Wednesday, October 15, 2014

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.

Sunday, October 12, 2014

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.

Thursday, August 28, 2014

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.


Wednesday, August 13, 2014

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."


Wednesday, July 16, 2014

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.

Sunday, June 01, 2014

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.

Saturday, May 24, 2014

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.