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.

Wednesday, May 21, 2014

Oh, hai.

It's been. . .a month? Six weeks? Seven weeks?

God, who knows. All I know these days is getting up in the dark, working under artificial lights, going home in the dark, and praying for the sweet, sweet release of death.

Not really. But close.

In the time since I last caught up with you guys, I have survived The Annual Music Festival That Makes My Commute Home Even More Unpleasant, three more checkups with various CANSUH doctors (all clear!), and a staffing reduction.

Because when you win awards and have fantastic patient outcomes and get featured in advertising campaigns, with pictures and everything, that's how you're rewarded: with staffing cuts.

And it's rained a couple of times, which is kind of a big deal, because our county usually breaks up and dissipates large thunderstorms. I think it's a function of having so much hot air here every couple of years, when the Legislature is in session.

But anyway, yeah: Manglement decided that we were just too damned efficient and fantastic, and so cut our staffing by a third. One of our nurses is out taking care of an aging/sick/dying parent, so that meant that I worked, like, all the time. I barely had time to eat something that wasn't fast food, let alone write.

It's frustrating to be managed by a person who has no critical-care experience. It's equally frustrating to be managed by somebody who hasn't laid paws on a patient in, oh, at least fifteen years--and it's worst of all when those two people are combined into one. I feel sort of like a character from "Savage Chickens"--there's this robot with a board with a nail sticking out of it who comes around whenever somebody Important is about to tour the facility, but otherwise never shows up.

So we're all trying to focus on the positive. Two of our nurses recently had babies, which is always nice if you like babies, and I am, so far, not going to have to have more surgery to chop malignancies out of my head. Boyfiend's foot-drop has completely resolved. The cats and dog are making a habit of cuddling together, a la A Peaceable Kingdom. Nobody's tried to punch me lately. (Well, they tried, but they didn't connect. Much.)

I have a couple good stories to tell. I also have some eyebrows to pluck. You can tell, by looking at my eyebrow game, which takes priority today. Tonight, I will be dining on white wine and scrambled eggs and biscuits with sausage gravy, oh fuck yeah.

Monday, April 07, 2014

My trainer brought in a new piece of equipment today: the big yoga-whoozit ball:

Little did she know I'd already found my spirit animal.