Jo FAQ

Welcome, readers from ScrubsMag and beyond! I seem to have some new followers these days and am getting lots of emails into the bargain, so I figured I'd do the triennial FAQ, version 3.whatever, to introduce you to the wonder/trainwreck/amorphous thing with flagellae that is Head Nurse.

Who are you?

I'm a middle-aged grouchy critical care nurse somewhere in the heart of Texas.

Where do you work?

Not tellin'.

No, really. Dallas?

Nope.

Houston?

Nope.

San Antonio? Austin? Bridgeport? Del Rio? Tyler? Pine Bluff?

No, nyet, nope, nay, and that one isn't even in Texas. Give up.

Are the stories you tell true?

About my animals, always. About my patients, usually--but I've changed dates, switched sexes, obscured and obfuscated diagnoses and treatments, and generally anonymized them to the Nth degree.

Who are all these other people you talk about?

You might've noticed that HN has a recurring cast of characters.

Nurse Ames and Pens are two of my best pals in the world. Stoya is a coworker who resembles (physically, not habitually) the porn star of the same name. Dr. Heron is a neurologist I work with; Dr. Crane is my own mouth-obliterating surgeon. Dr. Elf is the guy who makes the prosthetics I wear. Der Alter Jo is my namesake, opposite number, sounding board, and friend.

Beloved Sister, Sainted Mother, and Honored Father ought to be self-explanatory. Max, Flashes, and Notamus are (respectively) a very large dog and two brother cats with attitude. Attila is my trainer. The Brother In Beer and Abilene Rob are two close male friends. Rob also has a blog; if we're all very good and mind our manners we may get another post out of him someday. The Man o' God and His Lovely Wife, and Matt and Beth, are my neighbors. I think that about covers it.

What exactly do you do?

Brains, spinal cords, and peripheral nerves. My main focus is neurology and neurosurgery, with a special emphasis on degenerative motor neuron disease and stroke.

What do you do for fun?

I stand in one place and lift heavy objects over and over. I cook. I garden. I go out with friends. I play with Max and the cats. I drink good beer. I read. I sing loudly and off-key in the shower.

Oh, my God. I can't believe you wrote X about Y. I would hate to be one of your patients. You suck. I hope you die horribly.

That isn't a question. You're aware of that, right?

Look: If you're expecting unadultrated sweetness and light from a nursing blog, you've got the wrong blog. There is no other job, except maybe working with abused children/elderly folks/animals, that will make you hate humanity faster. There's also no other job that'll make you love individual people more deeply, or be more grateful to be doing what you're doing.

However, I'm not gonna lie and say that I love everybody or that I'm perfect all the time. If it pisses you off, go elsewhere: it's a free Internet. Please don't waste time sending me nasty, threatening, or abusive emails, especially if you can't spell. Thank you.

Are you married? Boyfriend?

No and no.

Oh, so *that's* your problem.

That's not a question either.

Will you post an advertisement/review for my shoes/scrubs/weightloss product/sex toy?

Head Nurse is an ad-free and paid-endorsement-free zone. Any product reviews I do I do either because I've bought the thing I'm reviewing myself or because I've worked out a deal to donate any moneys from the review to charity.

What's up with the fundraising links and moneygrubbing, then?

Those got their start shortly after I was diagnosed with oral cancer (see September 2010's posts through December of the same year for details). It became obvious that people with oral cancer were sometimes unable to afford treatment or equipment that they needed, so I decided to hit up the readers for cash. The response was amazing: we as a group raised more money than was really practicable for me to keep track of, so I took the PayPal link down.

Since then, several individuals (Tashi and Wash, whose blog is linked above) and organizations have come to my attention who need dinero. I post links to worthy causes or people as I see fit. Everything here is my own fault.

Got any further disclaimers to make?

How kind of you to ask!

Please note that all content on Head Nurse that is not otherwise licensed is licensed under a Creative Commons agreement. What this means is that I don't mind if you repost or borrow things as long as you check with me first. If you repost my work as your own or borrow things, Kharma will get you. All patients, doctors, and nurses are fictionalized to within an inch of their lives. What *that* means is that if I write about something that happened "yesterday", it could easily have happened last week or last year or eight years ago. This blog is not intended to be used for, and the author of this blog will not give, advice on medical matters. If you have a problem, see a professional instead of some schmo on the Internet. If you don't like things that are tongue-in-cheek, you should go somewhere much more earnest.

Everything here is mine unless otherwise credited. If I've fucked up and quoted you without attribution, please let me know and I'll rectify it ASAP. Likewise, if I manage to make a real howler either in spelling or information, tell me. That means that everything that I get wrong is my own damn fault, while everything that turns out okay is entirely due to the goodwill and grace of other people.

Any other queries? Ask 'em in the comments.

Is she outside-in or inside-out?

I've been thoughtful lately.

Not the sort of thoughtful that sends flowers for no reason, but the kind of thoughtful that explores ethical problems.

If you were taking care of a patient who'd specifically asked--when he could talk--for certain things *not* to be done, and you'd heard a doctor promising his wife that those certain things, if done, would only last for a couple of days and give that patient a chance at recovery, and you knew that statement was a bald-faced lie, what would you do?

*heavy sigh*

Here's the deal: a nice guy, about my age, came in with a nasty infection secondary to a recent bone marrow transplant. It was a MUD, not that that matters; what matters is that he and his wife had agreed on what was appropriate in terms of heroic care and what wasn't. He was able to talk for the first two weeks of his hospitalization, so we had a number of discussions about allowable things and dis-allowed things.

The poor guy took a nosedive a week ago. When I say "nosedive", I mean nosedive in the sense that only somebody with a platelet count of fifteen (not fifteen thousand) and a white count of two (not two thousand) can take a nosedive. It was sudden, unexpected, and horrible. I watched as the docs intubated him nasally because he was too jacked up to intubate in the usual way, then spent hours suctioning him so that he didn't choke on the blood he was oozing from every orifice.

That was something he and his wife and I had agreed wouldn't be done. Yet, because his doc said Oh, What The Hell, We Do This All The Time And People Are Better In Seventy-Two Hours, his wife gave the go-ahead.

I knew the doctor was lying at the time. I've never seen anybody get better after they've been intubated in this (much more complex than I'm telling you about here) situation.

The textbook response would be to schedule a meeting with the family and the doctor and lay out your concerns there. The textbook response never, in my experience, works. The Manglement response would be to involve Manglement, but again, Manglement never responds in the way you might feel is best for the patient.

Years and years ago, I had a guy in who was obviously actively dying, yet his docs (the same doctor, come to think of it) weren't willing to let him die. They kept pumping in fluids and pulling labs and running antibiotics, and it took me having an actual shouting match with a resident (me as a new nurse of less than a years' experience!) to change the treatment plan.

I'm not any less willing to shout now, and I'm not any less sure that what Dr. X is ordering is a bad idea, capital B, capital I. It's just that, in a critical-care unit, the stakes--no, the expectations--are different. You can't let people die with dignity in the CCU, because it's seen as a defeat. On the floor, where people die more often without the sort of technological insults they sustain in the CCU, they see dying differently. At worst, it's a neutral ending to a battle that's been hard-fought with honor. At best, when you have the privilege of laying a hand on a patient's chest to feel their heart stop, it's a victory over cruelty and unreasonable hope.

If I ruled the world, things would be different. People would still die, but it'd be seen for what it is: a transition in the same way that birth is a transition. I've talked before about midwifing the dying, and that still holds true: dying as an active process is just as much work as is giving birth. It's the lying there intubated with drips going and a tube in your nose and a tube in your bladder and more tubes here and there holy shit that deprives you of the chance to do your work.

And that, friends, is the problem with critical care: we do not allow things to take their natural course. There are some things we can intervene in, and should: brain tumors, spinal problems, you name it. The trouble comes when we start keeping people technically alive when they shouldn't be.

I do not know what to do. For the first time in my practice, I am at a loss. This is a bad feeling.

In which Jo feels rather more optimistic. (Now with improved spelling!)

Cancery McCancersons update! Well, not really. More like Evil Space Creature Obturator Update:

The interim obturator is GO. Dr. Obturator Elf is fitting me for a functional tracing later this month, and then the traced device will be casted in acrylic, and I'll have an entirely new roof-of-mouth.

Now, for the preceding in English:

When somebody like Dr. Crane comes along and removes the top of your piehole and most of the back of your throat, things change. Chief among those changes is your subsequent inability to talk without sounding like you're stuck at the bottom of a well with both a cleft palate and a sprained tongue. Seriously, I sound better without the prosthetic than I did just after surgery, but I'll never be able to be intelligible without it.

Also, because the throat is made up of a number of layers of muscle which heal at different rates and adapt to the obturator/speech bulb combo in different ways, there have to be different devices (I love that word: device. Sounds like an evil 1950's scientist is working on me) to cope with those changes.

The first obturator, the one that looks like a big pink bug, is called the surgical obturator. The second, the one I'll be fitted for in a couple of weeks, is an interim obturator. The big differences between the two are materials and size. The first obturator was/is made out of a softer material, to help coax the musculature in the back of my throat into the shape it'll need to be in to handle the later prosthetics. It's also freaking HUGE, because, well, there's a big ol' hole in the back of my head.

This second obturator is already smaller, and will be made of clear acrylic. It's not porous and will therefore be much more hygienic in the long term.

The interesting bit, though, is how the whole fitting process works. Check this out:

The back of your throat is really mobile. It changes shape when you talk, eat, swallow, sneeze, or even turn your head. Even going from sitting to standing changes its shape a bit. Therefore, you can't have a solid, smooth piece of plastic sitting back there; the muscles wouldn't "grab" right, and the plastic would slide around. You'd have leakage through your nose and sound, again, like somebody with a badly stuffed up schnozz who's at the bottom of a well.

Unfortunately, because you're making something that has to last for months or years, you can't have a nice, smooshy lump of, say, Silly Putty atop the obturator. It has to be rigid. The way it gets fitted, then, works like this: You wear the preliminarily-shaped obturator with a thick layer of wax on it for a number of hours, going along in the noiseless tenor of your way, and the wax shapes to the average configuration of the surgical deficit (or "big ol' hole").

In a way, it's like any other prosthetic: you take the average of all the activities that the device will help you with, and try to incorporate those activities into the device's finished shape. The difference is that this prosthetic is much smaller than an arm or a leg.

During the last appointment, Dr. Elf made a general outline of the big ol' hole with thermo-reactive plastic mixed with diatomaceous earth. (Why diatomaceous earth, I don't know; I think it has something to do with stabilizing the plastic, kind of like cornstarch thickens gravy.) The mixture that got globbed atop the base of the obturator and shoved into my mouth tasted just as lovely as you might imagine, but we ended up with something that sort of looks like the back of my throat, but about fifty percent smaller than it was just after surgery. The wax that Dr. Elf then used to make a preliminary functional tracing thankfully has no taste at all--and showed that the angles where my throat muscles come together have closed substantially in the last few months. The new obturator will be about half the size of the old one.

This is exciting as hell. I'll never be able to function without a prosthetic palate, but at least it won't be something that needs its own seat on an airplane. It also explains why my voice quality went from okay to fantastic and then back to sort of nasal and gurgly: the old prosthetic (the one I'm still wearing, the pink space bug) is now too big, and gets knocked around by my toned, rippling throat muscles. I have the equivalent of a Fitness America contestant in the back of my throat.

The weirdest part of all of this is how it's changed the shape of my face, to talk with this obturator widget. For a while, I had an even bigger set of lips than normal, because talking took a lot of work, lip-wise, to enunciate properly. Now I've got a sizey lump of muscle that looks a bit like a double chin, since it takes more tongue-muscle at the moment to talk/swallow/whatever. Dr. Elf assures me that all of this will fade back to normal as the process continues.

I'll post pictures of the two obturators compared and the second one in process if he'll let me photograph them. It's really cool.

And that, Chickadees, is why I feel vaguely more optimistic these days about this whole shebang.

March Moneygrubbin: Help a woman in need.

More than half of the women who have abortions in this country already have kids.

A whole bunch of women don't have the money either to have more kids or to have an abortion. Hell, a lot of 'em don't even have money for birth control (or bus fare to get to the Planned Parenthood in the next town that has free condoms, but which closes at three o'clock during the week).

Texas Equal Access is a fund that provides small grants--from fifty to a hundred bucks--directly to clinics that perform abortions, with the agreement that that money will go toward reducing the cost of a woman's abortion. It's only given after the woman in question has had a pregnancy terminated, so it's not like the clinics are rolling in money. Said women also have to satisfy certain conditions to demonstrate financial need.

(Side note: if you do a real-terms comparison of what it cost to get an abortion in 1980, when the only clinic in my county opened, and the cost in 1999, when it closed, then you'd see exactly zero profit. This is the norm for abortion providers in this country, the majority of whom are small, independent practitioners, who do reproductive health work as a sideline.)

There may be no worse feeling in the world than sitting at work, waiting for a call from your partner, hoping that he's been able to get the money you need out of the bank or from friends or relatives, because neither of you have a credit card. The woman whose partner isn't able to find the cash will be helped by your donation, so she won't have to shout "FUCK" across her workplace when it looks like she'll be pregnant for another two weeks, and go to a different clinic, and have a different, more involved procedure, to get rid of a pregnancy she'd tried to prevent and never wanted in the first place.

It's ridiculous that women have to go through this to obtain a safe, legal medical procedure.

Help a woman. Being pregnant when you don't want to be is like being an animal in a trap; chewing your own leg off is an understandable and reasonable reaction.