Aaaaaand as an antidote for that last post, possibly the weirdest rendition of "Working in a Coal Mine" ever. It's Swedish.

From Jezebel, strangely enough, and about Mark Sanford...

...but it still punched me in the snoot. To wit:

Lots of people do get into relationships that require way more work to hold together than it seems like is healthy for anyone. I'm as guilty of this as anyone else: I've had my ultimatum-issuing moments; my moments of pretending everything's okay for the sake of keeping the peace ; my moments of silently weeping in bed, waiting for someone to fall asleep, pretending that not talking about it can make the problems go away and that just trying harder will make us not-unhappy and that not being miserable is a step along the path back to happiness. Commitment is important, right?

And, sometimes, I suppose, it can be. But other times — many other times — the betrayal is too great and the emotions are too dark and the road ahead doesn't go back to being nicely paved, but turns into gravel, then dirt and then mud.

Random 4 am musings

One of the best things ever is waking up at 0400 and realizing you don't have to work today.

Add to that that the cats were all over me, doing their "We love you so much; here, let us lie on your belly" act, and it's been a good morning so far (all fifteen minutes of it, anyway). 

I wonder what the house's previous owners were thinking when they painted the office ceiling high-gloss beige.

It's time I defrosted the freezer. Yes, I have a non-frost-free freezer; my refrigerator is Polish. It's the only one I could find that fit the space I had for it in the kitchen. Plus, who needs 120 cubic feet of refrigerator space when it's just one person?

We need a new definition of patients eligible for rehab. If they're strong enough to get themselves into a wheelchair, get out the door of the hospital, get 300 yards down the street, and score some meth, they're not candidates for rehab and can head on back to the house.

Max is thrilled that his girlfriend is back. Sophie lives next door. She can play "So's *Your* Mama" through the fence like nobody else, and loves to wrestle when they're in the same yard. She'd been gone for a week on a camping trip, and Max was bereft. 

It's a really good feeling to wake up and know that not only do you not have to go to work, but you cleaned house yesterday and so have a free schedule today. I might, I dunno, fix some drawers in the kitchen this afternoon.

I just remembered that July 1st is coming up, and with that date, a whole new crop of residents will start rotations. It should be a fun month. 

Texts From Last Night is one of the funniest things I have ever read. I went through about 20 pages of it and was crying, I was laughing so hard. (Link not safe for work; not safe for Mom.)

If you're hitting your PCA button 122 times in an hour, and you're half-asleep while doing it, there's something not right.

I need some new light-blocking curtains for the bedroom. Hm. Time to go to Target, I guess.

One of my coworkers and I did a little song-and-dance routine while chanting the lyrics to "Short Skirt/Long Jacket" the other day. It went over big. We may have found a weekend job.

Somebody added stickers with the words "Don't" and "Believin'" to the stop sign at the end of my street. Whoever you are, I salute you.

Friend Suzie's mom apparently just killed her third rosemary plant. I have got to head over there and see what she's doing wrong. Killing rosemary is damned near impossible, even for me.

When I was told that I had to fill out a requisition for a 20-gauge coudet catheter, I simply went up three floors and swiped one from another unit. This is why the supply situation is so bad.

I wonder what I'm doing this weekend. For the first time in seven years, I am not working over the Fourth. Not quite sure how that happened, either. Something tells me the weekend will involve Prosecco and good Mexican food and a mariachi band.

Notamus just leaped from the futon to my shoulder. He is HEAVY.

And now it's time to stop musing and have some more coffee.

Zhausted, Take Two.

I'm ready for my exit interview, Mister DeMille; or, Don't Ask If You Don't Wanna Know

"Why are you leaving?"

It's a question I get asked on a daily (at least) basis. Do you really want to know?

It's because, when I asked not to be assigned to a patient who'd been sexually aggressive with me and harassed me both verbally and physically, I was told I couldn't refuse an assignment....yet Manglement did nothing to protect me or the other nurses from that winner.

It's because, when I go into the clean supply room, I can no longer count on finding the things I need to take basic care of a patient. In the name of saving money, we now don't have enough urinals. Or bedpans. Or bandages. Or catheters. Apparently, we were being entirely too profligate with our Foleys.

It's because, though I've worked on the same unit for seven years, Friends of Manglement get preference for assignments, vacation requests, and scheduling. 

It's because, in the name of saving money, Manglement has reduced our staffing to unsafe levels.

It's because, if a patient or a patient's family member has a complaint about a nurse/care aide/cleaning person, that complaint is taken seriously and the response is punitive. Conversely, if a nurse/care aide/cleaning person has a problem with a patient or "guest", even if that problem extends to threats of violence, "customer service" techniques are used to "resolve the issue", and the professional person's concerns are belittled.

It's because I'm tired of fighting every single damn day to be able to care for my patients in a safe way. It's because I'm tired of getting saddled with six or seven patients of varying acuities because the staffing office says that's how it ought to be. I'm tired of big decisions being made for the acute-care units by people who live on carpet and haven't worked a 12-hour shift at the bedside in twenty years. It's because I'm sick to my eyeteeth of the notion that "customer service" is more important than "good nursing care". It's because I'm exhausted by chasing around whatever person it is that needs to approve a request for a chest tube kit or extra IV pumps or more crackers for the patient pantry. It's because I'm tired of every single thing I do being evaluated, not on the basis of quality of care, but on customer service.

All I can say is, it must suck to be the manager of my unit. My manager's stuck between the very real needs of the nurses and staff and the insane demands of Manglement. Manglement makes it almost impossible for the manager of any of our acute units to actually do his or her job; instead, there's a bizarre combination of micro-management and total indifference that has got to be raising blood pressures on all ten floors. 

Fortunately for me (and anybody else who wants to go into or is already in critical care), the critical care pods are managed by a totally different group. The nurses get what they need, from equipment to staffing, and their worries and problems are taken seriously. I get a real sense of community and teamwork, since there's not a culture of "rat out your coworker, get a gold star" there. The managers of the CC pods are working nurses who pull shifts at the bedside every week, not just when they feel like they're getting rusty. The upper management of the CC pod, likewise, are CC nurses who hold down a job in management and one in actual bedside nursing as well.

Several years ago, Manglement instituted a number of changes on one of our acute units. Mostly they had to do with staffing and the types of patients the nurses would be caring for. Within six months, there had been a complete staff turnover on that unit, with a number of the nurses ending up, surprise surprise, in the critical care pods. 

This year Manglement did the same thing to my home unit. Nothing like learning from your mistakes, hm?

I'm the first to go. Somehow, given how many of my coworkers have taken me aside and asked me about the application process for the CCPs, I doubt I'll be the last.

Saturday subtlety.

So, yeah. It was a bad day the other day.

She'd been fine when I saw her at 0730. A little groggy, yeah, but that was because she was on tremendous amounts of Neurontin and various painkillers, a result of her having had a spontaneous epidural hematoma. (Note to Googlers: spontaneous epidural hematomas are extremely rare; two of my patients on the same day had had them. Such is life at Sunnydale General.) At any rate, she was moving all the limbs that she had been moving before, and could speak fluently, if sleepily, in response to questions.

Then, at ten past eight, her daughter called. She was concerned because Mom wasn't picking up the phone. Daughter is the sort of thorn-in-the-side, pain-in-the-ass advocate for a patient that we simultaneously dread and admire: she'd enlisted the help of a couple of family friends who were nurses, and she called regularly for updates. 

Anyway, Mom wasn't answering the phone. This wasn't unusual, as Mom tended to sleep in. Plus, as I'd said before, she was groggy that morning anyhow. But, because my Spidey-Sense started to tingle, I went into her room anyhow, to see if she needed help ordering breakfast.

I found an obtunded patient who couldn't move her right side and couldn't speak. She'd stroked out at some point in the last forty minutes.

After the usual stat CT scans, administration of Narcan and a bolus of normal saline in the vain hope that this was merely dehydration, rushing around notifying family members (thank God I didn't have to do that), and transferring her to the ICU, I sat down with the intensivist for a post-mortem of what might've happened.

Turns out she'd had an episode the day before of having one arm go dead. Her legs were already gone, thanks to that spontaneous epidural hematoma, and we couldn't feed her coumadin or heparin or any of the usual anti-clotting drugs, thanks to that spontaneous epidural hematoma. Although she'd recovered her arms in a matter of seconds the day before, the fact that she'd lost one at all (and by "lost one" I mean "lost all motion and sensation") led us to believe that she had some sort of clotting disorder besides the original one.

And, sure enough, she had a previously-undiagnosed bit of atrial fibrillation. A-fib, as we call it in the biz, is a condition in which the top chambers of the heart don't squeeze regularly. Instead, they sort of shiver. This doesn't affect how you feel, much, but it allows small clots to form in the backed-up blood that isn't cleared from the atria. When the heart muscle finally gets its shit together and manages to actually contract the atria, clots can shoot into the brain.

Which is what happened in this case.

The bitch of it is, the utter, total, black-furred bitch dog of it is, there was nothing at all we could've done. Some part of her clot cascade was impaired to the point that she had an eleven-inch long hematoma in her spine with no rational cause, so it's not like we could anticoagulate her. Doing so would've caused the hematoma to restart, and would've certainly killed her.

So, instead, she gets to live with only one (partially) working arm, no speech, and no ability to recognize her daughter.

The daughter was on the way to the hospital later that afternoon. I am not looking forward to seeing her. Even though there was nothing I could've done differently, and nothing would've changed even if I had witnessed the stroke, I still feel responsible.

Conversation over dinner

Me: "I can't help it. I'm feeling cranky. And grouchy. And disillusioned. And bitter. And grumpy. I no longer believe in love or the sanctity of romance. I hate everybody."

Friend Suzie, deadpan: "Take. A. Fucking. Motrin."

Product Review: Why the Germans are kicking our asses on the cleanliness front

Many, many years ago, I moved into an apartment where the previous tenant had been a middle-aged German woman. Everything was spotless. The coils on the back of the fridge were clean. The closet that housed the water heater was clean. The rug squeaked when you walked across it. The walls had been scrubbed. The tiny galley kitchen, off of which the back door opened, was so clean that I didn't waste any time wiping things down when I moved in.

Germans have a longstanding bad attitude about dirt, and now I now why.

Product Review: Miele Neptune

So I bought a vacuum.

A five-hundred dollar vacuum.

Sainted Father is slapping his thigh right now and making a noise of utter disbelief. Beloved Mother is raising one eyebrow skeptically. Beloved Sister is going "Nnnnggg" with envy. The Brother In Beer is wondering if I've ever vacuumed before in my life.

I bought a Miele Neptune after reading thousands--and I mean literally thousands; it took me weeks--of reviews online and finding very few negative ones. The negative reviews I found had to do with things like the length of the power cord and how easy it is to reduce the suction if you're clumsy and hit the suction-reduction button by mistake. Every model of Dyson I read about, by contrast, had volumes of bitching about noise, reduced suction, bits breaking off, things catching fire (!!!), and attachments not fitting correctly.

The Neptune arrived today. It is compact (about twelve by twenty inches), light (about six pounds) powerful (watch out for jewelry on the floor!), and quiet. Max, who gets nervous about noise of any sort, raised his head when I turned it on, glanced at the machine, and laid his head back on his paws and went back to sleep. The kittens had to be physically removed from the area; they were playing with the parquet head.

First I vacuumed the bare floors and wondered why the old vacuum/dust mop/Swiffer combination hadn't picked up all the dirt. The floors shine like they've been waxed, now. Then I moved on to the big jute rug in the living room, and wondered again what the old vacuum had been doing. After that I vacuumed all the walls and the ceilings and the top of the refrigerator and the bookshelves and a pleated fabric lampshade that I thought was cream-colored but, on vacuuming, turns out to be white. Then I vacuumed the top of the fridge, the bathroom floor, the utility room (aieee!), and the woodwork.

The entire time, the animals were totally unmoved. I heard a text-message alert come on my phone, and listened to NPR without having to turn up the volume. 

If I could vacuum myself without injury, I would. I think I would be clean enough to perform surgery without a preliminary scrub.

Drawbacks, if they can be called that, include the fact that if you're trying to pull the vacuum over a rug and around a corner simultaneously, it will tip over and turn itself on. Also, the cord is only about ten feet long. My house is a whopping 900 square feet, not including the utility/everything room, so that isn't a problem. The instructions that come with the machine are Germanic in the extreme, so you might want a couple of slugs of good liquor before you read them. The Miele cannot be used on animals or in wet environments. It also probably should not be used under water or in zero gravity, though it'd probably work in that last. And the suction control on the wand is easy to open by mistake, but only if you're as clumsy as I am.

Verdict: Save up. Spend five clams on a vacuum. Within fifteen minutes I knew this was the best five bills I'd ever spent on anything.

I had a wonderful post all written in my head....

...about how I watered the tomatoes last night and found that, although the neighborhood raccoon had tried to eat all of them, he'd missed a few.

Also about how it was the solstice, and thus how the sun had hung on the horizon for what seemed like forever on Sunday night, lighting the dinner and Rogue that my friends next door gave me.

Also about how the solstice reminds me of watching eagles hanging in midair over the mountains, with sunset not happening until nearly midnight, and the sense of infinite possibility.

Also about how yesterday was full of kittens and dogs and gardens and my basil blooming.

Instead, one of my patients went very, very bad today. It's nobody's fault, but I'll be taking a couple of days off. Because you kind of have to, after a day like today.

What To Expect When You're Expecting A Central Line!

So. You're in the hospital, stuck with a disorder or disease that requires multiple infusions of something nasty like chemotherapy or Vancomycin or suchlike, and your doctor tells you you need a "central line". What the bejimminy blazes is a central line, and how do they work? And why the hell is this a good idea, anyhow?

Listen up: you'll thank yourself for getting one, especially if your particular condition requires not only infusions of Nasty Stuff but also frequent blood tests.

Central lines are, as the name implies, intravenous lines that go into one of the really big veins that drains into the center of the body. They come in three types: Really Temporary, Sorta Permanent, and Really Permanent.

The Really Temporary type is most common if you're having something like plasmapheresis done for CIDP or MS. Normally it's inserted at the bedside by a surgeon, and it goes into the internal jugular vein (that's the big one in your neck). Very occasionally they'll put one into the big vein in your groin, but that's kind of a pain in the ass, so it's to be avoided if at all possible.

Most likely, your IJ (internal jugular) central line will have two separate toggles on it and will be short and sort of curled on the ends. Through this, nurses and doctors can draw blood and do plasma exchanges. It saves you from getting large-bore IVs started every time you need a plasma exchange, and saves you from getting stuck multiple times for blood draws....but there's a drawback: no matter how carefully-inserted the thing is, it has to come out after a week, two weeks at the most.

The Sorta-Permanent type of CL used most often is something called a PICC line. PICC stands for Peripherally-Inserted Central Catheter. It goes into your arm and threads up the big brachial vein, to end just above your heart. PICCs are very handy indeed, as they come in one, two, and three-lumen (opening) versions and can be used for everything from injections of IV contrast (provided they're the right sort) to blood draws to chemotherapy infusions. 

PICCs can stay in for weeks to months; I've seen 'em stay in and be usable for six months or more. Generally speaking, though, you want the thing out within about 14 weeks, just to reduce the risk of infection.

The Really-Permanent type of central line is called a Mediport. (This, by the way, is a brand name. Please don't sue me. Thank you.) Mediports are cute little buttons that sit under your collarbone and attach to a line that runs, again, into the big vein above your heart. The advantage of Mediports is that they can stay in basically forever, be used for blood draws and suchlike for years, and don't have as great a risk for infection as the other types of central lines. The drawback, of course, is that you're getting something implanted under the skin of your chest, so you're gonna need anesthesia and stitches and so on. Plus, they're kind of a pain to take out. However, if you're going to need chemo for a long time, like if you have MS and need periodic infusions of Rituxan, they're a good bet.

Mediports are accessed by a stick. That's another drawback if you really hate needles, but hey: it beats getting stuck with enormous needles over and over in one or both arms, right? Right.

The drawbacks of all central lines are pretty much the same: you could get a whopping infection either at insertion or later on. To combat that, they're put in using sterile technique, and everybody's very careful about using them. 

Another possible complication is that the line either busts through the vein wall or doesn't go where it ought to, leading to punctured chest cavities, internal bleeding, or other screwy stuff. Luckily, lines are what we call "radio-opaque", which means they'll show up on X-ray. Once they're placed, we can check that they're in the right spot with an X-ray, and reposition that sucker if necessary.

A final complication, and the most common one by far, is that the central line will form what's called a fibrin sheath on the end, so you can neither draw blood nor infuse drugs through it. Fibrin, by the way, is a component of blood clots. When this happens, we have a cool drug called TPA that can dissolve the fibrin, thus making the line usable again. And no, it doesn't mean a clot will go shooting toward your head; it dissolves the blockage into such small pieces that your body doesn't even notice them. I do a LOT of central line declotting at work.

That's your Central Line Primer for the week. Consider asking for one if you're undergoing treatment for MS, MRSA, cancer, or anything that'll require frequent sticks and blood draws. Your peripheral veins will thank you.