Rita

The last week at various times.

The sense of viral incursion is waning, but my fatigue remains. The hot flashes have gotten me to a breaking point, with no physical, mental or emotional reserves. Dylan got me an appointment today, and I'm taking Susan's advice to try HRT patch. I really thought I could ride it out. Also going to try to see my old therrapist for a touch-up visit. Basta.

Going for St. Rita today.

Puttering

Kept the window closed last night to keep the cat-traffic down enough to sleep. Wonderful, wonderful sleep.

Puttering around this morning, came across a cracked story, and this paragraph jumped out at me.

I spent the rest of each day with nurses. Nurses administered my medicines, helped me to the bathroom, brought in my food, changed my IV bags, X-rayed me with a portable machine that was super cool-looking, and basically waited on me hand and foot. To make it even more impressive, after I got out of the ICU and went to the oncology (cancer treatment) building, all of those duties were served by one nurse alone, who was nine months pregnant. She worked a 10-hour day, every day, until she finally started going into labor, which happened the day before I was discharged. Her reasoning for working such long hours while so far along in her pregnancy was, "If I'm here already, I won't have to go anywhere when it's time." So, yeah, I'm super glad I had that lady taking care of me.

And this is what all the tv hospital dramas get all wrong. Doctors are there all the time only in fiction.

Once a day, a doctor would come into my room, surrounded by a small flock of doclings, and ask me how I was feeling. They would tell me that I was doing well and then leave.

Yup. The nurses are the ones reporting any problems, watching over patients and making adjustments (that they have to page the surgeon/doctor to get orders for.) I know, because I'm the one who relays the messages in the OR between them.

And the thing about pregnant nurses? Oh, I don't think I've ever heard a heavily pregnant nurse NOT make a comment like that.

Eleanor has her chin on my shin, and all is bliss.

Tourniquet

The charting change. Well, I knew the tourniquet page wasn't perfect, because it wasn't even there during the training. Sure enough.

Tourniquet charting involves pressure, time up, time down and total time, placement and padding. In orthopedics, they are used at least 95% of the cases. About once a week, we use them bilaterally, doing carpal tunnel releases on both sides is the most common, but sometimes it's both knees, feet, or a tissue graft taken from the opposite side of the consented surgery.

Today, we placed tourniquets on both legs for a bilateral case. I tried to mark the same, and got a box saying "The Procedure is BILATERAL." Yes, and I want to put tourniquets on both. No dice. Could not get past the message. Yeah, that's perfect. Thankfully, although placed, they were not inflated, so I left a note. On the next case, I found I could not document placing a cuff on the opposite leg, either. Which wasn't an issue today, but certainly could be. There was no option to override.

There also wasn't the option of adding a second cuff, nor a third. Admittedly rare, I have done a case with three tourniquets, not all at the same time, both hands, and a leg for a graft.

Cages were rattled, hopefully we will get this properly "built" soon. That it has not been done is just proof we didn't need that no one thought of us, or didn't listen when our people working with them told them what was needed. Not the only issue, but the most telling.

Pneumatic tourniquets, set to a specific pressure, all timed, keeps the blood out of the field during work, prevents more than minimal blood loss.* We keep the time minimal, over 120 minutes and the risk of tissue damage just from the pressure increases. Less than 60 minutes is more usual. Although there are not any good studies about what is really safe, under two hours seems to be. A carpal tunnel release tourniquet time runs about 5 minutes, sometimes less.

Going to be a long process, this new system.




*Which is still not as much as one might expect, even without one. A careful surgeon doesn't get a whole lot of bleeding, for elective orthopedic surgeries.

Experimental

Two hard days, but with good people to work with, which makes all the difference. The last case this evening was experimental, I can't explain why without a potential confidentiality breach, but the surgeon placed experimental devices that in others will be eventually used to attach prosthetics that will move as a normal hand would move. Lots of set-up, and remote video, and recording, researchers with cameras and supplies. Nothing too strange, and they were very appreciative of my handling of so much (to them) equipment. Yeah, well, I've seen more new equipment and larger entourages many times before, this was relatively minor. Not to mention interesting. And I got a lot of it set up during the previous case. I have eaten more complications than that for breakfast.

Metaphorically.

This is probably why I have learned this wobbly, but untippable attitude. The lab/engineer/research folks seemed impressed. I considered it a slightly more complicated, busy case. Not the worst by far.

Worst most busy case ever was the arm disarticulation for bone cancer, with about 30 frozen section specimens that had to be run down the hall, two surgeons, residents, equipment everywhere, and just me, running. Fast. For about five hours. Felt longer.

Feeling better about the garden. Nothing I could do about the salinity but water more, and the rest is a matter of growing stuff there and lots of compost. Not planting would not have done anything but stasis. Three to five years before it will recover. I can cope with that, I have time.


I do love experimenting, collecting data, researching. Learning patience, an eternal lesson, never done.

Moby very chatty last night. Quite the variety of vocalizations for a long, long time. The news, one supposes. This is so much a new behaviour for him, we like to think it is indicative of confidence, and perhaps of confidences.

Crack

The advantage of sitting around at work for two hours with nothing at all to do, on a one room, short, day, is that people want to share neat stuff. This is the most awesome and frightening video.



Last patient added on, because, having been scheduled earlier in the week, but showed up drunk, case was cancelled. Individual drunk today as well. Still drunk, possibly. Took over 90 minutes to get the blood to the lab and the lab to run ethanol levels, while we sat on our hands. Anesthesiologist very against doing the case, for safety and legal reasons. Surgeon is digging heels in and insisting. How can a person obviously inebriated give legal consent? Well, it can't happen, although in an emergency it can be waived. Not at all at a specialty hospital for what is termed an elective procedure. If it can wait five days, it's not urgent nor emergent, by our definition. When we got results, three times the legal limit, 0.24, meant, no we can't do this. Oh, and patient denies having any alcohol today, and only a "couple of beers" yesterday.

Plus, if this person is this dependent, then it gets dangerous for them to NOT drink. DTs are not just a risk for staff, patients can go into seizures and die. It's safer to go cold turkey off heroin. Alcohol withdrawal can kill. And who would be held liable? Not primarily the pushy hand surgeon, but the anesthesiologist and the nurses who accepted the consent and sedated or anesthetized the patient without adequate back-up. Especially when our trauma center is just up the street, and regularly handles this kind of complicated situation. We have to treat the whole patient, not just the injury, and the alcohol dependence is a huge part of this situation. This person needed to be handled at a higher level.

Proverbs

Busy, busy day, and me the runner. I wrapped blankets to be sterilized, I rolled bias dressings because they were out, I turned over rooms - opening for the scrubs, making beds, shifting equipment. I gave breaks and lunches and cleaned and ran. I scrubbed in at 3, which was a bit of quiet relief in comparison. No wonder moving is not as daunting for me, it's no worse than a long day at work.

We have allowed ourselves a week to do the move. Closing on the 13th, which is a conference day for our surgeons, and we will likely only be running one room anyway, so getting it off was a piece of proverbial cake. Ta (ladi) dah! To move in on the 17th. Looks like we are going to have to have a Groundhog Day party, as I have been joking about doing for years, since there is no way I'm putting up and taking down a christmas tree as I pack up our stuff. Maybe I will put it up for the new place. Maybe. But we should be settled in sufficiently by then, knowing me. February 2 is a Thursday, so it'll have to be the Saturday after. Close enough.

It's kind of an ideal move, only a few stairs, two blocks away, from a small place into a larger one, not just one day. This, by the standards of a move, is going to be more, proverbial cake. It probably won't snow every day that week.

Thumb is much improved. But Dr. A, who I would have preferred to take care of this, but Dr. Tigger is hard to refuse, has told me I should have a hard splint, especially during the move. She was going to write a scrip for me to take up to the hand clinic, but I missed her before she left today. I'll catch her next week, and will follow her directions. Going to continue to baby it for a while, as it heals. Thumbs are best well cared for. Very important, opposable thumbs.

Going to bed early, to sleep, to recuperate. Inspection on Wednesday. Title being checked. Will start the packing process Saturday.

Moby still blissfully unaware, although we've told him. He'll know something is up when the boxes start stacking.

Hips

D's brother N. sent lovely almond christmas cookies, and red tissue paper, which Moby knew was just for him.

Winter whoooshed in, although it didn't feel as cold without the wind.

Weird day, obvious from the schedule, and it got worse. One nurse called in late, due to problems from the wind damage the day before. By then, I'd already set up the room, and assumed I'd be there, which I was. She got there as the first case finished, and a bugger of a case it was too. The next room along call it #2, had a surgery that went to hell on a greased slide with a handbag full of lead. Poor B had a difficult day. And room #1 - and it's surgeon- had to wait four hours for the surgeon in room two to finish, because surgeon #1 needed surgeon #2, as it was an unfamiliar procedure to surgeon #1. Surgeon #1 is not known for his patience, his catchphrase is "I feel myself Waaaiiiiting....." But he held it together pretty well, for him.

Room #3 was just three straightforward hip arthroscopies, but that surgeon had a much simpler knee scope to wedge in somewhere. Hip scopes are complicated set ups, takes a bit of time and a few hands to turn a room over to a knee, so we try to set up a different room instead. Given the delays, that looked unlikely. By 1500, I was scrubbed into the hip scope, and delighted when the knee scope went to .... room 2. So, once we were cleaned up, I went in and offered B relief. She accepted with near-glee. She certainly had the worst day, at least the other room had a gap. And it seemed good karma to kick her out. Surgeon #3 is very quick with these, so I figured it wouldn't be long. The other circulator and the charge nurse also stayed to get everything put away before we even left the room with the patient. One of those days that ends with good feelings and gratitude.

Stalwart

Working yesterday with one of our more... um, challenging surgeons. Two huge cases, no disasters, I just kept ahead, or at least up to him, all day. In no small part because of V, a great scrub, although I still often struggle with her accent. She does a lot of non-verbal communication with me, and we are both fluent there.

Arthroscopy is all about keeping the fluid going. Three liter bags of lactated ringers solution, four bags, two pairs spiked with Y adapter tubing, that flow into a double tubing that goes through a pump - with a control on the sterile field. Part of all this fluidity comes back through the suction on the shaver, some simply flows out and onto the floor. For keeping the floor from becoming a lake, puddle guppies, flat floor suctions, round but with a suggestion of fish shapes.

It all pours through the joint, providing the space for visualization, and flushes out debris. Running out (because one is busy doing several other jobs) causes whining (from the surgeon.) Bubbles from an air pocket when spiking a new bag, or letting it run out, get into the working space - which takes a bit of work to get cleared. Which slows down the case.

A normal knee scope, to debride away a torn meniscus, with a surgeon who manages fluid well, takes about two bags. Add in a resident getting practice, add another bag. Regularly for Dr. Challenging, 4-5 bags. In this facility, we have 20 liter self-contained suction daleks, called Neptune. They roll well, and there is a station in decontam where they offload and wash out. Best system I've ever worked with. Most routine knee scopes, they don't even need to be changed for two cases. For an ACL repair, usually one per case is sufficient. On a very large shoulder rotator cuff repair, a second one is fairly normal. That's the background so you will get this next set of numbers.



My long standing record for number of bags on a case - 23, recently fell when I got to 30. Yesterday, 32, THIRTY TWO, and filled the Neptune 5 (five) times, and I had #6 in the room ready. All with Dr. Challenging. All shoulders. And he hates the noise of puddle guppies, but yesterday I ran two throughout the case, and he didn't so much as mention that to me.

Recently, we were given a new stand to hang fluids, square tower, about 6" per side, with a knob and graduated notches to raise and lower each hook individually. This saved me yesterday, because I didn't have to reach up as high, but I could still easily keep the bags at different levels, allowing me to change them out more or less at my leisure, and keep the bubbles out. Raising one half of each double spike so the bottom of that bag is above the top of the other, the pressure of the lower one keeping the higher one from running out, until I had time to respike a full bag, then pinching below the single tube of the confluence to allow the air to flow back into the bags instead of down the tubing. An apparently empty upper bag can happily sit there for quite a while, as long as the lower bag is at least 3/4 full. Dr. Challenging only had to have me describe what I was doing once, and he's trusted me since. Some of the otherwise-less-challenging surgeons still remind me every time that I'm getting low on water, when I'm not. But then, the nurses I work with seem uninterested in my method, and I stopped trying to show them long ago.

Dr. Challenging, after our ten hours together, thanked me for being "Stalwart" - which I appreciated.


(I've gone back and edited this a dozen times, but if anything is still wrong, let me know.)

Back

As in the OR, it's not rude when a cat turns his back to you. See those ears? He's listening. Sitting close by.

Wound up scrubbed in all day, on some difficult - which is to say frustrating - cases. Didn't have the correct (proprietary) screwdriver to remove some hardware put in two years ago, although we eventually got it from the main hospital. Most of the rest of the problems had to do with my issues with my vision. Surgeon in good humor, considering. And considering that he is often rather cranky, especially on a day with a dozen surgeries. Short staffed, which is why I wound up scrubbed in, leaving us one short for lunches and resource. A PRN nurse circulated for me, which is never fun, since one winds up doing both jobs to an extent. Last case in my room ended as room #1 ended, the other two rooms came down within the next half hour, so room #1 staff and I helped clean up the last two. Sterile Processing was also short a person all day, so we all wound up in there getting them caught up. I put away freshly sterilized sets, wrapped all the light handles I could find, and all the drill sets, which finished me off. I cried "uncle" and came home at 6.

Tomorrow, I get my eyes checked, and I expect this will include bifocals, possibly trifocals. I'm at the point where I'm thinking, whatever it takes.

So glad to be home, cat and guy beside me. Feeling loved.

Beet

Going to dinner with D's parents. Thankfully, got off early enough. A speedy day.

This mesmerized me. Below is a rant, don't feel you should read it. Just watch this.




Despite our last patient being a squirrelly drama queen nutjob. Not that often we have a young, healthy crazy patient. Older, ill crazy folks are fairly common. These are the people who think the Nothing By Mouth thing is a kind of joke, tell everyone their life story without invitation, take longer for the pre-op nurses to get ready than the elderly, half deaf, mobility impaired patients - who we expect to take a while. The ones who have no impulse to calm themselves, even with clear and calmly repeated prompts to take a deep breath, relax. The ones who go down fighting, but without a known, clinical anxiety diagnosis. Had one when I was in Boston, in recovery room, having a complete freak out about the nerve block for her arm, wanted us to make it go away. Well, that isn't possible, it takes hours to wear off, that's really the point. Admittedly, it is an odd sensation, but most people find it amusing or mildly annoying at worst, not to feel a limb, to sense that it is in a different place than it actually is. This woman was screaming, demanding, squirming off the gurney. Her boyfriend stood and watched, a kind of awakening horror on his face. As though he'd known she was eccentric, but had no idea she was earfuckingly insane, and realization was dawning. He was determined to stand by her, get her home and safe until she was stable. Then, he was going to run away as fast as humanly possible.

These inconsolable people never get just local anesthetic with a whiff of sedation, they cannot be trusted to be still through the case, to tolerate any amount discomfort, not to try to get up and leave. It's a full on general, for simple safety. That we have quiet after is just a plus. I've seen the lighter version tried, and seen it go bad, prolonging the surgery unnecessarily.

We once watched the show Mad About You - for a couple of seasons, until the one where the lead female has surgery. She behaves wholly inappropriately, demanding and ridiculous throughout. I could never see the character as believable after. I know the difference between the abnormal normal of such a stressful situation, and the freakish abnormal of someone broken completely decompensating. Especially for a minor, ten minute, hand procedure, that most people could easily manage with a local or a bier block.

Still, takes all kinds. I just prefer the ones who have some modicum of self control, or a good reason not to be able to.

Twelve

A solid twelve hours work, but with good support. Lifted 64 three liter bags of irrigation fluid for four extensive joint scopes -two complex shoulder repairs, two ACL knee repairs. That comes up to handling over 400 lbs. Broke my own record of bags for a single case, from a previous 23 to a current 30. Changed out the 20L suction device 4 times on that one case. Started our last surgery after 1730, but thanks to a couple of folks staying to the bitter end of their shifts, we turned over VERY quickly.

Most of the day, I worked with P, who has very good eye language. I sometimes struggle with her accent, I have a deaf spot with a lot of Asian Englishes. But she is very good at catching my eye when she needs to communicate with me, or miming what she wants. Sometimes, she just writes me funny notes, and holds them up. And she tells me I'm rather good at picking up on her prompts. She will point, or look, and I go and check, bring her what the surgeon asked for - then I look at her to see if she already has it, and she either waves me off, or nods, and I (continue to) move. Likewise E who relieved her, gives me a word or a smile, and I respond. It's so important in this job, and a real joy when it works well. A kind of trust and respect.

From when P left at the end of her shift at 3, until E took over at 5, I had to deal with a scrub for whom this subtlety is a closed book. I feel her staring at me, but when I give her a questioning look, she rolls her eyes back. I look at the irrigation bags to check their level, and she looks at me for a while before realizing I'm not looking at her. No matter who I speak to, she answers. This is the kind of skill it is nearly impossible to teach, it has to be picked up by the observant and sensitive. Hard to describe, and those who don't get it get huffy and frustrated.

So wrung out when I got home. D made me dinner, I used the foot massager and iced my back. Moby slept on me quite a lot last night. Lots of dreams.

Laser

Playing with Moby a bit last night, and wrapped the ribbon around him, and in a moment of silliness, tied a bow. This seemed not to bother him at all, and he walked off to have a nibble. More that I was taking photos. It was still on when we went to bed. Well, he never got fussed about collars either. He presumably removed it sometime during the night for bath taking, which wouldn't have been difficult, it was very loose on him.


Today, a rope.

Fridays are just too long to manage posts, nonetheless ten things. Maybe seven things Saturdays. Scrubbed in on hip arthroscopies, simple stuff, but a lot of standing. D made chili for dinner, for which I am very grateful.

So, as I stood there, I thought of the surgery gadgets, most of which make a good sound, starting with clasps.

1. There is a kind of double clasp used on a lot of instrument cases, and all the sterilization pans. I pop the plastic arrow tab as I release the lower clasp, pull it up, and release the upper part to remove the lid. There is a particular feel and sound to it, and I know immediately if it wasn't sealed properly in the first place, or if the tabs are missing - without looking. Lots of variations on this double seal from the various suppliers. Reminds me of the adjustable metal clasps on my brothers' hand-me-down galoshes when I was small.


2. Clamps. Most of the instruments are clamps, and most of those are ratcheted. Clamping one of these on a towel, unclamping, clamping, unclampi... well, it's a great fidget. Oh, and very useful. Loading a needle onto a carbide coated needle driver is a skill all by itself. Putting it in the right place at the correct angle and direction for a left or right handed surgeon. Not difficult, but it does need to be actually learned.

This photo shows a proper shaped needle, but the driver is smooth - no carbide grip, only occasionally used in plastics. Which would be right, since there is no swedged on suture, but an eye, and only in plastics do we ever thread a needle with an eye. The direction is for a right handed user, but the grip needs to be closer to the back, and the angle needs to be up and out, not flat as shown.


3. Staplers. To close skin, or seal the gut after having to take a bad bit out. Really amazing variations engineered by people who can flex space in their head the way I can't. But my favorite is the LDS stapler, because it has a CO2 canister to power it, and it makes the most wonderfully satisfying ssshhhthunkgsss.

There is an inservice video here, skip to 55 seconds in to hear it, instead of going through the whole thing and fall asleep instantly of the utter boredom of it. Above all, don't buy anything.

4. Nerve stimulators. These are little, electrical, pen like objects used when doing repairs on hand injuries (mostly under the microscope) to isolate or locate a nerve. Always interesting to see enervation in action. Useful in a scrub's hands as a threat to cranky surgeons.

5. Laser pointers. Lasers have not proved as useful in surgery as anticipated, or still widely believed by the general public, with the exception of eyes and a few tumor specialties. But when a rep is directing a scrub on a new and/or very complicated instrument/hardware set, a laser pointer is a sterile way to say "this" doohickey and "that" thingmabob. IF they use it correctly, and don't just wave it around. Also good in other settings as a cat toy.

I've suggested a "bring your pet to work" day, but for some reason, no one has taken me up on it. The dogs would just lie under the tables, and lick the floor. Cats would jump up on the sterile field and take a nap... oh, wait, that could be a problem.

I had seven yesterday, but since the list was on the field, I could not bring it home. And I just can't remember the other two, so they couldn't have been very good gadgets.

Arthroscopy

I've been setting up hip arthroscopies a lot recently. Five in the last two days, so the list for them is in my head. It's quite a folderol.

1. Get computer and monitors started, as for any case. Return between each job to hit various prompts as system progresses.
2. C-arm in room, on correct side. If both left and right will be done that day, plug in main power to monitor so it can be switched from side to side without unplugging. Bag foot pedal, place under bed.
3. Adjust standard bed, leg segment lowered, fetch positioner.
4. Apply positioner, with leg holders on the correct side. Lock everything down.
5. Put pads on leg holders, available for later.
6. Get X-ray aprons in room, get my own thyroid shield from locker.
7. Two neptune suction (20 L) machines in position.
8. Hang and dual-spike 3L LR bags. Check amount of fluid bags on cart.
9. Turn on camera, light, shaver box, electrocautery, unravel foot controls for last two, cover with plastic bags and position under end of bed.
10. Set out chloroprep and shaver, have arm pads and towel clips. Armboards on bed.
11. Sheets on bed - another every case thing.
12. Meet patient.
13. Start music. Literally, not being poetic here.
14. Get local anesthetic.

1. Patient enters room on gurney with anesthesiologist, I get warm blankets, help patient move over. Put armboard on, take gurney out.
2. Remove grip socks, apply foot/leg pads, safety belt.
3. Tie up scrub gown. Assist anesthesiologist as needed.
4. Assist surgeon to position, although he does most of it. I take care of the arm tucked across the chest, apply warming blanket.
5. Get C-arm in position as they drape.
6. Plug in camera, light, shaver, fluid pump, suction, lay down dam blankets, make sure everything is working.
7. Chart, keep fluids and suction going.
8. Set up post op cooling pad and roller on gurney in hall, with O2 tank and mask.
9. Stave off boredom for the next few hours.
10. Move patient onto gurney, clean everything up, do it again.

Gibbous

From last week, when the moon waxed gibbous.

So good to circulate for an RN scrubbing. No matter how good the scrub tech, having a nurse in that position makes the day go easier. They cannot help but think about the stuff that helps the circulator, they have stuff in the room, they group requests together, they ask the surgeon for what else is needed. Just having all RN staff seems too expensive, but I often wonder if it would avoid a host of tiny expenses that over time would make it worthwhile. I'm just glad I got in while they were still routinely training RNs to scrub as well. I'm better at both sides of the job because I actually do both. As surgeons who have worked their way up are more considerate and less wasteful, usually as aides and ancillary staff, but even that makes a difference.

Thinking about the car habit of allowing space driving, letting cars in, not filling every gap. Comparing it to substances that stick and clump when going through a narrow space, versus material that flows and does not stick. I think when we drive closely and greedily, we become sticky, in exactly the same way. So when we allow space, we flow.

Residue

Evidence of the weekend fire. Apparently started by a campfire not adequately smothered from the day before. All out, now. This is taken from the parking lot at work, a University shuttle is visible in the lower right.

And yes, still snow in the mountains. One of the resorts was still open for skiing on the 4th.

Took the camera to work, as I am trying to take a photo every day. Here are the operating microscopes, part of a C-Arm x-ray machine, and all the (not lead) radiation aprons.

An operating table, partly dismantled. Used with a shoulder positioner earlier, and rolled into the hall for later assembly. The yellow is a gel pad. The strips are velcro to keep the foot pad in place.

Jour

Big concert on campus this evening, and my surgeon du jour has tickets. Not just any concert, but a band that came through last year, and cancelled, rescheduled today. He's set up a tailgate party for his party of 20 in the parking lot ahead of time.

This surgeon is one of those guys used to having his way, and a thorn in the side of our director of anesthesia for over-scheduling, and wrangling in add-on cases, under the half true pretense of it being 'all about the patient.'

So, our anesthesiologist tells us this morning of his plot. He will tell Dr. D'jour, at the latest possible time, that his last patient drank apple juice, and has to be delayed two hours, but he's more than willing to stay to take care of this patient. He deserves an award for his acting, it went perfectly. And Dr. D'jour? "If it's going to be another two hours, I'll cancel and send her home!" Swallows it hook, line, sinker, pole and reel. On the other hand, he does take it in stride when we all break out laughing. Repeatedly.

Scrubbed in, a lot of white noise as usual, music going, I can barely hear the resident dictating notes into the phone, and it sounds so much like a monk chanting, a priest saying mass to himself I have to remind myself it is not.

Cringe

I have been thinking about who I might be tutoring, and how to ask the Learning Center organizers about how to place me. And I wanted to ask for someone bright, of any background. I thought about having to teach my father, and the light came on, why I want to do this.

My father grew up in a French speaking family, "River Canard French," uneducated, illiterate French. He attended school in English, rural Ontario, no help at home. Even his parents were nominal, he was mostly "raised" by his older brothers - always a bad idea. Got to about sixth grade, but when I was in third or fourth grade, he was at sea with what I was learning. (Not that he ever really tried to help with my homework at any age.) He never read for pleasure, and was angry with anyone reading a book - considered it "rude." My mother only read when he was at work, and I learned to stay away from him when I had a book in my hands. I was often mocked for "thinking you're so smart." In his defense, he did pay for me to attend catholic school, mom insisted, but he could well have vetoed the tuition. Whomever he did it for, whatever his resentments, I did get a good education, and it was his hard work on a factory floor that paid for it.


Aside from a facility to keep his cars and house in decent repair - which is a considerable job, he had no real skill. He was a mean, petty, and stupid man. Unlike most kids who think their fathers stupid until their fathers get suddenly smart once the kid becomes an adult, I only lost more and more respect for him over the years. My mother got him playing Scrabble, and he did go through a phase, when I was in high school and college, where he did try to read better. Mom assured me he'd made a lot of progress, but I remain dubious, as she always overestimated him to me. The deck was stacked against him from the start, he didn't make much of what he had, making him a man to be pitied. My hatred has all evaporated.

But I need for whomever my student is, to not push all my father-buttons. I do want to give to someone what he needed, if he had just a bit of native intelligence, curiosity, will to learn. This old hurt is, I think, what moves me to do this. As soon as the realization came, it filled that question completely. I will talk with my coordinator about this weakness, and request consideration accordingly.

A woman's got to know her limitations.

Went to get my permanent tooth cap. Dentist put it in, had me bite down, "tap, tap." I tapped, then crunched. Broke the new cap before it even got in. So, they got the new one to the right dimensions, put the temporary back in, and made me a new appointment. I laughed with the dentist and his assistant, had to keep tapping and grinding on it to get the right shape for the remake. Fingernails on blackboard. I kept laughing, what else could I do?

That crunch is familiar not only from breaking my teeth, but from my work.

Sometimes I have to prep an arm or leg that is quite broken, after the patient is anesthetized, and I get that crunch of broken bone edge against broken bone edge. Crepitus is the official term. It's the one sound in my work, the one feeling, that still gets to me, viscerally. I told D about this most carefully, and it didn't take much. He knows that feeling from the inside, in all kinds of bad ways. And he needs to stop reading right here.

Really hard to have to hold a badly broken arm or leg, hold it in a sterile manner, wash it fairly vigorously with prep solution, while it is not stable, and making scrapey-crunchy noises, until it can be draped. Of all the jobs I have to do, this is the one that still makes me shudder. Doesn't stop me, but I cringe every time.

Pan

Last night:
Warm, windows open. Inside all day for me, another long day, but it's all income, and I can't complain too much. I was the runner, the opener, the turnoverer, the break giver, the clean upper. Got home by 1830, worn and welcomed.

That is the best part, that D always brings me home. Despite my fiddling with putting away my baggage and taking off shoes, and bitching about my day, he waits until I pause, then eagerly greets me and hugs me. It is a wonderful life, to be always wanted, embraced, welcomed. I am unspeakably grateful, to know where home is, always. I never forget it was not always so for me, that for long years I had no home. Twenty years on, and I still value this proof of being beloved.

I've been thinking about values, about what values matter. Certainly not family or religious values. I remember my mother talking about a new married couple choosing each other first. About how my brother didn't value family over friends. All about a vague kind of precedence. I never quite understood it. Loving one's father because he is one's father. Assuming love (should love ever be assumed?) due to genetic proximity. This very idea offends me. I've never been much motivated by money, only the security that sufficient money brings. I'm not a believer, not a joiner, not a fan of institutions as an ideal.

I value kindness, competence, serious attention to one's work, and great amusement at the vagaries of life. I value expressing love in any form as many ways as possible. I value art and wit and intelligence, as well as critical thought. I value care of the helpless, children, pets, the elderly. I value respect of those who have earned it, and gentleness for those who have not. I value discipline and self control, and those who know they have no control over anyone else. I value thoughtfulness and curiosity.

This morning:
Thinking about a discussion on another blog years ago, commenters getting hot under the collar about using a dishpan, the consensus that everyone uses them and they are useless. Their reasoning mostly in the negative - that their mother had one, neighbors, and they could not see why.

I use one, my mother did not. I remember having to plunge my hand into the cooling, greasy water to pull the plug, and retching as I did so. The water in the large sink lost heat very quickly, and I've broken glasses on the porcelain - a treacherous accident. So, when I got on my own, I bought a plastic pan to put in the sink, like my aunts did. Uses less water - that stays hotter longer. I've never broken anything on the softer material, and when I'm done, the dregs get poured down the disposal cleanly.

I remember a story from the infamous Reader's Digest, of a woman who cut the ends off the roast. (Yes, this was a very long time ago.) When asked why, she can only say she thought it has something to do with the flavor, because her mother always did it this way. The mother simply says her mother always did it. The grandmother is asked, and she replies "Because that was the only way to make it fit the pan I had."

I've never been any good at memorizing, it takes a huge amount of effort and time for me to get a short poem in my head, or a phone number. But if I know why something does what it does, why someone was given that name, why that number, it stays forever, clear and connected. It doesn't even have to be a big important why. Much of what I do at work is protocol, we do it that way because it works well enough, and simplifies complex tasks so as not to confuse others. The tourniquet has two hoses, one blue, one red. In this place, we always use the red one, unless both are needed for a bilateral surgery. Then we use Red Right, Blue Left. It really doesn't matter, as such, but prevents inflating the wrong one on both sided cases, and keeps the one not connected from being accidentally used - to no effect - on the rest.

Why do you do what you do?

Clouds gathering, proof that the mild day will be shoved aside for at least one more snowstorm. At least it doesn't stick around down here on the valley floor.

Suckage

Yesterday, only three rooms, but each one a bugger in it's own way. All long days, large cases, difficult docs.

P had Dr. Acid, loud, pushy - asks ... um, orders every damn set open, then doesn't use any of it. Poor sterile technique, often lets his resident struggle for a long time before stepping in, insists on the music being loud. Gets right up my nose, although P doesn't mind him too much, sees the humor. That would have been the worst room for me, but it ended earliest.

A had Dr. Tigger, also loud, thinks himself hilarious, wants what he wants, but often asks for the wrong thing - particularly for the larger, less usual repairs. S, our charge nurse, spent a lot of time trying to keep him from a complete meltdown, all day long. We heard about this indirectly. I get along with him pretty well, as I think he's funny most of the time. This room was still going when I left.

Dr. Bug was all mine, with each case requiring a different bed configuration, and he expected me to have all particulars memorized even though I work with him infrequently. He also has a black tech cloud around him, stuff just fails around him, cameras, lights, shavers - and when it does, it's always someone (else's) fault. Lots of 3 liter fluid bags to hang, and little to no help for our turnover, because we are also short staffed. We finished up second.

So, end of my day, A and S are trying to find something for Dr. Tigger, I'm putting my extra supplies away, S apologizes for not helping my room. I assure her I understand, the competition for attention was stiff. A complains of Dr. Tigger sucking up all the energy. I note that all three docs today are chaos generating, energy vampires. In the juciest, most emphatic way I can muster, I exclaimed,

"Today SUCKED!"


Which made both of them laugh, not the worst way to end an exhausting day. At least the misery was pretty evenly shared.


Reading over on Cracked about the irritations of life, and why they bother us so much. All good, then for one, a solution. Traffic waves.

Blue

Helping out in a room, along with two other nurses, Anesthesiologist rolled patient in, burly, very black guy, and he tells us about his dream.

"I had this dream, surrounded by white folks with blue hair and blue eyes. And I said, 'I'm in the wrong dream!'"

We all looked at each other, and laughed with him. Yup, mostly blue hatted, all white, a few with blue eyes.

I told him that sounded more like a premonition. He agreed. Made us all laugh. A relief, sometimes, to have the unspoken assumptions punctured outright, brought out and giggled at.

I really can't imagine any nurse I've ever known to treat anyone differently because of the color of their skin, or the gender of their partner*. Smokers or the obese, the hopelessly stupid or hostile, are so much more of an issue. Not to mention the obstructively crazy.

I remember once, working PACU for a day surgery OR, a woman had her boyfriend as her support person, and she was having a complete come-apart. Had a nerve block done for the surgical pain in her arm, and was utterly freaking out that she could not feel her arm†. Nothing to be done at that point, there is no reversing local anesthetic injected around the nerve plexus, but she would not be reasoned with, crying and screaming. And the poor guy was holding himself there, being a decent human being, determined to see his commitment through. Obviously realizing how much crazy he'd been dating. We all figured he would take care of her through the first 24 hours, then make a graceful but permanent exit. That all those charming quirks of hers were being seen in a fresh light.

I've mentioned this before, that the idea that men are babies when they are sick is just not real. I've seen all kinds of variations in how people deal with pain, nausea, drugs, without ever noticing any correlation between whininess and gender. Smokers are worse, needing far more drugs, and getting far less relief. Women having gynecological procedures are apt to be nauseated, young men and Asians are more sensitive to anesthetics, but women are not more or less stoic, as a group, than are men. Bunk. D is very brave and considerate when ill or hurting.

Favorite OR joke, guy coming in for further amputation for cancerous bone. Chatting with me, tells me, "Measure once, cut twice. Damn! It's still too short!"

Burst the bubble, tell the truth, have a laugh.


*Odd for a moment the first time a woman referred to her "wife" in Boston, but then it seemed so easy, shorthand that explained all I needed to know without the coyness of "partner" or "friend."

†Admittedly a weird sensation, like having your whole arm completely asleep, but that persists for hours. Patient's lose their sense of where their arm is in space, feeling like it is floating up, when it's obviously not. A disembodying sensation, so I'm told. But pain free, which is the point.