Ladies and Gentlemen

It's me! I'm alive!

Holy shit I haven't logged into my blog for so long!

Well check this shit out: I'm working as a flight nurse and loving life. I finally found the marriage between my nursing skillz and my love for autonomy and basically leaving me alone and letting me be great. I've transported sick as shit patients, some of whom I've even intubated by myself! (read: with my paramedic partner). My job is the freaking bomb and I love it. I want to tell you all about it.

So stand by, MoJo fans, the blog posts are forthcoming!


On Losing Jobs, and Moving On

Ever onward.

There's been a bit of radio silence from me, and it's on purpose, but it's not because I've been hiding under the covers with a box of tissues binge watching TV shows on Netflix and lamenting my life and all the bad shit I've had to deal with.

Or, maybe it is.

I also went to Vegas.

So I suppose you've all figured out that I got fired from that wonderful new job I had. Once again, MoJo is jobless. Sort of.

I had an offer from another hospital and I start in May. But the next few weeks are going to be hard. And now I have huge trust issues and insecurity issues and a shit ton of other issues that I could list but I'm sure you all can figure them out. And I don't even really want to be a nurse anymore. I suppose that's the depression talking, but over the past couple of weeks since the shit hit the fan, I have lost interest in ever doing this job anymore and instead I've been thinking of becoming a long-distance truck driver or something that doesn't involve interacting with other people.

So let's talk about being your own worst enemy.

Before I transferred to this new place, I had a wonderful job in a unit that was staffed with amazing people that I loved working with. I should never have left. But I wanted more. I am perpetually seeking more. More hours, sicker patients, more responsibility... blah blah blah. I am never quite satisfied with what I have. So I took this new job because it was exactly what I was looking for: more.

The culture shock with the new ICUs was ... well, it was something I had never planned on having to contend with.

The ER was amazing. I loved it. The ICU? Not so much. The patients were sick, yes. I had VADs and EVDs and transvenous pacers and all the crazy high acuity shit I had always dreamed of. But something seemed a little ... off ... about the nurses.

Suffice it to say, my outgoing congenial and inappropriately funny personality did not mesh well with staff. And a staff member lied to my boss and said I made a racist statement and she fired me.

Racist. Yes.

I'm a lot of things, I told my boss, but not racist. But she fired me anyway. I found out in the course of this that people thought I was aggressive and intimidating which served as a foundation for her decision. Well, yes to both of those things, but it's not intentional. Both of those descriptions of me are based solely on other people's perception of me and are not intentional on my part. Aggressive vs. Assertive or Intimidating vs. Having a Strong Personality is related to how people see you. If they LIKE you, you're Assertive with a Strong Personality. If they DON'T like you, you're Aggressive and Intimidating.

My clinical skills and patient care were never in question. But silly me, I always thought that being a rockstar nurse would save you.

Not true.

Remember how I said that nursing was a high-school popularity contest and I felt like I was perpetually exiled to the Freaks and Geeks table in the lunchroom? It's so true. And yet, even in knowing this I continued to be real and true to my personality and it got me fired. I am my own worst enemy.

This other nurse, I guess, didn't like my personality. Many other nurses don't like my personality... except I am unilaterally accepted in every ER I work in, so I guess my personality and presentation is welcomed among the ultimate freaks and geeks of this world: ER Nurses. And I'm ok with that, because my new job is in the ER.

I just want to go to this guy and be like "I helped you give a lactulose retention enema on your 400lb patient, you ungrateful shitbag! Fuck you and four people who look like you!" But, why waste my time? Will it change him? No. Will it get my job back? No.

To say that I'm embarrassed is an understatement. I feel like I can't show my face to the world ever again. I want to hide in my house and write manifestos and order food off Amazon because I can't even go to the grocery store without feeling like people are silently judging me. I want to hide in my den and lick my wounds and just try to survive for the time being. And I'm giving myself that.

But the time will come that I have to pull up my big girl panties and get the fuck on with it. Right?

My manager was cool about it all, and she gave me some advice. She said that I shouldn't focus on trying to get people to like me and basically I should let my nursing skills speak for themselves so that people respect me first and then like me. Okay, noted. I don't know if that was my goal from the beginning: to be funny and crack jokes so people would like me. That sounds shallow and pathetic. But maybe it's true. Maybe I missed the people and the environment of my old job so much I tried really hard to recreate it at this new place and it blew up in my face.

At my old job we would all sit and laugh and tell funny stories when we had downtime. There was rarely a night when we didn't high five each other or giggle like insane people over some joke someone told. We were like a family, save for a few people that I wanted to kick in the balls, and I felt like I belonged. I wanted that again and I was impatient to get it, I guess.

So now I'm moving on to this new job. And frankly, Big Bad MoJo is scared. I'm scared that I'll get comfortable with the people I work with and crack a joke or laugh at something inappropriate and someone will take offense and they'll send me packing. I can't have that happen again, you know? So how do I do this? How do I trust people again? How do I do my job and rely on my teammates-- which, in an ER could be the difference of life and death for a patient-- while trying so hard to be this different person?

Why are nurses so goddamn intolerant of other people? Didn't we have cultural diversity and acceptance shoved down our throats in nursing school and force-fed to us in every PolicyStat or Healthstream module or fucking inservice?? How about respecting MY diversity?

And, there it is, the anger. I'm so angry. I'm angry that I was fired over hearsay. I'm angry that I have to go interview at places and try to skirt the issue that I was fired. I'm angry that now I have to hide my true personality (which is pretty goddamn awesome if you ask me. I'm fucking awesome.) for fear of causing someone else I work with to have a critical panty-bunching crisis and run to my manager and complain. No, I have to just shut up and do work and fear social interaction because god forbid I laugh at the wrong thing.

I am thankful, though, that I was able to find a job this fast. You all pray or shake sticks or cut up a chicken or eat spaghetti and think about pirates or whatever it is you do that I am able to make this one work. Because after this I think I'm out of options and will actually have to be a long-distance truck driver or something.

Is your hospital hiring?


On Nurses Who Eat Their Young

If you're like me and are reading this blog or following me on Twitter, you were a dork in high school.

Maybe not a complete and total geek and outsider, like these assholes:

They aren't assholes. Just fucking dorks. Even the blonde one. 

But nonetheless, you were probably smart and kind of a bit of a loner maybe. You did your own thing, marched to your own drummer, didn't blindly follow what all the other kids were doing, all that shit.

Maybe I'm wrong, but I'm willing to bet you probably weren't like these assholes:

Assholes. Like, OMGahhhhh. 

The popular crowd at my high school were a bunch of bleeding, puckered assholes. I was so happy to grow up and get out of there. I was over it. I was ready to start being an adult and doing adult shit like drinking having a job and being responsible.

So imagine my surprise when I have my first big-girl, adult, responsible job after years of hard work and determination and find that my chosen career is not full of people like me. It's another bunch of bleeding, puckered assholes, plus people like me.

And I suppose every job is like that; quite a bit like high school in fact, where there are cliques of people who don't sit together at the same table in the lunchroom and who don't play nice with each other. We never really get away from that high school mentality.

This isn't to say that nurses aren't smart and driven people. Not at all. For the most part, nurses are highly skilled, talented, educated, intelligent people. It's just that a unit in the hospital almost becomes like a mini-high school. There are the popular ones and their hangers-on, the nerds, the fringe people, and the outcasts. Think about your unit and I bet you a billion dollars that you can pinpoint exactly who these people are, can't you?

So given that environment, add in to the mix the fact that nurses are by far the most disenfranchised people ever in the whole world. Pardon my hyperbole, but I firmly believe it's true. We're the ones who have this huge amount of responsibility, but no autonomy. We have this job where we're expected to know so much but can actually do so very little. We have to worry about adequate staffing, being safe on our job, being abused by patients and staff-- verbally and physically, management who cuts corners by taking our health insurance or benefits away, never getting to pee...we aren't even allowed to have bottled water or coffee at the nurses' station, for christ's sake. And since shit rolls downhill, who do you think bears the brunt of bad clinical outcomes? Maybe not in court so much, but we get counselled, written up, suspended and fired.

Wrap it up and tie it with a big pink bow and what do you have? An environment that is ultimately conducive to bullying and lateral violence.

And who gets shit on the most? New nurses.

They come into the hospital with their shiny new badges, all fresh faced and bright eyed and confident, eager for experience and to do all the cool shit they just learned in nursing school... and some old battle-axe preceptor they're paired with rips them a new asshole for forgetting to turn off the IV fluids when they drew labs. And this continues and continues and continues until that new nurse isn't so fresh faced and eager anymore. She's doubtful and timid and prefers just to shut her fucking mouth and get done so she can go home.

Books I've read on the subject say it's been this way forever, since the dawn of nursing, when nurses lived in barracks and got schooled on the proper way to crease a bedsheet and pinroll their hair. It's part of our culture. We indoctrinate new people into this culture because it's the way it's always been done, much like medical residents work 80-100 hour weeks because "that's the way it's always been."

Is this acceptable? What if people had the same attitude about, say, pediatric cancer that they do about lateral violence in nursing: "Well, *shrug* kids have always died from cancer, but that's the way it's always been. It's part of the culture." 

Or worse, they realize there's a problem and bitch incessantly about it on but never take any steps to fix it: "Well, kids have always died from cancer. It's horrible! I hate it! But it's the way things are, I guess. Gotta have a stiff upper lip and deal with it." 

Let's not fucking deal with it.
Let's make a change in our "culture."

First and foremost, if you're one of those people who does this shit? Go immediately to your bathroom, look in the mirror, and tell yourself to fuck off. And then tell yourself "I'm not going to be an asshole to people anymore." This is a hard step, but you can do it. But follow through with it-- don't be an asshole to people anymore.

Second, if you see this kind of BS happening, speak up. It doesn't matter if it's just like standing up to that popular jock who used to tease you about your braces-- meaning, impossible-- we all need to say something when we see bad shit like this going down. If your boss and the three people who always get to be charge nurse are the "popular" crowd, speak up to someone else if you can't speak to them.

Third, and more importantly I think than the previous two points, go to that person who is being shit on and encourage and empower them. And then go to the assholes and encourage and empower them too. EVEN IF YOU DON'T LIKE THAT PERSON. That is tantamount. There are many people I don't like (meaning, everyone), but I always always always try to be encouraging and empowering to the people I work with. Especially to the assholes, because you never know, they might be assholes because people were assholes to them.

Fourth, guys... seriously let's stand up for ourselves. Advocate for a new grad training program with dedicated preceptors who only do it because they want to, not for money or because they have to. Or, if you can and are so inclined, mentor or precept a new nurse. It's worth it.
Don't be silent when hospital policies make it impossible for you to function in your capacity in one of the most badass healthcare professions. Policies that make it impossible for you to take a break. Or can't have a coffee at the nurse's station. Or it's too expensive to have a break relief nurse because of the census. Or to even HAVE a break relief nurse. Or that your hospital doesn't have a lift team. Or you get written up for clocking out late because report on your patient on 4 pressors and inotropes and mannitol and 3%NS and complicated dressing changes went "too long." If we as a PROFESSION collectively stood up and said "absolutely fucking not" (empoweringly and encouragingly, of course) to a lot of these dumb policies, our environment would be better and thus we would feel better and there would be less assholes. Right?

Making a change, in the immortal words of Michael Joseph Jackson, starts with the person in the mirror. We ALL need to encourage and empower each other.

We ALL need to be the change that we wish to see in the world.

Lead by example: Don't be an asshole.

And here's that picture of a fucking cat hanging from a clothesline that you bought at your elementary school book fair to round out this sappy, sentimental drivel:
Hang in there, Baby. 

We, you and I, can make a difference. Let's end this culture of bullshit.

Love, (and I mean that sincerely)

New Job is New, Part 2 Electric Boogaloo

So many of you know I left my old podunk 12 bed "Med-Surg/ Tele" ICU for warmer climes and higher acuity. I'm in a new facility, a Level II Trauma center, with 5 ICUs and a giant ER.

Like, GIANT. Fucking huge. Cavernous and maze-like, even. I get lost all the time.

And FIVE ICUs. A Neuro/Trauma ICU, a 36 bed Medical-Surgical ICU (ICU 1 and 2), a Cardio-Thoracic ICU, and a Cardio-Vascular Interventional ICU (which are 'paired' like the two MSICUs). And I get to work in all of them-- maybe even the PICU.

I spent a month in the ER as part of my orientation to my new position as a Critical Care Float RN. I was so scared to even set foot in the ER again because of my past experience with that shithole Level 1. Come to find out, though, many of the people I work with at this new facility know EXACTLY what I was talking about when I said I would go home and cry and couldn't eat or sleep and felt a sickening sense of soul-crushing dread every time I would pull into the parking lot. They had tried it out there and ran away screaming after only a few months, too. Nurses, techs, a nurse-turned-ACNP, and even two doctors now work in our ED-- one who I remember put his hand on my shoulder after that nightmare-inducing pedi trauma and subsequent bitch-out session by my preceptor and told me "It's okay, they're like that here but you're a good nurse, you'll be ok." The only person who was nice to me that day is now at my Level II.

I learned that as a newbie I was hazed to see if I could "hack it." This meant, basically, that they fixed it so I would get the hard patients-- they would move my boarders around just to give me all the low-level traumas and ICUs. Safety be damned, let's haze the noob, or something. And they made me think that I was running around from room to room while other people were sitting and chatting because I couldn't cut it, not because they were purposely fucking with me. I learned that like 20 nurses had left in the few months leading up to me being hired. I even learned that one nurse higher up on the food chain thought I was too dumb to work in an ER!! What the fuck? What the fuck are these mind games, y'all?

Well, this sounds kind of immature but fuck it, I'm going to say it anyway. I sure as fuck showed them, didn't I? I persevered and overcame and I didn't let them break me. I did so well at this new place that they reduced my orientation period by two weeks and even offered me a full-time position on nights. Part of me wants to roll up in the Level 1 and flash my shiny new badge around and go "Fuck you, fuck you, fuck you, fuck you, fuck especially YOU and four people who look like you, and fuck you double, I did it, I'm capable of doing it, and I'm not stupid so the whole lot of you can go die in a fire. But don't come to my ED afterwards." But I won't. I am satisfied to feel personally and privately vindicated and validated. (Well, I'm sharing with all of you guys so I guess it isn't really that private but whatevs...)

So now I'm up in the ICUs for 8 weeks. I'm orienting to all of them at once, so one day I might be in CTICU learning about solid organ transplants and the next day be in the CVICU doing LVADs and balloon pumps and trans-venous pacing. Just recently for two days I've been in the Neuro ICU getting hands on training in EVDs, cranis, head trauma, mannitol and 3% NS.

Wanna talk about some scary shit? EVDs scare me even more than trauma ever did. My hands shook HARD the first time I laid hands on one. Wait, how many goddamn stopcocks are on this thing? Is it level to the tragus?? I don't know but I don't even want to touch it because I'm afraid I'm going to drop it and spill it and all this dude's CSF will come out and he'll herniate and die so no thanks. What?? We're going to CT? Right now, really? Um, I'm good thanks. I have to pee... yeah.. brb... Hold up, I have to touch this thing? NO I'M GOOD THANKS!

Haha, picture big badass tough as nails MoJo scared like a little girl from having to mess with an EVD, right? But I pulled up my big girl panties and did it and the patient lived so I guess it's not all bad, right? It helped to have a preceptor who put her hand on my hand and said, calmly but firmly, "Look, I have faith in your abilities. You've already proven that you have a clue and you're willing to learn, and so I'm going to teach you. You can do this and I'll be here the whole time. So, grab that level there and let's get started."

Part of me feels like a new grad, you know? I'm even getting ECCO training, which I never had, so it's pulling all the patchwork pieces of knowledge I've gotten in my 4 short years as a nurse together and tying it all up in a pretty pink bow. Being so gun-shy about asking questions and admitting that I don't know things was hard at first, but the people at this new place are so nice and accommodating-- and awesome like my old crew at Podunk General who I miss a shit ton-- they make me feel comfortable about asking questions and getting feedback. I wish I had applied for the new grad stuff here and had been patient enough to wait for the interviews rather than jump on the first job offered to me at that Shitty County Hospital. But you live and you learn, right?

This place has clinical nurse specialists and educators for each ICU and ED who actually come out of their office and give inservices on stuff that the staff might need refreshers on. The management is cool as shit because they only promote them internally, so the managers know what it's like to work at the bedside in that specific unit and they're that much more apt to be cool with us and help us through shit. That's valuable.

I guess what I'm saying is, I'm happy and hopeful. I feel nurtured and encouraged and totally validated. It's awesome and I wish every place had been as fucking rad as this place. I wish this experience for every nurse out there.

Yes, every nurse. All of you reading this. Every new grad. Even those assholes at the Level 1, the snooty bitches at my old County General, and yes, even that cunt of a preceptor I had as a new grad who told me I ought to just quit now and find another career because I was never going to be a good nurse. I feel sad for her that she believed that shit was acceptable because the culture of her hospital was so poor. Looking back, she must have been so unhappy at her job that she didn't ever think or realize that she was being laterally violent, and that shit is sad.

Well, I've shed all of that off like a bad ugly dress and just look at me now, y'all.


On The Events Going On in Oakland

Yep. I'm jumping on the bandwagon.

Everyone and their mother has weighed in on this case. Medical people, religious people, higher education-type people, conspiracy theorists, analysts, pundits, specialists, and people who are just plain stupid and shouldn't breed.

Sprocket Trials has compiled an amazing list of all the relevant shit having to do with this trainwreck of a case. I don't plan to be that thorough. If you want to dig through case documents and such, that's the place to go. Well researched, accurate, and very well written blog, there. And not just about Jahi. They write about other shit too.

I also don't plan to argue endlessly whether she is or isn't brain dead. She's dead. I've read Dr. Paul Fisher's report and the supplemental report from Dr. Heidi Flori, and even the deposition of that quack Dr. Paul Byrne that clearly references another doctor discussing the fact that Jahi had Diabetes Insipidus which, while not in and of itself indicative of brain death, solidifies the fact that she was indeed brain dead when taken with all of the other evidence.

This is what I want to talk about: the clearly uneducated and medically ignorant** media perpetuating misinformation and the idea that laypeople know more than us about medicine.

**ignorant, in this case, meaning simply that they have no education or idea about the stuff they report on. Not in an insulting way, although I have to really restrain myself from angry name-calling sometimes. 

Because as elitist and condescending as this sounds, we know more than you do. We can look at someone and see the likely progression of their illness based on sound medical evidence and experience, whereas you look at them and hope they get better. Hope that we make them better.

This doesn't mean that we know what decisions to make for you or your family member. No. You guys can choose whether or not to have a surgical procedure, or whether or not to go through chemo, or to remove the ventilator from your 80 year old grandma, or to elect for palliative or comfort care rather than curative treatment. You guys know better than us when it comes to making those decisions for your family. But it's up to us to educate you as far as your options go so that you can make rational and informed decisions, and sometimes intubating your 80 year old grandma with COPD exacerbation and CHF is not a reasonable option.

Sometimes-- no, actually all the fucking time-- it is NOT A REASONABLE OPTION to keep a brain dead 13 year old on a ventilator.

In the beginning of this debacle, nearly every news outlet and the McMath family continually discussed the removal of "life support" after the "routine surgery" she had. Don't journalists research anymore? Since when is a tonsillectomy/adenoidectomy, a uvulopalatopharyngoplasty and a bilateral turbinate resection on an obese 13 year old with prior surgeries and a high likelihood for comorbidities considered routine? Especially with a pre-scheduled stay in the Pediatric Intensive Care Unit at a world-class hospital?

People who undergo procedures at an Ambulatory Surgery Center or as surgical outpatients in a hospital are considered to have "routine surgeries." Jahi's wasn't routine. All of us medical professionals know this. But yet the public, lemmings as they are, hear from the media that this was supposed to be a simple in-and-out thing and form opinions based on irresponsible and incorrect reporting.

Then later on, the media started reporting on other people who supposedly were brain dead and miraculously came back to life. Again, media people. Do your fucking research. Or better yet, have medically trained people write news articles about medicine. One kid in England that the media and other laypeople wave around like a goddamned flag supposedly had a tragic horrific accident and was declared brain dead. Was he really? So, he fully met all the criteria for brain death and was diagnosed at the appropriate time under the appropriate conditions (because yeah there are set clinical criteria that have to be met for the diagnosis to be valid) and miraculously came back to life like Jesus?

Uh, no.

So either one of two things happened:
1. The doctor came in and told the family that he could possibly be brain dead or the injury could progress into brain death and it might be a good idea to withdraw care because who knows even if he does survive how much function he would retain, and the family didn't understand fully and freaked out and found another doctor, OR
2. He was diagnosed as "brain dead" too soon after his traumatic brain injury and it was a mistake.

I've seen more of #1 than of #2. Here's an example: I had a little old guy being released from the hospital on Coumadin for his new-onset A-fib. I told him that he needed to remain consistent in eating things like green leafy vegetables, because eating those things would affect his weekly lab draws, which his doctor would use to adjust his Coumadin dose. And he understood and did the whole teach-back thing, and I felt confident that he had assimilated the information. But then I overheard him telling his wife that he was never allowed to have spinach again. People, especially adult learners, don't assimilate information well.

So do you think it's a case of a doctor making a mistake (slightly likely) or the family-- who are in an intense emotional state, highly stressed and worried about their child-- not understanding (really, really likely)?

Moving on. So later, the media starts talking about Terry Schiavo. Karen Ann Quinlan. Jesse Koochin. They start mixing up "brain dead" and "vegetative state" and "coma." They reported on these things with about the same accuracy as I would have if I wrote about carburetors and pistons and drive trains, which is fucking none. They are not all different words for the same thing. They are completely different, with different associated levels of functioning. And so people hear about Terry Schiavo and her vegetative state and think "Well, she got better!! Maybe Jahi will too!"

Yeah, no. Irresponsible fucking reporting. More irresponsible reporting is allowing the McMath family unrestricted airtime, during which they said that the hospital is starving her, they wanted to take her off the ventilator while she was alive, and oh hey look her foot is moving when it's touched with ice so she's clearly alive, so on and so forth. Did the media give any doctor or nurse as much air time to speak generally about brain death and coma and PVS, spinal reflexes, the futility of giving tube feeding to a dead person, the fact that the hospital didn't "starve" her because of TPN and normal saline and electrolyte replacement and the fact that I seriously have had septic post-op gut surgery patients with necrotic bowels who haven't gotten tube feeds for two weeks and didn't starve to death because, especially with intravenous nutrition, the body can go for a surprisingly long  time without "food"?

No, they didn't. And so the media perpetuates this bullshit to the masses, who then go on to mistrust hospitals and doctors and nurses and then look to fucking nutjobs like Jenny McCarthy to get their medical advice.

Then here come the uneducated opinionated commentators. "Children's Hospital killed another little kid with the same surgery." "Children's Hospital wanted her for her organs." "The doctors wanted to kill her because racism." "Killing her was cheaper than keeping her alive, they're motivated only by money."

First of all, does anyone know if the same surgeon performed the exact same surgery on that 4 year old who died in her car on the way home? Did anyone look?
Did anyone mention that organ donation, at least in California, isn't even mentioned to families by the doctors or nurses caring for the patient and instead all donation is coordinated by an outside entity? And that the hospital doesn't get any kickbacks or perks or even a say in where the organs go? Did anyone bother to research this?
Did anyone bother to mention that Children's Hospital is in OAKLAND for Christ's sake?

I will venture to say that removing her from the ventilator would actually be cheaper. Yes. For each day that Jahi remained on that ventilator after her official diagnosis of brain death, the hospital was not getting paid because no insurance company is going to pay for futile care of a dead person. They had to eat the cost of all of her expensive and world-class ICU care. Money and resources which could have been better utilized in other areas. This part is true. Overhead is something we all need to be aware of.

But I'm telling you right now, if you come at me and tell me that my patient care is driven by money and not by my deep and steadfast emotional commitment to my patients as their fierce and loyal advocate, I will bust you in your motherfucking mouth. And so would 99% of every other medical professionals out there. Because fuck you.

Ok, deep breath, MoJo.

The problem now is the McMath family and their shyster lawyer will try and take this to court so that they can get some money from the hospital. And Children's Hospital-- ironically motivated by money but I guess it's ok when it benefits the family, huh?-- will probably settle out of court rather than stand up and say "No, goddammit, this shit is not okay." They allowed a family and the media to drag them through the mud, tarnish their reputation, and perpetuate mistrust of healthcare professionals and they will likely not do a thing about it.

So the one thing I want medical people to take away from this is, simply, STAND THE FUCK UP FOR YOUR PRACTICE. Be vocal in the face of misinformation, especially when it comes from The Almighty God of the People, The Media. Speak out against malinformation (h/t to Doc Bastard over in "Cameroon" for that one) (he's not in Cameroon, that's a joke) whenever and wherever you encounter it.

Because when a  douchebag shyster lawyer says that families, not doctors should determine death and people AGREE? Abso-fucking-lutely not. Do not stand for that.

I am so very sad for the McMath family. Don't mistake my anger for lacking compassion. But I'm angry that this was allowed to go on for as long as it did. I'm angry that an Alameda County judge heard an argument that cessation of care for a brain dead patient violated a family's First and Fourteenth Amendment rights and agreed. I'm angry that a gag-order and federal privacy laws prevented a world-class hospital from defending itself. I'm angry that the media not only perpetuated bullshit information but capitalized on a family's suffering for ratings. I'm angry that a lawyer gave a family false hope. I'm angry that a shyster dickbag with zero medical knowledge is trying to set a precedent which would in effect make it so that I might possibly have to care for dead people.

I'm angry that some doctor- or more than one- put a trach and a g-tube in Jahi. I'm angry that she has a team of caregivers who are perpetuating this false hope. And I'm so insanely angry that a former hairdresser and a self-storage magnate are capitalizing on this family's grief and need for closure so that they can get money to open their inpatient facility.

I hope that once this is over, Nailah Winkfield can bury her daughter and finally grieve her loss.

Rest in Peace, Jahi.


On Things I've Learned

You might not (or, might, given my propensity to speak directly out of my ass) know that I've only been a nurse for three years.

Over the course of those three years I have learned many many things. Some good and uplifting, some awful. Some useful, some trivial. But everything I've learned has brought me to where I am today.

That's the first thing I've learned. Hold on to your butts. I'm about to get all Baz Luhrman on you.

1. Every experience you have in this field is meant to teach you something. Figuring out what you're supposed to learn from any given situation is probably the most important skill you'll learn-- besides how to prime IV tubing so that your pump doesn't alarm every five fucking seconds.

2. If you set the volume to be infused equal to the rate of your insulin drip, you'll never be late for your q1h accu-checks. 5 units per hour for a 1unit/ml bag of insulin? Set your volume to 5ml. It'll beep in an hour and you know it's time for YET ANOTHER fingerstick.

3. It's ok if things don't get done in your shift. Even if the oncoming nurse is hella bitchy about it, even if you feel hopelessly inadequate because you forgot things or didn't have time to finish up all that tasky bullshit you encounter in a shift because you got busy or sidetracked or people coded or whatever, remember to tell yourself that there's a reason hospitals are open 24 hours a day.

4. ER nurses are fucking busy. You never know what's going on down there. They turn and burn rooms faster than chicks at a busy Nevada cat-house and rarely have time to breathe or pee, let alone hang that K replacement. You never know if they just unsuccessfully coded a baby, or were assaulted by a psych patient, or all four of their rooms were sick as shit and they got busy with other, higher priority things or their charge was on their ass to move that patient-- YOUR patient-- because the waiting room is full of level 2 acuity patients with a 6 hour average wait time. So, go easy on them. See item #3.

5. ER nurses: remember that we're busy on the floor too. That is all. Carry on.

6. DKA patients need at least 2 IVs: one for the insulin and liters and liters and liters of IV fluids, one for adds and other shit. So do GI bleeders. They're going to probably get protonix and octreotide drips and those aren't compatible with each other.

7. It's important to learn the habits and personalities of people around you. This may be difficult for some people to do. It was really hard for me. This may seem really shallow or like I'm advising you to put on affectations when dealing with people, but this is what has provided me with the most success in getting what I want and or need. Granted, there was a lot of trial and error, but I learned which doc likes witty banter and which one wants only the facts. Which doc wants to hear your suggestions and which one flat out doesn't give two fucks what you think. Which doc is willing to teach you things, and which one to avoid speaking with at all costs. I learned which nurse hates long reports, which nurse wants to know every minute detail, which tech will do anything you ask if you buy them a cup of coffee every once in a while. If you learn how to talk to people, you can always get what you want.

8. Twitter is an invaluable resource. Follow a shit ton of other docs and nurses on Twitter. It's like you're part of a worldwide all-encompassing compendium of medical knowledge, all at your fingertips. See: @Mojo_RN

9. You really are NOT as horrible-- or as great-- as you think you are.

10. It's okay to make mistakes as long as you OWN them. Be accountable. Never, ever, ever, ever try to hide or gloss over the fact that you fucked up. Number one, if people find you out your credibility will never recover. Number two, even if you get in trouble, remember that experience and true knowledge never really comes from doing things right. It comes from fucking up.

11. If you're in ICU? Learn your vent settings for christ's sake. That's not just RT's job, it's yours too.

12. Be fearless in pursuing your dreams and goals. I've learned in my short three years that people are never going to outright give you anything, especially their knowledge. Especially in nursing. Actively seek out new information and new experiences. Take classes, go to seminars and conferences, ask to observe whatever bedside procedure is going down in your room-- or, shit, if you can, if something cool is going down in someone else's room ask if you can watch that shit, too. I remember seeing my first chest tube insertion and it wasn't even my patient. It was cool as hell. And, knowing that the doc who was putting it in was the type of doc who looooooooooved imparting knowledge on his people (see #7), I learned a lot of cool stuff. Ask a million questions-- it's okay if people think you're annoying. Fuck them, you're trying to learn. Don't allow yourself to stagnate.

Also? Google everything.
What's a loculated pleural effusion? Google it.
What's the difference between SVT and Afib with RVR? Google it.
How do you tell and upper from a lower GI Bleed? Google it.

Google School of Nursing Alumni, Unite!

13. Apparently, you can give adenosine to patients who are in afib with RVR. I used to think that you couldn't, but THANKS TO TWITTER I learned that it can be a useful diagnostic tool with regard to cardiac issues.

14. If you're ever going to ask anyone for help-- turning, cleaning, bathing, drug calculations, witnessing your insulin, whatever-- be prepared to help out in return. People resent and despise that nurse who sits charting while everyone else is running their asses off. If you help out consistently and there's one night when you're just like ...fuck this shit I'm tired, people are 1000% more willing to cut you a break than if you're always that schlub who charts and texts while everyone else is running a code. (yes, that is a scientifically derived statistic. 1000% more willing. Look it up. On Google.)

15. Always have another bag of IVF in your room-- pursuant to your hospital policy, of course. But having another bag of fluids in your room will not only save you a shit ton of time, but if another nurse checks your beeping IV pump while you're in an isolation room cleaning up the 50th c. diff shit of the night, they are 1000% more likely (again, scientifically valid) to spike that bag for you rather than just adding volume and walking out.

16. Your patients are your patients. But so are everyone else's. Your patients are theirs, and theirs are yours. What?!!?!!!!! That's insanity!! you might be saying to yourself. No, I mean it. "It's not my patient" amounts for shit with regard to monitor alarms, IV pumps, call lights, ventilators, and the GODDAMN TELEPHONE. ANSWER THE GODDAMN TELEPHONE.

17. Your patients trust you with their lives. Be worthy of that trust.

18. There is a huge difference between being assertive and being aggressive. Learn this. I have not yet learned this. When you figure it out, email me at Thanks.

19. Don't take anything personally. Don't take that asschewing from Doctor I-Never-Want-To-Hear-Your-Opinion-Because-I-Am-God-And-Therefore-Infallible to heart. Don't be disheartened when you hear you've been written up, or that other nurses are talking shit. This is the HARDEST thing I've had to learn and I still struggle with it every day. But the fact of the matter is, people are going to talk shit about you for whatever reason: You're new. You know more. You're cuter. Your scrubs are too tight. You called in sick the past two days. You hit the keys too loud when you type. Your hair is a weird shade of brown. This happens. Let it roll off your back, be secure in what you know and what you don't, what you're comfortable with and what you aren't, and learn how to assertively (not aggressively) advocate for yourself. Other people's opinions of you not a reflection of you, but of them.

20. If you dangle your patient's arm over the side of the bed, it's easier to start an IV. But don't just go by sight, learn how to feel those suckers out with your finger. A vein feels springy, like a trampoline, when you push on it. Skin feels mushy. Tendons and ligaments feel hard like a cable. Practice feeling the veins on your arm and the arms of others close to you. NOT strangers.

Do try to start your IVs in places where your AOx4 patient is going to be able to move their arm easily and not occlude the damn thing every time they reach up to wipe their nose. But if you MUST go in the AC, a rolled up kerlix helps keep the patient from bending their arm all the way, thus pinching off the catheter. Take it out of the package and lay it longways across the crook of a patient's arm. Secure with tape or other kerlix and presto: no beeping IV pumps.

21. There is going to be shit that haunts you in this job. Literally haunts you. I remember witnessing my first peds code-- a boy who looked so much like my son I cried the whole time. I still see his face, and his little hand hanging lifeless off the gurney jerking with each desperate chest compression. And the screams of his father who lost his only son and wasn't there when he died. You will have your moments too. They will be hard to deal with. They will cause you to doubt why you even chose this bullshit profession in the first place. They will make you cry, scream, throw shit, and crush you beneath their weight if you let them.

It is imperative to have two things if you're going to last in this profession. The first is someone you can talk to who absolutely understands (without a shit ton of explanation) what you are talking about.

Listen up, spouses of nurses: if you're a florist or a long-distance truck driver you won't understand what your husband or wife is talking about when he or she goes on about the patient being maxed out on pressors and still hypotensive, or needing 30cm of PEEP because ARDS, or VFib or PEA or any of it. Regardless of how you try to understand and how willing you are to just sit and listen, sometimes (at least for me) it makes the situation more frustrating when you have to explain what the fuck you're talking about because the person doesn't understand. I just want to vent, not give you a pharm lesson. And, sometimes, our jokes and funny observations can seem to the layman like we're being insensitive or fucking gross or crass or hateful. Don't be insulted or jealous when your spouse finds someone insular to this profession that they confide in. And nurses: FIND THAT PERSON who understands that you're not being insensitive when you talk about how the patient farted every time you compressed her chest. I'm lucky that my hubs knows enough about this shit that I can babble on and on and he gets it without stopping every five minutes asking "What's Neo? Wait, what do you mean FIO2? What's a lactate?"

The second is good, healthy coping mechanisms. This is not going to the bar and tying one on. This is not avoidance. This is not compulsive shopping. Use your employee assistance program if you have to. But if you can't cope the right way and process this shit properly, this job will eat you alive-- and sometimes at the expense of your health, your sanity, and even your family.

LAST BUT NOT LEAST in this TL;DR "remember to wear sunscreen" bullshit post:

22. You can do it.

No, seriously, you can.

I mean it.

You will not hear this nearly as much as you want to in this profession. Nurses historically have a very poor track record of encouraging other nurses to be great. But believe me, you can do it. Tell yourself that in the car on the way home from a rotten fucking shift where everything went wrong and you're ready to quit nursing altogether and go back to waiting tables at the Waffle House. Tell yourself that when you walk back in from your break to your cursing, spitting ETOHer in four-points and your GI bleeder who needs 4 more units of packed cells, FFPs, and cryo. Tell yourself that after a shift where you've executed it perfectly AND stuck the landing. Tell yourself that often, but more importantly, BELIEVE it when you say it.

You aren't saying you're perfect.
You aren't saying you'll get it right every time.
You aren't saying you're better than everyone else.

All you're saying is, you can do this. Because you can.


PS No I'm not fired.

Meet The Cast of Characters: Special Edition

Everyone has that one doctor.

That one jackass that you want to sneak up to the call room and strangle in his sleep. The one with the weird personality that makes you wonder how they survived into adulthood, the one who wants shit done exactly how he wants it even if it doesn't make sense, the one who writes stupid fucking orders and then gets mad when you call him to clarify.

The one who loudly proclaims at the nurse's station that the nursing care of his patients is "abysmal." (Yes, this actually happened, he really said that.)

Well, this one is a surgeon. Ever hear that old joke "What's the difference between God and a Surgeon? God doesn't think he's a Surgeon." It's true. This douchenozzle thinks he walks on fucking water. He thinks that he farts rainbows and shits solid gold. He thinks that he is a gift to mankind, that his presence on Earth is something we should all be grateful for. That we should fall on our knees and thank God that he was fucking born, or something.

Yeah, no.

He's not even that good, is the problem. He's messy. He's rude and intolerant. He treats his patients like shit. And he hasn't the slightest fucking clue how to manage them, but yet insists on being in charge of them instead of having the hospitalist or intensivist medically manage his patients. As a result, we have to call him all the fucking time. We have to call for insulin orders for the diabetics, or diet orders, or daily labs. We have to call him because he doesn't write orders the right way-- we have very specific order sets that need to be filled out for shit like Sepsis protocol or vasopressors or electrolyte replacement. God forbid one of his patients gets intubated, he wants to run the vent settings himself. He doesn't listen to the respiratory therapist. He tried to put PEEP on a patient with a hemothorax, for Christ's sake. This guy is something else entirely.

So when any of us get one of his patients-- which is often because he insists on all of his patients coming over to ICU post-op because the nursing care there is so abysmal-- we all groan inwardly, say a little prayer (even I do, and I'm an atheist) and hope it goes smoothly.

The other day I got one of his patients. This old dude was status post ex-lap and resection. He's an old dude who hadn't pooped in forever and it turns out he has bowel cancer. Guy got dealt a shitty hand of cards. So, Doctor McFuckface puts him on a PCA, which is really awesome and nice. I was surprised.

Our PCA order set is very specific. I LOVE our order sets because, really, a child could understand them. A foreign child who doesn't speak English could look at our order set and go "Ach so! Ich verstehe!" It takes a lot of the guesswork out of shit, eliminates the need for us to call for a million incidental things, and it reminds docs about shit they might forget about (like ordering triglyceride levels for patients on propofol.) Hooray for order sets!! I don't care if I'm unpopular for that opinion. I love them. So there.

The one for the PCA is super simple. It allows you to choose the medication, Morphine or Dilaudid. Then the next box asks you to choose PCA bolus only, or bolus and continuous. The next box sets the time between boluses. The next box sets the lockout. Easy as pie. So he picked Morphine PCA bolus only, 1mg every 10 minutes, no lockout.

The next box is the source of all my woe and frustration. The next box caused this doctor to have a fucking nuclear meltdown in my boss's office. The next box caused this doctor so much heartache and pain that he felt the need to go to my boss and complain about me and now I have to go meet with her.

The next box says:
If the patient's pain is not controlled, the RN may give a 2mg bolus dose one time. If one hour after the bolus dose is delivered the patient's pain is still not controlled, the RN may increase the dose by 0.5mg a total of 2 times BEFORE CALLING THE MD FOR ADDITIONAL PAIN CONTROL MEASURES. These boxes have to be checked in order for us to be able to do this, and they were. They were checked.

So, this guy when I came on shift was saying that the PCA wasn't working. I gave him a 2mg bolus. About an hour and a half later he was saying that it still wasn't great but it was better. So I took him up from 1mg every 10 minutes to 1.5mg every 10 minutes. And then he said everything was fine. His pain was at a tolerable level. He went to sleep. I checked on him through the night and he'd wake up periodically and tell me everything was ok, and that the button was working, and that his pain was fine.

When the next nurse came on, the guy woke up and said "Oh, the pain. It's an 8/10." Ok, well, he had been sleeping for like 2 hours and not pushing his button so naturally he was in pain. "Push your button my friend," I told him. And he did, and he felt better. The nurse looked and saw he had 60 demands in 12 hours. She didn't like that.

You guys. 60 demands in 12 hours, guys, is not a huge deal. In 12 hours there are 720 minutes. A patient with a 10 minute PCA can push that button 72 times. And while I was managing that patient's pain he was pushing that button like every freaking minute or so until I got it under control. So 60 times. Big fucking deal.

Anyway. So I go home, right, thinking that I'm done and everything is okay. Until I get a text from my boss: Call me immediately.

The fuck?

So I call her only to learn that Dr. McFuckface had been in her office throwing a goddamn temper tantrum that this patient's pain hadn't been managed and that I didn't call him. Well, OF COURSE I didn't call you, asshole. I followed the PCA orders you wrote. So I explained to my boss (who hadn't looked at the PCA order set before she called me which would have solved everything) that I had followed his orders to the letter, exactly as he had written them. I told her that the patient had not reported to me that his pain was unmanageable. I told her that he had been on the 1mg settings ALL DAY without issue. And I told her if Dr. McFuckface has a problem I'll be happy to talk to him. Because fuck that noise.

Well, now I have to go meet with her and I'm scared and worried that I'm in trouble. I've been burned before so I'm paranoid that she's going to be all "Hand over your badge, security will escort you out." She won't, I don't think, but still. I hate meeting with the boss. It's hard out there for nurses like me.

This doctor and I do not get along at all, mostly because I simply do not put up with his bullshit. This one time he was at the nurse's station and I was taking care of his patient who was day two post op and needed sliding scale insulin orders. So I politely approached him and sweetly asked, "Dr. McFuckface? The patient in 9 needs sliding scale orders, especially if you're going to start her on a diet today. Would you mind putting her back on a low dose sliding scale? That's what she was on up on the floor."

So I'm thinking, since this is my first real interaction with him, that he'd go and get the order set and fill it out, right? Nope. He scribbles "Low dose sliding scale" on an order sheet and hands it to me. I can't give this to pharmacy. WTF am I going to do with this? Cherish it? No. So I go and get the order set and hand it to him and say "I'm sorry, doc, but pharmacy needs it to be filled out on this. Plus there's other things that should be addressed, like if you'd like her to have correctional and nutritional and whether you'd like her to have Lantus as well."

He lost his goddamn mind. Seriously. And I guess he was so used to losing his mind and all the other nurses just taking it that he was hideously unprepared for what happened next.

Yall ever see The Color Purple? Where Sofia and her boyfriend are in the juke joint with Harpo and his new girl Squeak and Squeak gets up in Sofia's face and calls her a big ol heffa and then slaps her? And then all the musicians pack up their shit, like "Whoop, time to go" cause they know that Sofia is about to cloud up and storm all over Squeak? Well, people know me, and they know that I don't take kindly to that kind of shit. And so I say to him, "ExCUSE me?" And everyone stops and looks. And it gets deadly quiet.

"Who do you think yo're talking to like that?" I say. "Do you think that's an appropriate way to speak to someone? Are you seriously yelling at me right now because I asked you to fill out the proper form?"

"Well, I'm a busy man! I have patients to see! I can't be bothered with damn paperwork! I wrote the order, what more do you want?" he yells.

"Yeah, patients including the patient in bed 9, whom you've already seen but neglected to order insulin for. We use very specific order sets here, a fact of which I'm sure you're aware since you've been working here much longer than I have. I asked you politely to manage your patient. I do not deserve nor will I tolerate your behavior. I suggest, sir, that you refrain from speaking to me in such an unprofessional and condescending manner in the future if we're to work together." And I hold out the insulin order set to him, looking over my glasses with my eyebrow raised and my jaw set and a don't-you-even-fuck-with-me look in my eyes.

So he starts sputtering and gets red in the face and then slams the chart down and grabs the paper from my outstretched hand.

And that's when the charge nurse came and led me away because she knew it was about to get even uglier. I got spoken to about that incident, told by my boss that while she admired my courage to stand up for myself, Dr. McFuckface is BFF's with hospital administration and can make my life miserable and it's probably not a good idea to challenge him.

Which is total bullshit.

Do your fucking job. Do your job the right way the first time. We're a fucking TEAM, for crying out loud.

Anyway. Wish me luck.

Hopefully Still Gainfully Employed MoJo

The Difficult Conversations We Have to Have

I'm sure we've all had that one patient who comes in sick as shit and is still a full code and you go... wait, what the fuck?

What the actual fuck??

I recently had a conversation, sparked by a post on Twitter, about these patients and their family members who come in completely clueless about the disease process, why they are sick, why they don't get better, and whether they will ever recover.

Wayne ‏@Toaster_Pastry 14 Nov We could probably reduce 1/2 of the medical wrongful death lawsuits if patient's families understood the big picture.

This sparked a discussion on Palliative Care Teams and their role in offering treatment options to patients and family members. Palliative care teams are great at this, in my humble opinion, but they aren't there at 0300 when you have to intubate that patient with end stage uterine cancer and mets everywhere who insists on full treatment even though they weigh 40 kilos and have a large mass occluding their left mainstem bronchus.

Because that patient and their family members don't-- or, won't-- understand that they are dying.

They don't understand that they will never come off of that vent. They will never get better. Ever.

If there's one thing I've learned in my short tenure as a nurse it's that there are no miracles. There really aren't. That might sound cynical or jaded or fatalistic but let's be honest, people, there is no Hail Mary in the last 5 seconds of the game of life that will save your ass from being eaten alive from the inside out by cancer.

The doctor in the tweet above prefers to have these difficult discussions with patients himself. This is understandable, and commendable. Nurses fill this role often as well. As do chaplains and social workers. And palliative care teams.

But patients and family members don't understand most of the time. My own sister didn't seem to understand the relationship of fluid overload on her heart since her kidneys couldn't get rid of the excess. As a result, she got CHF, and COPD from smoking, and cellulitis and pulmonary edema and a whole host of other comorbidities which resulted in a whole shitstorm of sick that, at the end, there was nothing we or the doctors could do anything about.

I don't know if it's because the patients and families just lack basic medical knowledge, or they think that it can't be as bad as the doctor or nurse or social worker is saying it is, or they think that we're just stupid or what. But denial is rampant. Denial should be a medical diagnosis, a nursing diagnosis, a psych diagnosis, an ICD9 billable code, a core measure, and a class in medical nursing psych tech and pharmacy school.

We're sorry, Mr. Jones, but you have a terminal case of Denial.

I used to be so down with education. It was my favorite thing. I loved sitting with my patients and talking to them about restricting their fluid or not smoking or making sure to be consistent in eating their leafy greens while on Coumadin and taking their insulin and checking their sugars every day. But then I got to working in a place where I was able to see the same people coming in over and over and over. The same CHF lady who needs to be intubated and diuresed because she drinks Big Gulps from 7-11 every day and wonders why she can't breathe. The same COPD'er who doesn't wear his CPAP at night and still smokes and wonders why he can't breathe. The same noncompliant diabetic in DKA or HHNK. The same liver patient who doesn't take his lactulose and comes in altered with ammonia levels in the 300s. And it's like... is it me? Do they not get it? What the fuck, man? Why do they keep coming back??


But you do, right?

You do.

You code your CHF'er or your COPD'er. You wipe your DT'ers ass for the millionth time after the lactulose you pour down his NGT. You titrate that insulin every hour for that noncompliant diabetic in DKA. You do it because that's what you fucking do.

I have had to be present for these conversations many times. Most of the time it's about withdrawing care after we've done everything we could.

But how do you have the conversation with the patient and the family about whether it's appropriate to do anything? How do you look that family in the eye, for example, and say "You know, it's really inappropriate to intubate your mother because she's eaten alive with cancer and we will never get her back, ever. She will never be well."

How do you sit Mrs. Jones down and say "You know, your father has aspirated at the nursing home so many times, I know he's done it again this time, but it's probably not appropriate to intubate him again and again and again. This will only keep happening and it will get harder and harder to get him better."

How do you explain to them that, because of the disease process, they are just going down a road from which there is no coming back? That at some point there will inevitably be an event horizon and that will be the end of it? That you can't make them better, you can't fix them or reverse the damage, you can only prolong the inevitable. You can only keep plugging the holes in the dam until one day the dam's going to burst, you know?

How do you do this and make them understand it like we understand it?

But instead they steadfastly insist that you do everything. And when it plays out exactly as you said it would, they look to find fault with you, the doctors, the hospital, your care. They question your expertise. They give you bad reviews on Yelp. They write to administration. They say "You never told us." "We didn't understand." "We had no idea this would happen."

Case in point:
I admitted a guy who had been sick, went to his primary doc, and got medication for "some kind of infection" according to the family. They didn't even know what kind it was. And they said he started to feel worse but didn't go back to the doctor. And he stopped taking the antibiotics because they "weren't working." They didn't even know what kind of antibiotics they were. They didn't know what medical issues he had besides some heart problems and blood pressure problems. They didn't know what medications he took, just some "water pills" and a blood pressure medication. Because he had heart congestion, which they thought was like sinus congestion (because they both had the word "congestion" I guess?) they told me he took a lot of sudafed, they knew that much. Well, anyway, he was found down in the bathroom with agonal breathing.

The ER docs tried to explain to the family in the ER that, look, this guy is on his way out. (I'm sure they were a little more gentle than that, but that's the gist of it.) But the family insisted: do everything. So they tubed him, got him a central line and a little Levo and Dobutamine. His white count was in the 30s, lactate was 11. Lytes were all fucked up. Chest x-ray was whited out-- he had vomited and aspirated. Guy was on 100% with 18 of PEEP and his sats were still 88. Got him over to the ICU and he was just a mess. We couldn't ventilate him. No urine output. Mottled skin. Fixed and dilated. So the conversation began again, this time with our ICU docs and me. And the family still insisted we do everything. Even though we explained in detail what was going on. They thought he'd be fine. They thought we didn't know what we were talking about.

And then he coded.

And you know what the wife said?

"What did you do to him??"

What did we do to him?? We put a tube down a dead man's throat and breathed for him and gave him medications in that gigantic IV in his neck so that his blood pressure would be more than 70/30 and so that his heart would beat better LIKE YOU INSISTED.

And so as we're coding him and I'm doing chest compressions, the wife is screaming "What are you doing to him? Is he dying? Is he dying right now?!" I wanted to scream at her, tell her, "He was dead when he came in, ma'am. He should have gotten a morphine drip and been given the decency to die in peace." But what the doc said was, "Yes, he is."

After rounds of CPR and shocks and Vfib and PEA we told the family there was nothing more we could do. And the wife accused us of giving up too soon. She demanded we try again. She left the ICU cursing our names, angry that we couldn't save him.

What else could we do? What expectations did she have? Why didn't she understand what we were telling her?

Come to find out he was a noncompliant CHF'er with diabetes, a smoker with COPD, drank to excess. Had multiple inpatient visits. The dam finally broke for this guy.

So what do we take away from this? One nurse in the discussion said "Advance Directives!"

Advance Directives are great, but not so great if the patient doesn't understand that their care is going to be futile and checks "I want everything done." We can't coach them when they fill it out, either.

What are your thoughts, Dear Readers?


Meet The Cast of Characters At My Job


How are you guys?

I'm great, thanks for asking. Shit has finally gotten normalized for me, the upheaval in my life has subsided (for now) and I'm settled in a job I love with people that I ...tolerate.

Come on, I've always only 'tolerated' other people, did you expect any less of me this go-around?

So, without further ado, let's meet some of the people I work with!!

First up is Dr. Soulpatch. Dr. Soulpatch is aptly named, because of the little fuzzy caterpillar who lives under his bottom lip. This soulpatch is totally incongruous to his nature. You would expect someone with a soulpatch to be cool, chill, maybe do cool shit like listen to Bob Marley and ride a bike and go to Burning Man. Or perhaps they like wine and french poetry and Nietzsche. But Dr. Soulpatch is ... not that guy. He's robotic and hyper-efficient and uber-focused and very much a person who probably has very little fun at all ever. He probably drives with his hands at 10 and 2 at precisely 65 miles per hour in the far right lane on the highway with his radio tuned to the emergency broadcast station on AM Radio "just in case." And he can't put a central line in to save his life.

True to form, yours truly has been trying to entice Dr. Soulpatch out of his shell. Dr. Soulpatch didn't quite know what to make of this brash and outspoken tatted redhead who asked him direct questions and looked him in the eye with arms folded and frankly discussed her thoughts and ideas. Dr. Soulpatch is Old Skool in that he thinks nurses have "their place" and here comes me and my opinionated mouth challenging him and his fundamentals. Dr. Soulpatch didn't used to smile or laugh at work. Now he does. Dr. Soulpatch didn't used to crack off-color jokes at work. Now he does. He still can't put in a central line, but we'll get there.

Dr. Count Von Count is my favorite by far. He's a diminutive dark haired swarthy German fresh off the boat from Germany. His accent reminds me of Oktoberfest and schnitzel and my favorite muppet from Sesame Street. We bonded on my first day working with him when he asked where the ultrasound was and I told him in my broken half-assed German it's "links, um de ecke und gerade aus auf dem Soiled Utility Zimmer, my freund."
"Sprechen sie deutsch?" He said.
"Ja." I said.
And the rest, as we say, is history.

Dr. Count Von Count loves the nurses. He lets us run rampant. Whatever we ask for, he gives us, not in a way that means he hasn't a fucking clue what's going on, but moreso in a way that says "I trust your judgment and I will listen to what you have to say." Dr. Count Von Count isn't afraid to ask us nurses "Vell, vaht do you tink?" He's the coolest fucking doc on the planet. My schedule aligns with his and most night we're working together and it's pure. fucking. magic.

Dr. I Admit Everyone to ICU is my least favorite. Can you guess why? Oh, hemoptysis two weeks ago with a slight fever? Admit to ICU R/O TB. Oh, alcoholic whose last drink was last week? Admit to ICU for DTs and ETOH Withdrawal. Patient with H/H of 9/26 and a history of ETOH? Admit to ICU R/O GI bleed. Heart rate 130s? Admit to ICU with SVT. BP 180/76 in non-compliant diabetic with history of hypertension and CKD3? Admit to ICU with hypertensive crisis. God dammit, man, stop admitting floor patients to ICU!

Dr. I Admit Everyone to ICU is an old navy doc whose reasoning is this: It's better to have them decomp in ICU than to have to transfer them later. Dude, you're 80 years old. Seriously. Floor nursing is way more technical than it used to be when you were a spry young fellow. They can do cardizem drips or PRN pushes on the floor. They can give 4 units of PRBCs (for H/H 9/26!!!!!!!) on the floor. They can give lopressor IVP on the floor. Give us a fucking break already man!

How about the nurses I work with, you say? Are any of them noteworthy, you say?

Why, yes, they are!!

Nurse Hyperspazz is one that comes readily to mind. Nurse Hyperspazz is consistently at an 11/10 on the "fucking crazy" scale. Nurse Hyperspazz can have two really super easy Dr. I Admit Everyone to ICU's med-surg patients and be just as frazzled and freaked out as if he had two vented multiple pressors septic shock patients. Nurse Hyperspazz loves to complain about the assignment. He likes it very specific: His rooms have to be together. He has to sit at a specific spot at the nurse's station. His patients have to be one hard, one easy: for example he wants, like, a vented septic patient coupled with, say, a patient awaiting transfer in the morning to med-surg because they were admitted by Dr. I Admit Everyone to ICU. GOD FORBID he gets an ETOHer.

I tweeted about nurse Hyperspazz the other night. This nurse is absolutely insane. He got mad at me because he didn't want first admit, so I took one for the team and offered to take it just to make him shut up and calm down. Turns out I got the super duper easy patient who needed nothing but protonix and ETOH cessation counseling and he got the one who came from ER unstable who needed intubation and multiple drips and a central line... and since it was Dr. Soulpatch on that night, that meant he'd have to be in there for the 3 hours it takes Dr. Soulpatch to put a line in. POOR NURSE HYPERSPAZZ. The entire night was filled with him queening out yelling at folks and running his large meaty hands through his mullet bitching about how busy he was. 


Nurse I Don't Give a Fuck is that person who will sit at the nurse's station and chart on her two patients while the whole rest of the unit is in a room working a code. That's all I know about her because she doesn't talk to us. So fuck her.

Nurse Let Me Help You With That is great at first, but then it's like ok. I don't need you to show me the ST Analysis on the monitor because I've already looked at it, evaluated my patient, and gotten an EKG and cardiac enzymes ordered from Dr. Count Von Count "just to be on ze safe side." Thanks for helping. The bonus about Nurse Let Me Help You With That is that he knows eeeeeeeeeehvrything about the patients on the unit, so he's especially helpful when, like, lab calls asking if you still need that 0200 lactate.

All the other nurses are pretty awesome and fun and nice and helpful but they don't make for good blog fodder so... moving on...

Where has MoJo been you might be asking.


MoJo has been here. Tweeting. Resting. Enjoying life. But I've missed you guys and decided it's time to breathe some life into this blog again. I promise all of you who still read this drivel that I will try not to be away for long again.


In Which I Write About The Incident

So you all know that I landed my dream job, right? I was an ER nurse in a Level One Trauma Center for a grand total of four months. Well, through a series of unfortunate events I am no longer there. I bet you all are wondering what happened.

I got fired.

And quit.

And basically had a bad breakup with my job.

Now that sufficient time has passed and I've finished crying and the nightmares are pretty much over, I can tell you all about it. Mostly.

You see, this isn't going to be a gristly recounting of The Incident, but of the aftermath: the time I spent questioning my abilities and wondering if I had a mental disorder and laying in bed not eating and all of the requisite craziness that happened following The Incident.

And my decision to leave that job, while it hinged on The Incident, was actually made many weeks before It happened. I think I had mentally checked out way before that hobo tried to kill me.

So, I can tell you that as far back as I remember I have wanted to work in an ER. I steadfastly refuted everyone's assessment of my abilities that maybe I wasn't suited for the chaos and danger and heartbreak of an ER. I put my head down and plodded along, ignoring everyone's advice because fuck them. My paramedic friends, my teachers, my fellow nurse friends all told me the same thing... but I had made up my mind that I was going to work at the Trauma Center and god help anyone who stood in my way.

So, after a year or so of knuckles to the grindstone hating my jobs and dreaming of The Promised Land I finally got an interview. And then, the job offer. I DIED that day, oh my God, my dreams had finally come true!

But then I started working there.

And I hated it.

But I refused to admit to myself that I hated it. Because if I admitted that, then I would be wrong and everyone else would be right.

It was horrible. Everything was horrible. The things I saw I can't unsee. Dead children. Dead babies. Traumatic amputations. Brains. Screaming families. Death.

And the violence. I had been bitten, threatened, punched, scratched. My coworkers told me to make sure I documented everything for when-- not if-- I ended up in court.

I bet you're thinking, MoJo, it can't be that bad. Seriously, you can't possibly have seen all that in four months.

But I did. And it haunts me.

I spent many breaks crying in the bathroom from fear, from stress. How was I going to handle this and not kill someone? How was I going to handle four patients, all of whom could be actively dying, and make sure I got everything done right? And how was I going to do this and hold on to my compassion for my fellow human beings? Because I didn't just lose faith in myself in that ER. I lost faith in humanity.

And then, The Hobo. And his knife. And the cops and the guns. The Incident. I have never been in such fear for my life. I was scared for my life. The enormity of that moment still hasn't fully registered in my brain, even today so many months later. I could have died that day.

I was fired the next morning when I reported for work at 0700. The conversation basically went "We're going to release you from probation." "Oh, good, because here's my resignation I typed up last night at 3am because by the way I haven't been to sleep yet."

They were cool about it. They told me that I was very smart and professional but that they knew it just wasn't for me. And I told then I knew, too.

But the damage had been done. I was full of doubt. I didn't know if I even wanted to be a nurse anymore. How could I have worked for something for so long and then, once I got it, fail at it so utterly, so miserably?
I was ashamed, embarrassed, humiliated. I was angry. I was hopeless. I was relieved. I cried for two days. Remembering even now brings tears to my eyes because I'm still not over it. Part of me wants to call them and ask them to please give me another chance, if only to prove to myself that I'm not a failure.

The other, sane, rational part of me says "You set a goal, you achieved that goal. If it doesn't work out, you set other goals and then get to work achieving them. That's life. Get over yourself."

I could tell you that I have a new job now, in an ICU, and that I pull ER shifts now and again in my little 79 bed hospital. But I almost feel like the taint of failure will never leave me. I'm back on the bottom rung again because I tried to bite off more than I could chew and fell so far and so hard that for a time I didn't think I'd ever get back up again.

It's going to take time to rebuild my confidence. I'm sure I'll get there someday but I feel like much of what made me "me" was my brazen and unapologetic belief in myself and my refusal to accept anything but what I wanted. I feel like I've lost so much of that. I'm more tentative and hesitant now. I second-guess myself. Isn't that funny? What does that say about me-- that losing a job has damaged me so thoroughly? Did this make me crazy on top of hopeless and full of self-doubt? What the alternate fuck, MoJo?

So now I've begun the process of pulling myself up by my bootstraps and putting on my big girl panties and getting the fuck over it. This is part of the reason that I wanted a fresh start on my blog, to go along with a fresh start of my career and my "self."

Someday maybe I'll go back. After a few more years of learning, becoming more seasoned, growing as a professional and a person I'll go back-- not hat in hand, but with my head held high ready to take it on again. To get back on the horse that threw me.

Or, maybe not.

Either way, I'm taking you fuckers with me.