I have all the time in the world.

It was not an easy day.

We were short-staffed, and I had a patient on palliative care, whose family needed my attention much more than the patient did. Let's face it: when their urine output drops below 20 ccs an hour (those Foleys are placed for comfort care, but it's more the nurses' comfort than the patient's--we can tell how close to dying you are by how well your kidneys are working) there's not much we can do. We turn and do a partial bath every two hours and wipe their faces and clean their mouths, but it's all for the family. The person who's dying has long since ceased to care.

So I had this palliative care patient, and a patient on a titrated drip, and a walkie-talkie woman, ninety-fucking-six years old, with a tiny lacunar stroke that didn't affect her at all. The most we were doing was tuning her up; making sure her blood pressure was okay and her electrolytes were within normal limits. We weren't going to try to change her diet or stop her from smoking. At ninety-six, you're running on genetics, and who am I to say you should give up the Parliaments for an extra, horrible year of life? Keep smoking and die at 102.

So I was in a hurry that morning, making sure her breakfast was to her liking. "My husband," she said, "always liked a poached egg every morning."

She hadn't ordered poached eggs. "I can't stand them. Slimy things" she said.

She had an omelette with mushrooms and sausage and cheddar cheese. I remember this exactly because I love that particular omelette. With hash browns and pancakes.

She had toast.

Anyway, I was in a hurry. I was hungry, I wanted my own 200-calorie breakfast, I had to take vitals on the guy who wasn't on palliative care and swab the mouth of the guy who was, and this woman said, "My husband always liked a poached egg every morning."

"I used to get up," she continued, "and make him an egg and toast, and then feed the baby. I didn't have much milk, so I had to give him goat's milk and cereal."

She reached out for the omelette and I cut it up for her. Hurriedly.

I was looking toward the door, wondering why the monitor was going off, when she took a bite of toast. "It was January when we stopped having milk at all," she said, spewing crumbs everywhere. "That wasn't so unusual. You know, cows only used to give milk when they were nursing calves."

I knew that from the Little House books and nodded, distractedly, wondering if the alarm I heard actually meant something or was just artifact.

"In April, the soldiers came and kept us from going out of the neighborhood."

That sent a prickle up the back of my neck. I looked at her, ninety-six years old, two children who came to visit and then had to leave to take care of their work, six grandkids, two great-grandkids. And I did the math and realized that this might be her and my last chance to talk about this.

We are losing them every day, those people who fought a good war, and the people who were caught up in it, or who were targets of it. I will never forget the man I took care of who had crude tattoos memorializing his jumps as a Russian paratrooper on his bicep.

"What was it like?" I asked, "not having any milk?"

She said, "You have more important things to do. People are sick."

I said, "I have all the time in the world."

Worst day, or worst day ever?

So we have this new thing at Sunnydale: the nurses from the neurocritical care unit charge for both the NCCU and an overflow surgical/med-surg/ortho unit on a different floor.

Right now we have our usual nine beds in NCCU and eleven beds on the other floor. (I'll call it "ortho," because it's mostly post-op and pre-op orthopedic cases, but there are important exceptions, one detailed below.) Once the NCCU expands to include epilepsy patients and an epilepsy monitoring unit, we'll have a total of twenty-six rooms to charge: thirteen on each floor, with the possibility of two of those rooms on each floor being double-occupancy. That's thirty patients, give or take.

On two different floors.

Yesterday I got saddled with charging both units. Tiny Dancer and Diamond Bright were on the CCU side, and Bender and Kali were on the ortho side. Thank God for good assignments: ortho was staffed with two experienced nurses, and Tiny Dancer, though she's new, is totally unflappable. She moves through life with her head held high, her posture perfect, and her hands and feet moving at a million miles an hour, if need be.

Halfway through the day I had two critically ill patients on the ortho unit, three different patients who needed blood (no overlap there), a very sick person on the neuro floor, two interns, no nurse aides, and no prospect of lunch. Did I mention that these two units are on different floors? As in, I have to ride the damn elevator to get from one to another?

I did? Okay. Just wanted to make that clear.

At about two o'clock, just as my blood sugar was tanking, I made a major mistake.

We were about to get a patient who was in the middle of a no-kidding psychotic break. His family had found him, two nights ago, wandering naked around the neighborhood, talking about death and God and angels, and had brought him to the ED--from where he'd been discharged and sent home with instructions to present to the psych clinic the next day. The next day he was no better, and was possibly worse, talking about going home to God and taking his kids with him. He still hadn't been able to keep his pants on. This guy was badly off and getting worse.

Obviously, he hadn't taken his meds in about ten days. Part of the problem was that he had had his thyroid and parathyroids removed about a decade ago, and had been well-maintained on replacement therapy until ten days ago, when he stopped taking everything in pill form. His TSH was 15. Because he had no thyroid. And no meds.

So psychiatry, rather than admitting him to one of the medical beds in the psych unit, decided he needed a bed on a med/surg floor. . . and sent him to us.

Suicidal, on an OPC, unwilling to let anyone touch him, combative, hallucinating, unable to settle to reality, on a med/surg floor. With only two nurses, no aide, and eleven patients (I took the eleventh patient, an unstable post-op, because nobody else could).

So, anyway: the mistake. I called the psych doc on call rather than the hospitalist on call, because we didn't have an accepting hospitalist yet. I wanted to ask a couple of questions, like "Is this patient appropriate for a general med/surg floor?" and "Are you sure you don't want to admit him to the psych unit?"

I called the wrong person. I should've called the hospitalist, even though one wasn't yet assigned. This was explained to me at length and in the most insulting, condescending way I have ever encountered, by the psych doc.

Here's how you respond if somebody fucks up: "That patient is going to be admitted under Dr. X's service, so you'd best call Dr. X's on-call for that question." In that situation, I would apologize and get off the horn asap, then call Dr. X's resident.

Here's how the psych doc responded: "I don't think it's appropriate or professional for you to blah blah blah blah wasting my time blah blah blah well you know thyroid storm can cause blah blah blah blah blah blah ad infinitum ad nauseum so very unprofessional of you blah blah blah if you really knew how to care for these patients you would realize blah blah blah. . ."

I finally broke in and said, "You know what? You're right. I was totally unprofessional and inappropriate, and I am so very, very sorry for wasting your time." I then hung up the phone, gently, and will probably get written up anyhow.

All I can go by is what the admissions folks and the computer tell me. You're listed as the admitting doc; nobody's bothered to let anybody else know that you've handed off your patient to a different service. What could've been a thirty-second conversation turned into a five-minute harangue.

Maybe she was having a bad day. I know I was by that point.

My boss walked in to the break room and found me crying tears of rage. She was completely un-fazed and asked me why I was upset. I told her I missed my teenaged flattop and bicycle chain and Doc Martens; that, if I'd had them, I would've gone and curb-stomped that cunt. She didn't even blink.

I love my boss. At that point I flat-out worshipped her.

So, yeah. That was my day. My legs are screaming from running up and down stairs (elevators are slow in our building), I'm incredibly proud of Tiny Dancer and Diamond Bright for handling tricky, delicate people without incident, and I wish I'd had a quart of ice cream last night.

Minor corrections.

It is "welt," not "whelp." A welt is something you get on your skin. A whelp is a newborn puppy. If you tell me your patient gets covered with whelps when they take penicillin, I will be momentarily charmed by that mental image. I might miss what you say next.

It's "stent," not "stint." I don't want you to stint somebody's heart, as that means that you've given that organ less than it deserves. You can stent it, however, in order to improve blood flow and muscular function.

It is pronounced "lairINKS," not "lairNICKS." Likewise, it's NUClear medicine, not NUCUlar medicine. I can forgive G.W. Bush everything except this perversion of pronunciation.

I know that "menstrual" is a difficult word. Men-stroo-al. It requires that you do the difficult "str" move with your mouth. It's not "mensurral" or "mensril" or "mensrahl," however. Men. Strew. Uhl.

(Also, while we're on the subject of things that sound like other things, I am Ms. Miz. Rhymes with "his." That should make it easier.) (If you really have a hard time with "Ms.," might I suggest "The Great And Terrible Jo, Ruler of the Five Kingdoms, Holder of the Shadow Proclamation, Destroyer of Worlds, Boss of All of You" as an alternative?)(You'd have to prostrate--not prostate--yourself.)

(Do I really need to mention that it's not a prostrate gland? I don't know of a single gland that lies down on its face.)

It's really, really important to know the difference between micrograms and milligrams. If you tell me you gave somebody twenty-five milligrams of a drug that's normally dosed in micrograms, I will assume one of two things: either that you're a large animal veterinarian or that you're a dope.

Likewise, the difference between liters and milliliters is kind of important. Please don't chart that you gave five hundred liters of normal saline to a patient intraoperatively, unless you really, truly did have them floating in a small swimming pool.

If I'm giving you report and I tell you that the patient's t-max is thirty-seven-point-two, don't ask me to convert that to Fahrenheit. You have a converter in your charting program, or on your phone, or via Google. (It's 99F.) You're an ICU nurse. Use your converters.

I should probably make it clear here that I don't mean to rag on civilians. If you're not a medical person, I don't expect you how to pronounce words, or spell them, or even use the correct term. Remember that patient I had who reported a fibroid tuna in her uterus?

I will not laugh, smile, or even rub my upper lip if you're a patient or other civilian and you use the wrong word or say it wrong or don't even know what that widget at the bottom of your whatever is called. You're not supposed to. This is specialized terminology, used by people in a specialized field. It saves time and increases accuracy for us, but it's confusing and discouraging for you.

However, if you're a nurse giving me report, or calling me report, or a doctor, or somebody who's paid to know how to express themselves clearly about a given situation in nursing or medicine, I will quirk one eyebrow up slowly if you use the term "whelp" or "stint." And I'll stare at you.

While I imagine your patient covered with puppies.

OMG, y'all. SEATTLE.

Mom's birthday was last week, so I spent last week in Seattle with Beloved Mother, Sainted Father, Beloved Sister, and The Boyfiend. Other participants included Der Alter Jo, her husband, Archie the Mastiff, and A Number of Wild Animals.

Mom and Dad are well, thanks for asking. Dad, after his last tumble-thump, tumble-thump-tumble, has been prescribed a neck brace (to be worn for 90 minutes at a time) and physical therapy three times a week. Mom is still dealing with the occasional Moment when her a-fib gets snarky, but otherwise is okay. Dad has a number of complaints about Seattle and its political leanings, but that's fine, because that's how you know Dad is okay.

Boyfiend and I made it a priority to stop by the pond near M&D's house at least twice a day, to ensure that the Baby Duck and the Baby Raccoon were okay. Baby Duck survived the week (although, on my last day there, his mother went to the bar and left him peeping furiously until she returned). Baby Raccococoon fell off a log while trying to wash his hand-paws, with a despairing "gronk," and had to be hauled out of the pond by Mama. Archie the Mastiff was overexcited, according to his size 00 owner, but all I saw was a gently waving tail. Hermione the Heron caught two fish and one bullfrog that I witnessed.

Der Alter Jo and her hubby are blooming like roses. It's rare that you see two people so obviously suited to one another, doing things that they're so obviously suited for. At one point, DAJ said "I'm not sure I've stopped being a nurse; maybe I just have to turn those skills to other things." Being that she's doing the ADA program right now, I think she's got it covered.

Beloved Sis and Boyfiend and I spent one afternoon with really old family friends--and by "really old," I mean that the male half of the couple showed up with a toothpaste squeezer on my folks' doorstep when I was but a fetus. We had enormous amounts of coffee and multiple salads and some roasted chicken, and entertained a three-year-old who looked so much like her mother (whose birth I remember) that I thought, when she opened the door, "I'm in the right place, but the wrong decade."

It's weird, seeing faces you recognize reproduced on babies' heads.

Anyhow, it was lovely. I scored a Seattle Trifecta: I had a coffee at Google, then caught an Uber in the rain (it was a Prius, of course). My skin changed to plaid flannel and I grew a beard instantaneously.

I also walked up and down hills so much that the outsides of my ankles swelled up and my butt muscles complained. I drank some amazing pale ales (Botany Bay is a good one, if you can get it on tap) and ate really good, really fresh food. I slept well and woke up early, in time to hear the Stellar's jays being annoyed with the crows, and regretted not bringing string cheese on my walks in order to feed those crows.

Oh, and I got sunburnt. Of course. Because that is how I roll in Seattle: sunburnt.

Do NOT go there.

An incomplete list of websites I strongly urge you to avoid:

Urban Remains Chicago

Hygge & West

Plant Delights

Ivey Abitz

On the upside, I know what I'll be doing with my lottery winnings.

A well-oiled machine.

"What you need to do," the house supervisor said to me, "is learn to lower your expectations."

"Fuck you," I replied, with a sunny smile.

We'd just gotten a patient in, a guy in his fifties who was, according who what we'd heard from the house soup, status post-TPA, hypertensive as a habit, with a dense left hemiparesis. We'd heard that from the house soup because there had been no report from the outside ED from which he'd come. There had been no warning that the patient was on his way; we'd been waiting since early afternoon and it was now five minutes from the end of the shift. Of course.

Luckily, the dude could talk. Peej and Bethie moved him on to the bed and Peej took a first set of vitals.

His blood pressure was 80 over 44.

(Note for the non-medical among us: 80/44 is a perfectly respectable blood pressure for, say, a teenage girl who runs track. It's not good for a guy in his fifties, and it's *especially* not good if said guy has been running, since time immemorial, in the 150's over 90's or higher. Your body gets used to a certain amount of blood going at a certain pressure to all your organs, and something much lower or higher than that usual can cause problems.

A low BP, in particular, can lead to hypoperfusion of the brain, especially after an ischemic stroke. That means that all your stroke symptoms come back and further damage is done because there simply isn't enough blood, at high enough pressure, to fully supply the brain tissue.

To give you some idea of how important perfusion is, we normally allow our patients to run as high as 180 systolic [the top number in blood pressure] and 110 diastolic [the bottom number] after a stroke that's been treated with TPA. We definitely want to keep them above 100 systolic.)

Peej read out the number. I called to Bethie to bring a bag of normal saline and tubing, and started to trend the bed such that New Dude was lying with his head down and feet up. After determining that he didn't, as far as he knew, have congestive heart failure or any allergies, Peej started a bolus of fluid. Bethie called the doctor's lounge, trying to raise somebody--anybody--with an MD after her name to come and check New Dude out.

Just then, New Dude's left side started working again. He said, "Hey! I feel less dizzy! And I have to pee."

And with that, Doc Paul showed up and the night shift took over.

The unusual part of all of this is that both Bethie and Peej are new to stroke. Peej is a new nurse, flat out, having just finished her internship. Bethie did epilepsy stuff for years and worked on an HIV unit in the bad old days before protease inhibitors, so she's experienced, but strokes aren't her thing.

Peej is tall and slender and graceful and serene. She wears her hair in a bun, but that's not why people ask if she's a ballerina--it's her unshakeable poise and excellent posture that makes them think she dances. Bethie is me in a few years: foul-mouthed, fratchety, sarcastic, and with an amazing collection of weaves and wigs. Nobody, looking at the three of us, would ever suspect that we could work together well, let alone be friends.

But we did and we are. It was a minor crisis, not somebody spraying blood all over the walls, but Peej especially handled it beautifully. When I was six weeks out of my training, I panicked when faced with the same situation. Peej never broke a sweat, even taking time to explain to the recently-arrived family what was going on. I am very proud of her.

And we are, in my words, a well-oiled machine.

Or, in Bethie's words, "A fuckin' well-oiled fuckin' machine, man."

The Human Body: Major Design Flaws Edition

Knees: Why do knees have to bend the way they do, and why are they so out-there and unsupported by something stronger than ligaments? If you go sideways just once, everything stretches out of shape and you're left with a dicky joint forever. Plus each joint has to handle all the weight of the human body on an angle (especially if you're female).

Elbows: Same thing, but with a really limited range of motion. Silly idea.

Temporal Bone: Why such a thin casing over the brain in just a couple of spots? If you're gonna have a solid barrier of bone, make it thick all the way around.

Cervical Spine: "Hey! Let's put an eight-pound lump of bone and meat jello on top of this stack of bones filled with meat jello, and make it really vulnerable to breakage or stretchage!" As an extra added bonus, nothing else in the body will work if you fuck part of this system up.

And we can't turn our heads 270 degrees the way owls can, and we have a bad layout of large vessels in the neck. It's just a fail all the way around.

Urethra, female: Who thought of putting the opening to a system that must remain sterile in the middle of a soup of bacteria, some good, some bad? Who, having done that, would think it wise to make the entrance to that sterile system only a few centimeters long? This is, mind you, without the acidity of the mouth or the protection of mucus to keep bad bugs in check.

Prostate, male: Oh, come *on.* How did "secretory gland inclined to swell and block the flow of urine" get design approval?

Any area through which a nerve has to pass: Let's make it really, *really* small, then add a bunch of stuff around it that's likely to swell and irritate the nerve. Brilliant.

The lack of regenerative capabilities: IKEA could design a better body overall. If something breaks, you just limp on in to the Meat Part Store and buy another bit to screw on with a teeny Allen wrench.

No, I'm not feeling bitter today. Why do you ask?

Ch-ch-ch-ch-changes. . . . .

It's been a rough couple of weeks on the neurocritical care unit.

Marcie left; she went to neurosurgery's clinic, to cat-herd all their patients into craniotomies and gamma radiation. Kitty is in Europe as a whole for a month--actually forty days--and I'm wondering what the fuck I'm supposed to do without her, since I can't get the EKG printer to work correctly. Deej is going to work in a post-surgical ICU near The Schwankiest Mall Ever. And I'm left, oddly enough, as the nurse that everybody turns to when they have a question.

I wasn't expecting this. First I was a new nurse, but with experience in places much weirder than Sunnydale (Healthcare For The Hellmouth)--thirteen year olds with a methadone card and a 17-week uterus, or a bookstore where people might actually pull out a gun if you didn't buy back their obviously stolen books. Then I was a slightly experienced nurse, with some questions about the finer points of, say, Mobitz blocks or pseudobulbar syndrome.

Then, all of a sudden, I was that nurse everybody turns to.

There's Beth, but she's more cardiac than neuro. And there's Shiny, but she's not particularly forthcoming, although her smile lights up her face and she's always ready to help. She thinks her English is worse than it is, so she keeps to herself.

So I'm the one everybody calls when they have an IV they can't start. Or when they have a patient who's suddenly satting 80 percent on a nonrebreather. Or when the 97-year-old granny who's on palliative care decides to stop breathing, but nobody's sure she's dead.

Protip: If they're cold, and their pupils are fixed, they're dead. Just sayin'.

We had a lovely, amazing, talented 27-year-old dancer with a barely-week-old baby in. She had given birth, and then suddenly stroked out. Not because of her pregnancy, but because of a rare autoimmune disorder. She stayed with us until Tuesday last week, when she projectile vomited and became unresponsive. And we discovered that she had stroked out the entire left side of her brain, full stop, no hope.

So we brought her back from CT and suspended treatment, and allowed her little boy in to see her.

At the same time, our 97-year-old granny was giving up the ghost after a right MCA stroke that had led to aspiration pneumonia.

I didn't have them at the same time; I was busy with a crack-addicted heavy drinker who came in with a potassium of 6.7 (insulin drip ahoy) and a sodium of 117 (oh hello hot salt). Still, I was the person that the other nurses came to when people stopped breathing.

And so I got to pronounce one patient with another RN and notify the doc for a second patient at the same time. They stopped breathing, both of them, at 0936 am. I hope that grandmama showed the young mom the way toward the light. Any other thought would be too much.

Patients transition without pain if we do our jobs right. I am transitioning from the bumbling medium-experienced nurse to the Old Salt With Tales To Tell. I hope I can do it fairly painlessly.

And, of course, as a child of the 1980's. . . .

"She led off alone on the intro to 'When U Were Mine,' her guitar thin and high and lonely. Then the rest of the band swelled up under that, with Willy on his electric demon fiddle. Carla and Dan had come up with a bizarre percussive patch for one of the synthesizers, and hung it on the end of the fiddle's phrases. The effect was that of a succession of violins being bitten neatly in half.

Eddi found that the single-minded frenzy of the first set had passed. She still had the crackling energy, but she had a clear head to use it with as well. She tried to make every note glow; she felt the rest of the band respond to that and stretch like a racehorse seeking that one winning length. . . ."

Emma Bull, War For The Oaks

Do not be this person.

This week I wanted to die, in a sustained and sincere manner, rather than return to work after my first shift back from vacation.

Why?

Because I had a patient. Who weighed six hundred pounds. That's a BMI of 79.9 if you're counting, and not something that you want to aspire to. However, the trouble was not the patient. The trouble was one of her family members, the one Person You Should Never, Ever. Be.

This Person was, she claimed, a cousin-level relative of my patient and, she claimed, a neuro ICU nurse. The fact that she was a neuro ICU nurse at a hospital in the most far-flung district of the most distant, inbred county of Back Of Beyond that Texas can provide didn't matter; she was, by God, an ICU nurse who dealt with brains and That was It.

She questioned why we were doing her relative's transesophageal echo under general anesthetic with intubation rather than at the bedside. They do them all the time at the bedside in her ICU, after all. I was forced to point out that with an airway that doesn't even register on the Mallampati scale (graded from 1 to 4, with 4 being the most difficult to maintain), a BMI of nearly 80, and the need for continuous BiPAP while awake, her cousin was not the best candidate for living through bedside sedation.

Then she accosted our doctors, asking why we hadn't either given TPA or done a clot retrieval on her cousin. Her cousin presented to her small-town ED ten hours after her symptoms began, thus making her ineligible for clotbusters. And she'd had a watershed stroke, which means that there are a lot of itty-bitty clots along one pathway that one large artery follows, so nothing to retrieve.

In short, the Family Member You Should Never Be knew just enough to be dangerous. We had it out when I found her increasing the rate on the IV pump. My patient had congestive heart failure, and CHF patients can't take a lot of IV fluid, even if their kidneys are working well, which this woman's weren't.

We all fell suddenly and irrevocably in love with Dr. Hernandez, who took the brunt of her questioning. When her voice reached near-hysteria levels as she demanded, "Why didn't you do MORE?? You haven't done ANYTHING!" he responded, "Why didn't *you* do more before your cousin reached six hundred pounds?"

Because, People, this is the thing: nobody weighs five or six hundred pounds without somebody helping them out. At that point, it's difficult, if not impossible, for your average five-foot-four woman to get her own food. Extreme obesity is like heroin addiction, but with family support and enabling. It's harder to treat than heroin addiction, but just as deadly. And the families of these folks have often been the go-to people for high-calorie food in quantities that would blow your mind.

So yeah, that happened.

It was kind of a long week.

What I did on my vacation.

The benefit of selling your soul and most of your waking hours to a corporation like Giganto Research and Healthcare, Inc. is that you, eventually, accrue almost enough vacation time to feel like a human being for part of the year.

I just took two and a half weeks of vacation time. Getting it was surprisingly easy; all I had to do was widen my eyes slightly and mutter about evisceration, and my various bosses gave in and signed off.

So: I had two and a half weeks off. What did I do?

I got a new bed. King-sized, which means Mongo and the cats and I can all sleep comfortably at the same time, and so can The Boyfiend, when he's here. It's amazing how much difference those few inches make. Yes, it's a pain in the ass to change the sheets, and yes, I'll have to go to the laundromat to wash the comforter, but believe me: TOTALLY WORTH IT.

I got the mattress and box springs from Wink on the basis of reviews and their 101-day test period. The mattress is a hybrid--that means it has both memory foam (which I hate) and springs (which can be problematic in terms of motion transfer), combined in some highly-technological way.

My previous mattress was a Sealy Posturpedic metal-frame deal with a pillowtop. The only way in which that mattress was better than this one was in the sag when you sit on the edge. This mattress has some sort of plastic framing that allows you to use it with an adjustable foundation, but it sags a bit if you sit *right* on the edge.

Other than that, this mattress is TITS. I lie down, I turn over twice, I know nothing until the morning. They've somehow managed to combine springs so that it doesn't feel like memory foam and memory foam so the whole thing doesn't shake when Mongo turns over. Yes, it cost hinty-bazillion dollars, but every half-cent of those dollars was worth it.

I cleared two or three years' worth of weeds and dead shit and mulch and crappy low-end weedblocking cloth out of my front beds, then dug in several hundred pounds of composted manure, then re-weed-blocked it, planted things, and laid down mulch.

That alone took me two of those weeks. I have two beds, one 9 x 13 and one 9 x 11, and they hadn't had any attention in a couple of years. (Don't ask me what happened; I don't remember. All I know is I got a nastygram from the city about my weeds and kind of gave up after that.)

Now I have several dwarf yaupon hollies, something grey with purple flowers and the common Latin name "vomica," and a selection of other perennials growing in those beds. There are more plants coming, things like lavender and pentstemon and salvia and honeysuckle. I even planted a rose bush to balance the rose bush I planted when I moved in here. It's all very nice.

And I hung three dozen miniature mirrored disco balls in cascades on either side of my porch.

And I planted herbs in pots and then put tiny, brilliantly-colored plastic dinosaurs in the pots. (Did I mention that I spray-painted the pots' rims different colors? Well, I did, and it looks like Pinterest barfed on my porch.) Oh, and today I built a brick pad with antique bricks I dug out of the back yard so I'd have a dry, stable place to put the trash cans.

Gardening Fever has me by the throat now, so of course I have to build a TARDIS for the yard (a YARDIS) and hang mirrors off the trees and get a bird bath at some point.

Monday I go back to work. Apparently we have a new intern; she has a degree in English lit, which is good.

And I have two weeks off in July, which I will be spending in Seattle, which is better.

Half laughing, half gritting my teeth.

Years ago, I wrote briefly about the experience of being a synesthete and how I discovered synesthesia. I had kinda always figured that everybody saw the number eight as a nice, round, juicy blueberry color and that Katy Perry tasted like burned cheese and was burnt-orange. It took an NPR story and a conversation with my sister to prove me wrong.

And I had thought about it exactly zero times since. The way you experience the world is the way you experience the world; it's not something you consciously analyze unless something is brought to your attention. Thankfully, my synesthesia (and that of my sister) is not crippling; it's just an interesting party trick. It's utterly consistent and so completely a part of the way I move through the universe that I don't even notice it any more.

Until today. Today, when my pill case showed up from Amazon.

See, my NP got on my ass the last time I saw her (Tuesday) about not being consistent with vitamin D and fish oil and all that stuff. I really need to take certain things every day, I know, but for some reason my hand just floats over the big bottle of fish oil capsules every evening. So she yelled at me a little, and I went home and ordered a seven-day pill organizer. The box for each day has four little compartments, and each box is a different color.

THE BOXES ARE THE WRONG COLORS.

And, dudes and dudettes, this is a problem. Tuesday is lavender when it should be acid green. Sunday is a soft magenta, which does not appear in this set of boxes. Monday is *not* supposed to be purple.

It's bad enough that I got all confused while I was sorting vitamins out. There are some things I'm only supposed to take three times a week, and those went into the wrong boxes. I put all the boxes back together in the holder in the wrong order. It was a physical effort to make the colors match the labels on the boxes.

I am a partial synesthete. I will soon be a partial synesthete with a label-maker, as I relabel all the boxes so that they match, or at least come close to, the days of the week.

Things For Which I Will Never Apologize, Part One:

1. Not answering phone calls from work or checking work email while I'm on vacation. Leave me voicemail if it's really important and I'll call you back.

This policy stems from the time the house supervisor called me and asked me to come in one morning for an "incentive shift." I replied that sorry, I couldn't come in, and got subjected to a lecture about how not-a-team-player I was and how my coworkers were going to suffer. I said, "Yeah, yeah, but I'm in CANADA" and that was that.

2. Being paranoid about the weather this time of year.

Bad enough we get hailstorms and flooding that wipes out entire towns, but add in the "Oop, another tornado" element and yes, I will stay glued to the NOAA webpage.

3. Thinking that "Burlesque" and "Spice World" are the pinnacle of Western movie-making.

Those two movies are the closest thing we have to Bollywood, unless you count the "Step Up" series, which I have never seen.

4. The things I keep in the fridge, like stinky cheese and kimchi.

I live alone.

5. Liking my animals much much much more than I like most people.

*They* don't complain about my stinky cheese, and an incentive shift for Mongo means lots of fuzzy, snorting hugs.

Mongo has a bone!

I was wandering around HEB today (I hate shopping without an appetite; it leads to a weird larder) and saw GARGANTUAN BONES for sale. There were weeny, teacup-Schnauzer sized bones (about twelve inches) and GOLIATH BONES (that was the name), so I bought a GOLIATH BONE.

Mongo took it from me with mingled excitement and trepidation. He chewed it for about ten minutes on the back deck, then walked around the back yard, stepping very carefully, with his head on one side as he carried it off-center in his mouth. He made sure Rocky next door and Gracie two yards over saw it, and plumed his tale out when the boxer mixes on the other side of Rocky began to bark.

He couldn't figure out where to hide it. There are two trees in the back yard: one is property of a cat, the other is a peach tree that, as yet, is not big enough to hide anything under. So he tried by the shed. Then he tried next to the deck. Then he tried by the bushes on the northwest side of the yard. Nothing worked.

So he brought his GOLIATH BONE indoors and, after a drink and a little toes-up on the living room rug, proceeded to look for a place to hide it inside. So far it's been in the bathroom, behind the toilet (no go; Humans peeing apparently are not conducive to a hiding place), in the office where I type (but he can't get to the couch at the moment, dammit), and in the linen closet. The linen closet is okay for now.

The previous three dogs I've been owned by were all either northern breeds or working breeds, or combinations of the two. That meant that Elsie would happily crunch the trochanter off a cow's femur, or Max would cheerfully, between tail-wags, chomp the bone in half at the middle, or Strider would simply make the damn thing disappear in under an hour. It was a short-lived, if dramatic, way to entertain a dog: buy them a bone much larger than anything in the human body, then wonder what would happen if I died in my sleep.

What Mongo lacks in barely-civilized, wolflike instinct he makes up for in entertainment value. I felt kind of bad for him as he pranced around the yard like a Tennessee walking horse, trying to keep The Bone from falling out of his mouth, but also amused by the fact that he grabbed it by the meatiest part rather than in the middle. And he's barely gotten two bumps chewed off since noon; this bodes well for the possibilities of an open casket funeral should I kick off during the night tonight.

Speaking of open caskets, I have started a BSN program (yes, my dears; I'm finally giving in to corporate pressure to have letters after my name) online. Tests are done with a webcam provided by the school; I have to be in sight of a proctor and with my entire workspace visible by same during the testing process.

So, I was wondering: is this the appropriate time to pull out the strapless ballgown, elbow-length gloves, and tiara I've been storing for a special occasion? I mean, my Psychology Through the Lifespan test is important; should I dress for the occasion? Would it be worth it to make the proctors crack a smile? Surely they could use a little levity in their jobs.

Mongo is yelping at one of the cats, who had the temerity to investigate His Bone. Gotta go.

There is a bloody bite block on my wall, just above my desk.

It's in a biohazard bag, don't worry. It's pinned to my wall, just above my desk, so that I can see it every single morning and remember why the hell I got into this crazy business in the first place.

We do a significant number of what are called transesophageal echocardiograms on our unit. Unlike transthoracic echoes, which take place when a tech holds an echo wand against your chest, a TEE takes place under moderate sedation, with a cardiologist feeding a long, skinny tube with an echo camera on the end of it down your throat.

You can't do this without sedation. Try, and you'll end up with a retching, fighting patient and a poor-quality image. It's just flat impossible to ask an alert human to stand for having a two-foot length of something the thickness of my index finger inserted down his or her throat and manipulated. So we sedate. We're a critical-care unit; we're all trained to administer sedation and recover patients who've been sedated.

Then, one day, Doctor deSade showed up. Dr. deS. was a new guy for us, from a different branch of cardiology, and nobody had worked with him before. The initial signs weren't promising: normally TEEs are done early in the morning, both because we want our patients to have time to get over their sedation and because they've not had anything to eat or drink since midnight. This dude promised to show up at around eleven, which is pushing it, but then didn't show up until past two o'clock.

Kitty and I each had a patient undergoing a TEE that day, so we gathered our sedation meds, our throat-numbing sprays, and our sedation-med-antidotes. The first patient was mine.

Dr. deSade put the bite block (a firm foam widget with a hole in the middle that keeps a person from biting on whatever's placed in her mouth) in, after spraying the patient's throat with benzocaine, and began to feed the probe down. "Do you want any sedation?" I asked.

"Give her one and twenty-five," he replied.

(Now: "one and twenty-five" refers to the milligrams of Versed and the micrograms of Fentanyl that the patient is getting. We normally sedate at two and twenty-five, going up from there in two milligram and twenty-five microgram steps. It's not unusual for a patient to soak up five of Versed and a hundred of Fentanyl. Both are short-acting and easy to reverse, so we prefer to front-load the patient, as it were, giving them more sedation at the beginning, and letting it wear off gradually toward the end of the procedure. So one and twenty-five was weird.)

She fought. She gagged. She cried. I had to hold her hands down as the procedure continued, and I got very nervous about her blood pressure--up into the 260's systolic, which is a dangerous place for a post-brain-bleed patient to be. Eventually, Dr. deS. agreed to let me give her another milligram of Versed, but no more. Absolutely no more.

So, at the end of the case, after I'd pulled the bloody bite block out of her mouth--and you really have to work to bite hard enough to draw blood with a block in--I stuck the block into my glove and then into my pocket. And I took Dr. deSade aside, where nobody could hear us.

"Listen," I said, "I understand you have a personal protocol for your TEEs, but we also have to make sure that our patients don't have to deal with a lot of discomfort. This woman's blood pressure was far, far too high for safety. You might consider administering more sedative before beginning, so as to lower the risk of complications in this patient population."

I had been formulating that speech for the entire twenty minutes of the TEE. What Dr. deSade did flipped me right the fuck out: he started shouting.

He continued shouting all the way up to the nurses' station, where he leveled a finger at me and shouted, "I want to write this nurse up for unprofessional behavior and for questioning my orders!"

And that, my chickens, was when the line I'd rehearsed every day in front of the mirror for more than a decade came unbidden to my lips: "Just make sure you spell my name right."

I think I hissed it.

Poor Kitty had to do a TEE after Dr. deS had had his tantrum, and guess what? Her patient did the same thing. Moreover, the guy had had another TEE a few months before and unfavorably compared Dr. deSade's to his previous one, within the doctor's hearing.

And I got written up.

But Dr. deSade got written up twice, independently, by both Kit and me, for being a fucking jackass when it came to sedation.

My patient cried when I told her how sorry I was. She was expressively aphasic, but could understand everything that was happening. I have never felt so bad as I did that afternoon--I wasn't able to protect her from somebody with an ego problem and an attitude.

Both the TEEs came back, read by a different cardiologist, as having poor image quality due to patient agitation. The write-up Dr. deS filed wasn't acted on; the ones Kitty and I filed were. Dr. deSade is no longer welcome anywhere near our patients.

Sometimes doing the right thing is why you get into a business as irritating and emotionally draining as nursing. And sometimes, to remind yourself of all of that, you keep a biohazard above your desk.

My week, in pretty moving pictures.

Doctor Sunshine, who has a reputation for badmouthing everyone and everything around him, strode out of a room and announced to the residents with him, "You'll find that this unit is weak. The nurses aren't as competent as the ones in surgical critical-care."

Four nurses, two mid-levels, two residents, and a student later complained to their respective superiors about what Sunshine had said. The particular irony in this situation was that the incompetent nurses in our weak unit had been warning Sunshine that a particular patient had been decompensating for hours. He hadn't listened. Boy was he surprised when that patient went to the pulmonary ICU!

Sunshine then got pulled into a Very Big Meeting with his boss. Said boss is a good guy, supports the nurses he works with, and has a very calm way of dealing with petulant twats like Sunshine. 

Sunshine just didn't have a very good day. Poor baby.

He accosted Marcie in the hall today and asked her who had "turned him in." Marcie was kind enough to hold her tongue and not tell him that there were at least four independent complaints.

All I have to say is:

God, I love nursing students. And new nurses. And newbies, in general.

The best shifts I have come when I get to precept nursing students or new nurses. It doesn't happen very often, probably because I have a bad, bad reputation with Manglement when it comes to new RNs. I say things like "Don't let that doctor talk down to you!" and then call the doc in question out when he's been an asshole. That does not make me popular with people whose job it is to make sure the fruit plate in the doctors' lounge is fresh and full of papaya.

Still. . . .when I get to precept a new nurse, or a student, it's such a freakin' high. People who don't know a lot, or anything, about a discipline ask the best questions. I'll be talking to a newbie about the diagnosis for Mister X, and say something like "and, of course, he's very disinhibited because he had this right-sided stroke" and the newbie will be all "Wait, what?" and then I'll have to explain it in plain English. Which is exciting, because of the whole translation aspect, and also because I have to dig deep into this brain that's been doing this for a long time and come up with answers to the questions that'll certainly follow.

So, Newbies of every stripe, pay attention:

1. Really and truly, no question is a dumb question. 

No, seriously. If you ask me a question that is extremely basic, I will not get mad at you. Often the most basic points of a problem are obscured by language or the cool stuff that isn't so basic. Ask away.

2. If you meet an instructor who says "Nurses eat their young" or "All nurses are codependent," look at them only through slitted eyes.

Most nursing instructors these days are, thank God, decent nurses. Still, you'll occasionally run into one who couldn't hack basic nursing, either because of a lack of brains or a lack of spine. Those are the ones who will tell you horror stories about nurses. Ignore them. Most of us--especially the younger ones--are without bullshit and without an agenda. We want you to succeed, we want to see you on the floor with us, and we're ready and willing to help you out.

3. Likewise, be aware of the Cunt Nurse.

The very first day I was on my own after orientation, back in the Jurassic period, I was present for a conversation between two Old Nurses. They were talking about a neurosurgery resident, a woman, who was both extremely bright and more than usually attractive. The gist of their discussion was that she must've slept with the chair of the department to have gotten as far as she did.

I remember sitting quietly, sorting my charts out, and thinking "Jesus, that nurse is a fucking cunt." I was right. She *is* a fucking cunt, and I still work with her, and I've not seen anything in the past fifteen years to convince me differently. (The other nurse she was talking with was a manager, and was fired shortly thereafter.)

The point here is that if somebody badmouths a colleague without reason, or fakes a kidney stone to get out of precepting you, or generally makes you think "that person is a cunt," you are probably right. And cunts never change. Avoid them.

4. Please have the basics down.

And by that, I mean the absolute basics. Know how to tell the upper back from the lower back. Know where the brain is (hint: it's on top). Be aware of how to take a pulse. (Note that I don't require anybody to be able to take a manual blood pressure; it's surprisingly tricky and needs lots of practice.) Know how many legs your average human should have, and whether or not your patient has a uterus. I don't require more than that, honestly. Unless you cop an attitude, and then I will make you sweat.

5. As for making you sweat, we won't do it in a mean way.

Unless you cop an attitude. As I did when I was a new nurse, and boy, did I ever have to answer for it. We may ask you tricky questions and wait, as you shift from foot to foot and glance at your fellow newbies for help, until we give you the answer or you come up with something that we'd never thought of before. We won't pimp you the way doctors do, don't worry.

Mostly, honestly, we ask you questions not because we want to know if you have the textbook answer, but because we want to see you work out a plausible answer on your own. Hell, I'll take a flamingly wrong answer that's well-conceived over a boring, flat textbook answer, simply because the wrong one was more interesting and gave more scope for teaching.

Don't be scared. Unless you're an asshole. Then, be scared.

Today I went to a funeral.

I walked in to the church and looked for people I knew. The first person I spotted was Mike, Jenna's husband, so I walked straight up to him and hugged him.

I have never seen anyone look as empty as he did.

Then Jenna's mother found me, and her brothers, and her various other relatives, and I got hugged and kissed to the point that I no longer cared about leaving makeup marks on their nice clothes.

I sat down about six rows from the back, in a pew that didn't have anybody in it. I stayed there until the music started and the family came down the aisle. Jenna's mom grabbed me and said, "Jo, you're family. Come sit with us." I started to ask "Are you sure?" but she had my hand so tight that I decided to shut the hell up and go with it.

So I ended up in what was nominally a family pew, right behind the family, with Lauren and Casey, the PAs who took care of Jenna when she was really sick.

I'm glad they were there. I didn't cry because they were there.

Everybody there but me, I think, was a believer. They read poetry and psalms and proverbs, and talked about the value of a capable and thoughtful wife. They talked about the love of a good friend, and how they were sure she would be waiting for them in Heaven when they died. They called her a pearl of great price and said her value was beyond that of rubies.

Here is the Jenna I know, the one who I was both nurse to and friends with:

She was jealous of the shirt that I have that says "My cancer is rarer than your cancer. Neener neener."

She was always more than ready to talk about something other than her illness. Mostly, that something was how ready she was to get back to work (teaching) or her kids or her husband, but it also turned to how weird life could be.

She was totally unshockable. I sent her texts with pictures of the guys across the street doing half-naked yoga on their roof, or the pile of clothes somebody left in my front yard, or the latest whacko project that one of the neighbors had conceived, and her response was always "I miss Littleton. It's such a great place!" Sometimes that was followed by "Did that dude ever come get his clothes?"

Jenna was never, that I saw, really angry about what had happened to her. I'm sure she got angry at times, or got rebellious against what she saw as God's plan for her, but she never did so with me. That's not to imply that she simply accepted things as they were: she most emphatically did not. As Lauren said, the most incredible thing to watch was how she went from being scared and anxious to being strong and confident. She didn't so much fight as she just lived, in defiance of everything.

Mike and Jenna visited me at work one day and I asked to see her head. She was really, really cute without hair. Like, more attractive than anybody has a right to be.

At her funeral, there was a slideshow: Jenna with Mike. Jenna with college friends. Jenna, as a toddler, dressed up in a bee costume, her grandmother by her side. Jenna holding a fishing pole, frowning at somebody off-camera as she stood knee-deep in a river. Jenna sitting atop some promontory somewhere, with all the sky behind her, having hiked all that way. Jenna pregnant by the ocean.

Jenna and her baby son, both of them bald as cueballs, grinning the same grin.

Here is the secret of being a nurse: your memory becomes a library of people who are no longer here. Sometimes that makes you feel like there's been too much grief. Sometimes it makes you angry at a God that you're not even sure exists, because if He or She did, then why would we need children's hospitals or funerals where toddlers are in the front row? Mostly, though, it just makes you thankful.

I didn't make a huge difference, or do anything heroic, or actually do anything special. All I did was break my personal rule and become friends with a patient. This time, that person died. This time, I was stupid and opened myself up to that horrible feeling of not having done enough, the feeling of having failed a person who is much better and kinder than I will ever be.

And next time, I will do the same damn thing all over again.

I got lucky this time. I met Jenna, and I am proud to have been her friend. She was good people.

And I will never, ever, ever forget her.

Things of which I will never tire, part three thousand and forty-six:

1. The look on an attending's face when the nursing staff in the NCCU actually knows something. We read our patients' charts before the shift begins, we review lab results, we read EKGs and check out the results on CT scans and EEGs. Yet, for some reason, the attendings will never get over that first, pure shock of a simple nurse knowing something he (usually "he") doesn't about a patient.

(Nota bene: this is not all attendings, just a couple. Dr. Vizzini and Dr. Manbags come to mind.)

2. Pure thankfulness from a resident when we solve a problem or save them from a hideous fate. Dude/ette, that's what we're here for. You got problems? Yo, we'll solve them. Check out our scans while the 'puter revolves 'em.

3. The patients who say they don't want to take metoprolol/metformin/insulin/hydralazide for their problems, because they "don't want to mess up (their) bodies with medicine." These patients fall, generally, into two camps:

     a. The patient, male or female, with an A1c of 10, a resting systolic BP of 210, and a creatinine of
         4; or,

     b. The patient, female, with acrylic nails, bleached hair, Botox, breast implants, and liposuction,
          who has had her mercury amalgam fillings removed because they leak "toxins" into her
          bloodstream.

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

Yes, I've been a long time gone. For that, I do truly apologize.

Back in December, the fine folks at Mind Over Media, the people who'd been my liason with Scrubs online magazine, informed me that my services as an essayist would no longer be necessary. (Nothing wrong on my part; Scrubs decided to go in a more fashion-related, nurse-o-nality {dear sweet baby Jesus} driven direction).

I realized quite suddenly about three weeks ago that I'd been blogging, or writing weekly essays for some company or other, for more than twenty years. It started in the early 1990's with a website called ParentsPlace and went from there. I also suddenly realized, about three weeks ago, that I hadn't written shit for HN, and it actually felt pretty good. So I continued on, not writing anything, until I had had enough "I've got to blog this" moments at work and in my personal life to make it worthwhile to put fingers to keyboard again.

It's a little strange, having dissected both my personal and professional lives for--hang on to your asses--twelve years!! to suddenly stop, but I think it was good. I quit looking at life through the lens of bloggable versus boring, and had a break from trying to stage things in writing in my head. Maybe the quality of my stories will improve? Perhaps that's too much to hope, but it's been an instructive, and very pleasant, break.

Thanks to all of you who wrote, wondering if I had been abducted by aliens, the Zeta cartel, an underground supplier of international supermodels, or PETA. I am fine, and I appreciate your concern.

That said, I have to make lunch for tomorrow. We have a brand-new attending, just hired on, whom we have to break in. My job will be getting him used to reports that contain Queen lyrics.

"Take a right by the porta-potty, then a left after the second backhoe."

If you were to come to Casa Del Doghair, those would be the directions you'd get.

Every five years or so, Littleton's infrastructure guys decide it's time to replace the gas lines/sanitary sewers (that's how they refer to them: "sanitary sewers." I would hope there's no other kind)/water lines/electrical distribution system/various bits of asphalt in my neighborhood. This month, it's the sewer lines.

Do you have any idea how big sewer lines can be? I did not until this week. Apparently, replacing several thousand linear feet of sewer lines requires backhoes, something The Boyfiend calls a backtracker (on reflection, I think he made that up), a crane, and a whole shitload, pun intended, of disturbingly large plastic-and-metal tubes. These things are large enough to get lost in. And right now, five of them are piled up on what used to be my side yard.

So be careful if you come visit. Don't climb on the equipment. And for God's sake, don't cut that left after the second backhoe too close, or you'll end up ten feet underground in a big hole, with a bunch of men in orange vests staring down at you.

In non-sanitary-sewer-related news, nursing, both as a job and a concept, is eating my lunch. Mostly as a job. The concept of nursing is fine and dandy and I'm still all up in its metaphorical grill, but the practice? is leaving some tread marks across my back.

Part of it is the new residents we've got at the moment. We trade out residents more frequently than just once a year, so every four months or so, it's like July all over again. Not all of 'em leave, of course, but we get enough new post-grad-twos and threes to make things exciting. Here's an example:

SCENE: Interior, day, conference room. Six doctors are milling about, drinking coffee and PSLs and munching on PowerBars.

DOCTOR ONE: Okay, you guys. We have a full house today, so we've got to move somebody out of the unit. Who've we got that can go to the floor?

DOCTOR TWO: Um. . . .let's see. We have three TIAs that are stable and almost done with their workups. We have that patient with the left MCA stroke who's waiting on rehab placement, and the lady with the cerebellar stroke who needs a cardiology consult. Oh, and then we have that one guy with rhabdo, in status, with an insulin drip, who we're working up for DIC. He's four hundred pounds and in four-point restraints, too.

DOCTOR THREE: Sounds to me like we ought to move out the rhabdo.

DOCTOR ONE: Great idea. You write the orders and I'll let bed control know. Oh, and listen: be sure you write an order for strict ins and outs and put in the notes to nursing that they have to d/c that Foley immediately, okay? 

I'm spending Thanksgiving with the weirder half of The Boyfiend's family, in a prepper compound, with feral-hog hunting as part of the weekend's entertainment. At this point, I am looking forward to it.

And maybe, before I go back to work, I'll end up at the bottom of a deep hole under a backhoe with a bunch of men in orange vests staring down at me.