Overtime

Here's what I think--I think I'm going to actually garden this year.
The house is a mess. Working 4 days in a row is almost impossible to do, and keep sane. Jay warned me I would go crazy if I continued to do this. I think he might be right. I'm taking some time off next week, thank goodness. The kids will be gone. Everyone I meet and see seems like an imposition. Everyone an annoyance. I don't know how people live the way they do, self included. People seem too close. Their smells bother me, their hair, their conversation. Everyone looks foolish. Everyone is too fat or too thin, or too loud. I'm becoming a fascist.
The worst offender, of course is myself.
I don't want people to talk to me, sound itself is almost intolerable.
I felt better after I sat for awhile, but it's safe to say, I think, that my nerves are pretty raw.
By the fourth day of work, my inner dialogue is almost unbearable. Mondays. I hate Mondays. The most self-righteous, patronizing group of nurses work Mondays.
Wiz calls them the Monday Saints.
"Ahh...the saints of the unit, so clearly aware of their superiority--what would we do without them?"
Ughhh. They are insufferable, the bunch of them.
$564 I get for dealing with them.
Monday money.
Who are the Monday saints?
There's Regina, who I've told you about before. The one who refuses patients. There's Nathan--29, self-righteous, full of advice, always delivered in this folksy way, with the subtext of "you suck"--i.e. "Did you want her in the chair that long?"
There's Walter. Who puts Jesus into every sentence. Such as "do you think we have enough nurses to handle another admission?"
"I think we do, but it doesn't matter if I think so, it matters if Jesus thinks so."
or.."How's your wife doing after her gallbladder surgery? Is she getting better?"
"Jesus is making her better."
or "Achoo!"
"Bless you, if it is what Jesus wants."
or..."How are you?"
"I believe I am well, but I know I am blessed by Jesus."
SHUT UP!
Jesus...
It's my orientee's second to last week. Then she's out on her own. I'm not sure how much I actually like her. She's a good, reasonably competent nurse but I'm finding she has this strange, almost psychotic blind spot when it comes to her own errors. For example, last week, we had an admission--septic, pressures falling, and we were starting pressors. She didn't check or label her lines and started the dopamine at the same rate the maintenance IV fluid was written for--a dose that would have probably outright killed the patient in about 15 minutes. Because I'm on top of her, I caught it, but when we discussed it at the end of the week, she had completely rewritten the incident in her mind.
"the drugs we use are scary," she said.
"Yes, they are. You found that out the hard way, didn't you? We had a near miss."
"Yes we had that dopamine hanging and we didn't know whether it was ours or whether it had come from the other hospital."
"No, that's not the incident I'm talking about."
"Well, don't you remember?" she asks. "There were two bags and you were running them both?"
"No, " I said slowly. "That isn't what happened."
"Yes it is."
"No it isn't. Let me remind you--you started to run the dopamine at the same rate as the IV fluid because you hadn't checked or labeled your lines."
"I don't think that's what happened...." she started to get really defensive.
"That is exactly what happened. Do you remember it now?"
"I don't remember it that way."
I started to feel exasperated.
Finally, I got her to admit what happened. But the incident, and our review of it, really has me worried.
Things move so fast in our unit that mistakes or almost mistakes are bound to happen. It's why we have so many checks and double checks and it's why we try to cultivate a blame-free atmosphere. It's got to be a place where you can admit to mistakes, or lack of knowledge, so that everyone can bring their best to treating the patients. If she covers or reframes, she'll screw someone up, and the hostile blankness in those opaque brown eyes really bothered me.
During rounds, the Dragon did a terrible thing.
I was letting my orientee handle rounds, and she was interrupting inappropriately--this is another thing that bothers me about her--she doesn't listen to other people.
He turns to me and in the middle of her sentence he growls, "You don't like her very much, do you?"
I was taken aback. I don't. But I thought I was covering it.
"Of course I like her!" I mean, what do you say?
"She doesn't like you very much," he says to my orientee. "You'd better step it up."
Well, two points for the Dragon, I guess. But...I'd rather be putting a nurse I could trust out there. I really think there's something a little wrong with this one. But how do you quantify that? She's hitting all her marks...
well that's my 1/2 hour.

Who breathes?

Folded in, contracted, like an umbrella, rusted together, welded stiff. Curled in agony, curled like a fetus. Malnourished--the rehab in Virginia hadn't been doing their job. Tried to put pillows between her knees, couldn't pry them apart. Veins flat and flaccid, bones piercing the skin from the inside out. Jaw clenched like a pit bull, the teeth loose and dirty from lack of oral care, bed sores, break down, perfed stomach, septic. Cold. Warmed her up. The only thing that moves are her eyes--her left eye seems to see and perceive. I didn't get this at first.
I've become hard. I watch students and new nurses come into our unit and they're so soft, so compassionate and caring. Slow. Gentle. But if you're going to become good at this, you have to make a compromise between fast and gentle. And sometimes gentleness and kindness aren't what you think they are--but that's a different meditation. I have lately very few patients that really get to me, but I wanted to throw myself over this child and weep.
First time on a motorcycle. 17. Went for a ride on her best friend's (a boy) new motorcycle. Climbed on the back. Here she is in our unit.
Old head injury--over 7 months. I don't usually see them after they leave here and go to rehab.
She looks like a concentration camp victim.
"Is this normal? Is this what happens? Was she neglected at the rehab?"
Cindy Chang, our impeccably dressed, workaholic, incomprehensible chinese unit dietition answers me, "is what happens, head injury, no muscle, cachexis. See it all time."
But I'm still horrified. "But couldn't we fatten her up somehow?"
She smiles. "Obesity big problem in America."
"Shut up."
When the girl doesn't like what we're doing, she bites down and holds her breath. She's intubated, because she's been septic. But it resolved miraculously quickly. God, young bodies are miracles. So are old ones. But young ones, even compromised. Boom boom boom. Life force surging through. She hates the tube.
I try all weekend to get her extubated. Over the weekend, we have, unfortunately, our laziest nastiest respiratory therapist working. She just wants to keep her intubated. The residents, new to the floor are scared and intimidated. The RT keeps finding excuses.
"She'll get pneumonia."
"Her lungs are clear," I argue
"She doesn't have the ability to clear her secretions."
"So she should stay intubated all the time? She wasn't intubated in rehab."
"We might have to go to the OR again."
"Anesthesia could intubate her again...I believe that's part of their skill set..."
I don't want to get to nasty with her, because, in the long run, I need the good will of this fucking RT more than winning my point of extubating this girl 2 days early. It's like a chess game around here, some times. Know your pieces, know how they move. How far you can push them, when you can get them into position for someone else to take them off the board. If it was life threatening, I'd get nasty, but we aren't yet to the critical point of risking VAP (ventilator acquired pneumonia). I could push it faster, but in the next room, someone is busy dying--on pressors, desatting, and this RT isn't good with stress--to be effective with the other, more critical patient--but at 1500 on Monday, after battling it for 4 days and being put off--I finally get hot. I drag Baggins, our diminutive fellow into the room. The girl's lips are swelling and blistering around the tube, the tape cuts into her cheeks.
"RT didn't extubate?" he says, surprised.
"RSVI's too high--but that's her baseline. It's just an excuse. All day."
We get the RT in--
"We're extubating now." He says.
"Her RSVI's too high. And she holds her breath when she's mad"
"Let's just give it a shot."
"Okay--I've got to go check the ventilators on the other side, and go to CT scan, but then I'll do it." Hedging.
"Okay," Baggins says, "I'll go ahead and do it. You have your pager, right?"
Sometimes, I hate Baggins, and sometimes I love him.
So we extubate. The girl sighs a long sigh. Then starts breathing and falls asleep. Sats high. Jesus.
Would you do that to your kid?
In between our usual inane conversations about things like excess body hair, we talk about this.
Quality of life.
But how can you ascertain that? And you know, you're not here just for yourself. You're here more for other people. We fear suffering so much, we say we fear causing it, but we cause it all the time. I don't think this is true, when people say that. I think they fear something else. If it were my kid, and he was still looking out at me through his good eye, and holding his breath when he got mad and biting nurses, I could not let him go. We think a life is worth something only if meets certain standards, and this error in thought is what leads us to both passively and aggressively commit acts of violence on others--others of other races, of other creeds and faiths. It's why we're able to go to war in Iraq, it's why we're able to ignore the Sudan, it's why we're able to ignore the poor of our own country. Same error--we think we're God and can decide when a life is worthwhile and when it's not.
Who breathes you?
Who is breathing?
The girl, the creature, skin and bones, lies in our tower, our twilight ship. Breathing just as surely as you and I.
Breath of the world. Breath of all. We can only serve.
That's my 1/2 hour

Nick's Birthday

Today's Nick's birthday. He's seventeen years old. After I dropped Lilly off at school today, I took the car in to be inspected (you would not believe cosmic forces arrayed against renewing my tag--all of yesterday was about trying to get my tag renewed and failing, miserably--but that's another story). The mechanic, a very blue-eyed base player, hit on me last week. I had stopped in at the station to fill up the Saab and it broke down right there. Right at the pump. I had to buy a new battery, but at least I got flirted with. So, long story short, I decided to get the car inspected there--I mean--go where you're appreciated, right?
"It'll take about 45 minutes." he told me. He had told me yesterday the car didn't need to be inspected, something which the girl at the DMV, dripping with bling set me straight on. I have never seen more rhinestones on a daytime ensemble. Earrings, fake chanel pendant, jeans, even the tips of her nails.
"The mechanic told me I didn't need to have the car inspected."
"He told you wrong--"waving a gleaming hand. "Just go back and tell him from me. I'll let you in to the front of the line. I'll remember you."
I love the Little Dixie DMV. This is the only DMV in America that's actually kind of fun to go to. I've never had a bad time there. I've never waited more than 6 minutes for help.
I went back to the garage, but they were full. So that's why I was there this morning.
So this morning I'm there in the cold with 45 minutes on my hand. Near the garage is the town cemetery, Office Depot, a Walgreen's, an Sherman elementary school (where I went to school--one of the first integrated classes--I was beaten up daily and had corn thrown at me every day at lunch), and the public library. I decided to go to the library.
My dad bought Nick this huge black down coat from a store in a mall. Nick refuses to wear it. "It's a gangsta coat, Mom," he informs me. It is. But it's warm. So I wear it. It can probably stop bullets. I walk up the hill to the library, and peek in the door. A well groomed young woman walks up who cannot be anything in life other than a librarian. She smiles. "Are you Libby? No badge yet, huh? I'll swipe you in."
I must look sort of eager and respectable. She thinks I'm a new employee. For a second, I play with the idea of pretending to be Libby for the morning. Good practical joke? Yeah....but I'm all respectable now and too many people know me. They would think I'm losing my mind.
"No...."
"Oh,--the library doesn't open til 9" she tells me pleasantly.
So I keep walking.
I decide to go to the cemetery. Every day, I try to do one weird thing. No matter how small. It keeps me engaged. And, believe it or not, other than the time I accidentally kicked a ball into the cemetery in 1st grade and had to go retrieve it (the cemetery borders the playground), I have never gone in by myself.
So I turn in down the narrow black asphalt road.
Funny how we keep our conventions, even in death. The tombstones of married people, for example--the wife's is always shorter than the husband's. Here are the names I've grown up with--the names of streets and stores and colleges. Some of the dates are heartbreaking. Farther back, the stones change, smaller, carved, names fading, dates in the 1700's--and lots of phrases like this: "born in Virginia in 1786--died here in 1850." The first people came to our town in the early 1800's from Kentucky. I look across at the empty fields--sparsely scattered with stones. The Taco Bell. The empty part was supposedly filled with slave graves. The plots are for sale now. The Taco Bell was built on the graves. It was stuck by lightening the first year it opened. We know why...
There's the stone for the 1st president of the university--and next to him is one for his son. I read the dates--1839-1859. Buried his son. Nothing in here can tell that story.
I think about Nick, 17 today. All the birthdays behind us. The childhood behind us. His childhood's in the proverbial can. Done. All the things I wanted for him.
On his first birthday, Nick and I went to the zoo. We rode an ancient, patient, sawbacked elephant. I still remember the stiff hairs on its back and it's astonishing shiplike sway as it walked in a circle. There were flamingoes, and Nick was so delighted--we had to go back again and again--he loved them best.