presbyterian Dallas have pointed to the RNs as the weak links in a chain.

I'm sorry, guys (because they are all, frankly, guys, and NOT nurses): in order for a fuckup of this magnitude to happen, a number of links in your chain of failsafes have to break. It doesn't matter if you have a "health care team" if members of that team only see each other in the bathroom and when they're punching in. People have to communicate, yes, but they have to be given the opportunity to communicate, which means proper staffing levels and backup when it's needed.

For one, nobody noticed the travel history when it was submitted the first time. That means that the ER staff was either understaffed or slammed, or both, and/or that the intake nurse never got a chance to communicate face-to-face with the rest of "her team." So you had a team in name only, screenings in name only, and procedures in name only.

Conclusion the second: Whoever had the job of preparing the Dallas area (and my area, come to that) as a whole for Ebola did a piss-poor job. The nurses I work with have been talking about the probability of caring for an EVD-infected patient since July, when it became apparent that the outbreak was getting out of hand overseas. ER nurses I work with have been wondering what, exactly, to do for protective gear and isolation facilities, since not a lot of hospitals have more than curtained cubicles in the E R. We do not even have an international airport in this area. What must it have been like in the breakrooms in Dallas?

To give you some idea, one of my besties works at a large academic medical facility in the Dallas area. It's the sort of place you take gunshot victims or people who've been hit with a chemical contaminant or folks who've been bitten in half by a llama. She told me yesterday that her facility's prep for Ebola (and keep in mind that this place has a busy ER in a highly international area) has consisted of one streaming video and a lot of assurances from administration that they're working as fast as they can on a protocol.

Guess what, Administrators of the World? The CDC and WHO and MSF already have protocols in place. All you have to do is devote the time to learning them and the money to proper materials.

Conclusion the third: If you are a nurse anywhere in Texas, you are screwed to the wall. You might wonder why the nurses at Presby who spoke out are being protected by the largest nursing union in the US. It's because you're told, as a nurse, that if you say anything negative about something that happens at your facility, you will be fired. Period, full stop, do not pass go.

A couple of years ago, somebody got mugged in our parking garage. A nurse I worked with put it up on social media that she no longer felt safe in that garage, and wondered why we didn't have better lighting. Two weeks later, she was gone. Fired. For a med error that had happened months before, and for which she had received no prior counseling. All totally fine and legal in Texas, kids.

Imagine what it must be like for the Presby nurses who were sent home, day after day, to their families and dogs and cats and knew what they'd been in contact with. They can't say boo for fear of being fired and placed on the informal blacklist that exists in this state.

Conclusion the fourth: Texas nurses need a union. Yes, unions tend toward the bloated and bureaucratic. Yes, unions sometimes do more harm than good. Yes, yes, yes, I know all the arguments.

But right now? The nurses in this state are being hung out to dry by their bosses, and nobody's getting upset, except in a very low-key, please-don't-fire-me kind of way.

If I had to care for a patient with Ebola tomorrow, I would have no appropriate protective gear. I would also have no way to refuse the assignment (not that I would; I'd pull up my big-girl panties and pray like hell). I would have no way to protest that I was taking care of the patient without proper safeguards in place. The most I could do would be fill out an incident report after the fact and hope that it got to somebody who gave a good goddamn.

They say you can't be fired for calling safe harbor here, but I've seen it happen many times. And there's no way to register that you're nursing under duress. None.

Unions add a little muscle to the arguments that nurses make. It would be nice, for once, not to feel like I'm stepping out on a tightrope over a windy canyon full of hungry alligators, naked, with a bad case of chiggers on my ankles. I would like some fucking backup, please; a little bit of muscle that I could use to enforce the staffing ratios and protocols that my administrators brag about on promotional materials.

I have no problem at all taking care of somebody with Ebola. I don't think it's necessarily the best idea to have such a disseminated system of care; perhaps we should look into certain hospitals specializing the way Emory and Nebraska do.

However, if it comes down to it, I am more than happy to do it. I did not sign up for this job because I thought it would be glamorous or easy.

All I want is a little consideration, a little preparation, and a smidgen of concern for my safety. From what I've seen of how things have been handled up to this point, I doubt I'd get any of that.

**It occurs to me that this is the most bolded, italicized, and screeching post ever posted in the posting history of this here blog. Sorry 'bout that, y'all.

In Which Jo Has Doubts About Her Floor.

WARNING: THIS IS A RENOVATION, NON-NURSING POST. IF YOU DON'T LIKE HEARING ABOUT CONSTRUCTION OR DEMO, GO ELSEWHERE.

Some of you longer-term minions might remember when I bought Casa DogHair and renovated the bathroom. The shortest version, for those of you who haven't sobered up yet, is this:

The people who owned CDH before me were both of some size. They were also not good with maintenance. This led to the bathroom being entirely rotted out in vital areas, which in turn led to Then Boyfriend and I redoing it.

I should mention here that Then Boyfriend had a weird work schedule and I was working all the time, so I had very little input into the construction. I helped with demo, tiled the floor, and that was it.

So when I stepped through the bathroom floor a few months ago, it came as a bit of a surprise. TB had told me he knew what he was doing; in fact, I knew he had worked construction in the past. So I trusted that he knew how to install a bathroom floor, make the shower water-tight, all that stuff.

Instead, what I found was un-taped cement board in the shower that had been waterproofed on the wrong side, weird joints that weren't water-tight, and a floor that. . . .well.

Normally when one installs a tile floor, one lays a sheet of plywood down and fastens it to the joists. This provides a stable surface for what's to come after. Then, one lays a quarter-inch-thick layer of thinset mortar down and uses that to bed cement board. It's important, when you're laying tile, to have a deflection-free (no bouncing), solid (won't shift laterally), independent (not screwed to the joists) surface for the whole shebang. Plywood screwed to joists is layer one. Mortar-bedded cement board, screwed to the plywood bur not to the joists, is layer two. Properly done, the resulting monolithic surface should last a lifetime.

He had laid half-inch cement board over a vapor barrier and nailed it to the joists. There is so, so much wrong with this that I can't even. I had to liberate a fair two gallons of water from under the floor, atop the vapor barrier, where the weird seams had leaked.

Here's the deal: demo of a properly-installed tile floor of this size ought to take a solid day or day and a half of work. It took me forty-five minutes, and I didn't even break a sweat.

After I demo'ed the floor, I began to get the willies about the shower, so I started peeling tile off of the walls with my bare hands, no joke no kidding, and the whole project got exponentially bigger in about ten minutes. Shower tile should not be removable with one's bare hands. 

But it was and it was and here we are, with a plywood floor barely tacked down and shower walls covered in plastic.

Which brings me to the floor. All of the preparation for laying tile will result in a floor that's at least 3/4 inch higher than the floor outside the bathroom door.

The Boyfiend, who actually *does* know how to do this, has done it before, and is doing it right this time, floated the idea of lowering the joists under the bathroom to give us sufficient clearance to have a seamless transition between the wood floors outside the bathroom and the future tile within. Over dinner last night, he and his brother The Psychopath debated the various ways this could be done, with The Psychopath insisting in a querulous voice that we'd have to pull the tub (find me four strong and patient men and a space warp, dear; that tub is wider than the doorway) and jack up various bits and bobs of the foundation.

Boyfiend insists this is not a big deal. I have my doubts about that. As I told him last night, when I hear a man say "It's no big deal; it'll work out fine" I know that I'm gonna need three hundred bucks and a course of antibiotics, stat.

So I started thinking of alternatives and came up with a roll of rubber flooring in a coin pattern. It's exactly the same thing that Daniel used over at Manhattan Nest a gazillion years ago. It's cheap, totally waterproof, and there will be no seams.

And it's thin enough that we won't have to lower any joists or do any other major structural work.

Boyfiend is still snoring away, but I plan to hit him with this idea once he's up and has had some coffee. And we shall see.

Meh.

I've decided it's not the heat here in Central Texas that bothers me; it's how long it lasts. I could easily handle a worse summer than we've had here--only a couple of days over 100 degrees!--if it just ended sooner.

Something about the constant bright sunlight and the lows in the 80's really wears me down.

So does work. Work is wearing me the hell down, People.

I almost had to call in the Ethics Peeps this week. Mama is dying of a nasty sort of metastatic cancer that's hit her brain, liver, spine, and various other bits of important equipment. She has a midline incision from her breastbone on down that won't heal, a couple of cracked ribs from a previous code, 3+ edema every-damn-where, she's breathing too fast and her heart's wearing out, and she's seizing constantly and has been for about the last three weeks. Oh, and she has a galloping infection under her scalp, where a bone flap was taken out when some other neuro guys somewhere else resected a tumor in her brain. That's the least of her problems, frankly.

We've spent the last two weeks trying to convince Son that perhaps Mama should, when Jesus calls, actually pick up the phone. She was a full code this entire time. That means, for you non-medical people, that if her heart or breathing had stopped, we would've gone into Super Nurse Grey's Anatomy Mode and tried our best to bring her back. (Well, not really. I would've walked slowly to that particular code.)

The trouble is that, when you're trying to save people who are that sick, you end up torturing them.

Even the best, most well-executed code has only about a three-in-ten chance of bringing the patient back. And by "bringing the patient back," I don't mean they walk out of the hospital. I mean we stabilize them enough to get them into the CCU, where they'll be intubated and sedated and have drugs pumped into them that will keep their blood pressure up while causing their intestines to slough off and their hands and feet to turn black and gangrenous and we'll put 'em on external continuous dialysis and they'll have tubes coming out of every orifice. . . .

It's ugly. In twelve years, I have heard of--not actually seen--one patient leave the hospital under his own power after a code. Part of that has to do with the people we code: not many, because we're big on comfort care and being rational. Part of it has to do with the population we serve: once your brain goes bad, there's not much point in keeping your heart beating, and no real good way to do it.

Anyway. Mama and I had gotten well-acquaint (or as well-acquaint as you can with somebody who twitches and moans) and I was looking forward to the probability that I would be breaking more ribs, causing her belly wound to come apart and her guts spill everywhere, and generally doing something I didn't want to do. We actually had a call in to the ethics committee about Mama, when a doc I had not met before came sailing in like a white knight and saved the fucking day.

The dude is new to the hospitalist program. I met him for the first time after he'd been straightforward and a tiny bit brutal with Son about Mama's chances. I could've hugged him. Instead, I called Ethics back and told 'em to stand down.

Mama is now a DNR. She's not on palliative care yet, but I'm happy just being able to not have to consider coding her.

Sometimes things work out okay, relatively speaking.

What I thought/What I said

The interviewer asked, "What's making you want to leave your current job?"

I'm tired of watching my coworkers coming in, looking defeated.

I haven't had a sit-down lunch in six weeks. One of my coworkers weaned her baby early because she couldn't get anybody to relieve her so she could pump breastmilk.

Our acuity increased at the same time our director cut our staff, so there are delays in care that I find unacceptable.

We've been rebranded a "step-down" unit, so none of us will get critical-care raises or credit, but we're still taking CCU patients. We still float to the CCUs.

The attitude of the administration to our unit is "do more with less; you're nothing but big whiners." When the director brushed off legitimate concerns with the response that we were "jibber-jabbering," I died a little.

I showed up at six yesterday and started working immediately, because there were three admissions at once and none of the resources or help we were promised were available.

We're having falls and bad patient outcomes as a result of short-staffing, and we're getting disciplined for them.

I can't get a damn MRI statted because I can't find somebody who can monitor a patient on a drip in the tube.

Our manager refuses to back us up when things get dangerous.

The doctors I work with recognize the problem, as do the nurses in other departments, but still nothing is done.

I'm exhausted from not eating, not peeing, not taking a day off, and the rest of my life is suffering.

Although we stand in solidarity as a unit, the director is telling his bosses that there are a few bad apples spoiling the whole bunch, and that getting rid of them would fix the problems.

Which is why, I guess, that all but one of us are looking for new jobs. And that one person is reconsidering.

Because when you have a wife who's on palliative chemotherapy, even a potential gap in insurance coverage beats working here.

The training and education we were promised hasn't materialized.

We're used as a dumping ground for VIPs, when actual sick patients are pushed to other, even more crowded units.

We've won awards and have certifications out the wazoo, but the things that made those certifications and awards are gone now.
Yet we're still expected to make do, somehow.

And if we stand firm on staffing grids and patient safety, we're written up and our patients are moved elsewhere, to make room for the aforementioned VIPs.

I dread coming to work every day. The only thing that makes it possible for me to sleep the night before a shift is Benadryl. And bourbon.

I'm terrified that something horrible will happen, that a patient will die or be injured, because we don't have enough staff.

That almost happened last week. A patient with a sudden neurological decline had to be transported to the operating theater by two doctors, because we were short nurses to monitor him.

I miss the days when I could leave work and not ruminate on possible mistakes or oversights I might've made.

I miss being a nurse rather than a combination unit secretary, patient care aide, phlebotomist, janitor, social worker, and engineer.

Broken equipment stays broken for months.

Our infection rates are up and our patient satisfaction scores are down. We've been told we can be disciplined for both.

I loved this job for years, and fought really hard to keep just this thing from happening. I'm incredibly proud of the work that we do and the outcomes we've had in the past. We've done it all together, as a group of very stubborn nurses, in spite of--not because of--our managers and administrators. I'm tired now, and I want to back off and not fight every single day for basic safety and resources.

"Well, I've been doing the same thing for more than a decade, and I felt like it was time to branch out and broaden my skill base."

I finally got the hog skull clean and got another Cancer Buddy.

Our network reaches around the world. It is above the law, beyond the government, and untouchable by the church. No power in the 'Verse can stop us.

So I was talking (ie, emailing) to my newest Cancer Bud tonight, and I twigged hard on something she said to me: that her dread of chemo was "just me feeling sorry for myself." It kinda set me off.

Back when I was recovering from having my mouth resected, I posted something in which I vented about feeling sick, and tired, and not knowing what was going to happen, and being in pain. And a very well-meaning commenter pointed out that I should suck it up and deal, because after all, my tumor was minor and I was going to live.

Which was true. It was also about the wrongest thing, I've since learned, that you could say to anybody with cancer.

Instead, you should encourage them to feel like shit about their diagnosis, because their diagnosis is shit.

It doesn't matter how "easy" a course a person with cancer has, or how "minor" their tumor is: from the moment you're declared free of evidence of disease, that is the best you can hope for, ever. I will never be cured. I will always, I hope, be NED (no evidence of disease).

Every dentist's appointment, every visit with my surgeon, every MRI or CT or plain old doctor-poking-at-my-neck exam is fraught now. I used to enjoy getting my teeth cleaned. Now I wonder if there's something that I've missed in the week leading up to it, and wonder if there's something that *they* missed in the week after. Those feelings do go away, of course, but they ramp back up in the month or week or day before another appointment.

Even something as simple as biting my tongue in my sleep--and I'm a terrible tongue-chewer--makes me paranoid to the point of spending dozens of minutes in front of the mirror, yanking my own tongue back and forth and peering at it.

So, yeah. This fall will be four years. After five, I'm good until twenty, given the statistics, unless more people get my sort of cancer and the statistics change.

And I am still allowed to feel sorry for myself if I wish, because that's how you integrate something like this into your life.

As I told New Cancer Buddy, eventually some ridiculousness about your situation will make you see the humor, however dark, that's there. You'll stop your pity-party and get on with things. . .but that pity-party, that grieving for the way things were before you had to put in a prosthesis or before you lost your nipples or your thyroid, is important. It helps you reconcile the way things used to be with the way they'll be from here on out.

Being brave--or being expected to be brave--is a horrible burden to place on somebody who's going through this, no matter how minor or low-grade. Everybody needs the freedom to flip the fuck out, and people with cancer are often denied it--"brave" is seen as the only truly acceptable way to deal with the diagnosis.

Years ago, there was an article in the "Onion" headlined something like "Local Man Fails to Put Up Brave Fight In Face of Cancer Diagnosis." That's how ingrained the Brave Thing is.

So, fuck Brave. I may be deeply disappointing Sara Bareilles, but I say flip out like you need to flip out. There's always time later to pick up the pieces.

There's a hog skull in my kitchen, next to the stove.

It's soaking in three-percent peroxide as we speak.

I spent the early morning taking it out of its enzyme bath, scraping bristles and cartilage, miraculously rehydrated, off its surface. Then I soaked it all day in Dawn dishwashing detergent and warm water, to see if it needed degreasing. It didn't. So now it's soaking, upside down and looking rather ghastly, in a sixteen-quart Sterilite container with lid, on special at Target for $2.59.

It has two unerupted molars and inch-and-a-half long tusks that curve out and up, leading me to believe that this was a 14-month-old (or thereabouts) male hog. I know it's male; I do not know its exact age because it was feral.

Boyfiend owns a parcel of land waaaay to the northwest of here, where towns with names like Uz now exist only in old folks' memories and brackish wells. If you go way up past Yeehawton and past Joe and west of Era, you'll find his ancestral lands. Back in the day, the communities there were so insular that the German-language newspaper was still published during the Great War. Pretty much everybody is related to pretty much everybody else. There are tiny winding roads that cut through the llano and run past tumbledown stone houses, and those roads have the names of his grandfathers and uncles.

And, of course, there are hogs.

Feral hogs are nasty. They turn arable land into wallows, kill young trees and sometimes young livestock, foul water and trample native species into the mud, and can and will kill a man with little notice. If you were to go mushroom hunting along the banks of the Red River on the Texas side, you'd hear them rustling through the underbrush in snorting groups, though you'd never see one. The male grows, as he ages, a three-inch thick curtain of cartilage from his neck to his hips that covers his vital organs. You can't shoot through it with a .45 (though a .308 will make a dent) and his skull is too thick to penetrate. An adult male feral hog can weigh hundreds of pounds, move at 30 mph (48 kph) in short bursts, and has no known predators besides man. Add razor-sharp tusks as long as your hand, a voracious appetite, and a harem of sows that can birth a dozen piglets as early as six months old, and you have a capital-P Problem.

As fierce as hogs are, a group of hungry coyotes can bring down a young one, and that's what happened. Boyfiend and his brother were out on their land several months ago and found the carcass of a young hog, mostly eaten. Boyfiend thoughtfully marked the spot and returned this week, triumphantly bearing a skull that nature and nature's creatures had rendered (mostly) clean. He handed it over to me with his hand wrapped in a plastic bag. I took it and exclaimed and danced around and then put it in to soak for two days in a solution of Biz and warm water.

Even when they're mostly clean, soaking skulls smell pretty bad. Scraping the thing with various sizes and shapes of scalpels and utility knives was disturbing as well. Cartilage is tough until its soaked, and then it gets this weird. . .gelatinous texture. Luckily it's easy to tell cut-away-able stuff from bone.

I think the skull will turn out pretty nice (purty naas) once it's done. I won't be able to get all the weathering and fungus marks off of it, but it'll at least be clean, mostly white, and disease- and pathogen-free. I'll let it sit outside in a place that gets sun all day yet is protected from Mongo and the cats (ie, the shed roof) and we'll see how it looks in August. About that time I'll have figured out where to put it in the house, so I can turn it over and admire the teeth, and trace the curves of the orbits and the dents where skull muscles attach.

It was a good finish to a week that saw me getting punched repeatedly in the tits.

Contrary to how I might sound here,

I am rarely in a mood to authentically injure somebody.

Yesterday was different.

We've had staffing changes and new responsibilities added and a whole bunch of other bidness I won't go into; suffice to say that things have been tense and difficult for the last couple of weeks.

It was 1430. I'd spent three hours trying to keep an insufficiently-sedated patient from crawling out of an MRI tube, then gotten gut-punched. People on ventilators, even if they're sedated, can come up with a surprising amount of will and strength and coordination.

I wanted a cup of coffee. Correction: I was dying for a cup of coffee. The floor manager had recently cleaned out our station, preparatory to The Great And Terrible Joint Commission coming for a visit. I figured, since I keep my coffee pods in a cabinet that's designated for personal effects, that they wouldn't go anywhere.

Our floor manager is great. She's skilled, hard-working, empathetic, and determined. We're very lucky to have her. I admire her a lot.

But she moved my coffee. I opened up the cabinet, saw that it was gleaming, clean, and empty, and immediately said, "I will shank the bitch who moved my coffee."

After looking for the coffee pods for fifteen minutes, I gave up and had a cup of the elderly, stewed stuff in the breakroom. (Is there some physical law that prevents breakroom coffee from ever being fresh?)

Note to everybody, everywhere: You don't just move a woman's coffee without warning. Doing so might invoke disciplinary action, up to and including termination. With extreme, undercaffeinated prejudice.