Iowadrift

Lost

Oy, vey.  I had this whole lovely post about yesterday being my last shift at work, and what I would miss about my job, and how I loved the balance it brought to me, and how I did not love getting home at one in the merry morning after a night of handing out narcotics to shady people, and the computer up and ate the whole darn thing (the post, not the shady people) just as I was remembering to save it. 

Damn and damn and damn.

I refuse to be sat upon by a machine, though.  Which is why, though I can't re-create the post, I can at least make a list.

THINGS I WILL MISS ABOUT MY JOB

1) I got to walk into a room, change out of my Mom clothes and into my scrubs, and walk out in the ER.  Externalizing the change in roles from home to work was very helpful.  Also, when I hit the door and smelled that hospital smell, my brain clicked into medical mode and out of Mom mode, which was a relief.

2) I was usually so busy I forgot about everything but what I was doing that instant, which was persepctive-making.  By the time I was driving home and remembered whatever worries I'd left behind that morning (what has suddenly inspired the boys to demand I dress them alike: did I actually pay the Visa bill or just THINK about paying it: where did the Urplet hide my iPod: why do I never seem to have any underwear that fits: will our current health insurance bridge until TTD's new insurance kicks in 3 months after his start date?) the time and distance had sort of pulled said worries' teeth.

3) I liked the balance of hand skills, judgement, intuition, linear scientific thinking, and common sense my job demanded.  I liked walking the daily tightrope of trusting my own judgement while continually second-guessing myself.  I liked seeing how far I could push my skills (safely, of course!) and I liked the constant learning. 

4) I liked the cameraderie among the ER staff.  I liked being one of them.

5) I liked some of the patients.  I loved explaining something and having their eyes light up as they said, "Oh!  No one ever told me that before!"  I liked being able to ease pain.

6) I liked driving away from the house and knowing I wouldn't see my kids until the next morning.

7) I liked the paycheck.

THINGS I WILL NOT MISS ABOUT MY JOB

1) I did not like spending ten hours on my feet with no time to eat or pee, while patients hurled themselves at the ER as though they were lemmings and we were the cliff. 

2) I did not like feeling as though all my years of training had boiled down to handing out narcotics to deadbeats in Cedar Rapids, Iowa

3) I did not like being cursed at by patients because I WOULDN"T hand out narcotics.

4) I developed a fiery hatred for low back pain: both treating it and experiencing it.

5) I hated suturing kids

6) I dreaded having the radiologist call me from the reading room and say, "Now, what exactly were you hoping to learn by ordering a CT on that patient?"

7) I hated driving away from the house knowing I wouldn't see my kids until the next morning.

What about you?  If you left your job tomorrow, what would you miss?  What would you be delirious with joy to leave behind?  My biggest worry now is how I will integrate the change in role: I'm still an NP, but I'm an unemployed one for the time being, and I always find that challenging--and delightful, to be sure, because I am all for long, lazy mornings in bed...no, wait, that was before I had kids: never mind.  Anyway, what challenges would you face, sans job, and how would you approach them?

Also, we have discovered that the new floor we were going to put into the basement shower before the buyers took over the house?  Is going to have to turn into a new floor for the whole damn bathroom, along with a whole new wall and a whole $4,000 more than we thought.  So, you know, you could send money, too.

8)

Memorium

We were home with the kids this afternoon, getting ready to go to a pumpkin-carving party.  My husband answered the phone and handed it to me: "Charge nurse at your work wants to talk to you."

This doesn't happen much.  I answered, apprehensive, and the nurse said, "Could you hold for Dr. Nice Guy?"  I held.  I'd actually talked to him earlier in the day about a patient we'd both seen recently, so I figured he was calling about that. 

Then a different doctor came on the line.  "I have some bad news," he said.

The senior ER physician died suddenly this morning.  He had a heart attack while working out at home.  He had a wife and college-age children.  He was young, healthy, and fit.  And he just...died.

He was a good man.  He was a good doctor.  He practiced emergency medicine for more than twenty years, and saved a lot of lives.  His death will leave holes in many other lives. 

Think of him, if you would, and of his wife and children and all the other people whose lives changed today because he died.  Remember him.  His name was Bill.

My Tall Doctor is sleeping beside me as I write this.  I am going to turn off the computer now and do what I used to do when I came home after a weekend on call for hospice.  I'm going to lie beside him and feel his chest rise and fall beneath my hand; I'm going to listen to the sound of his breath moving in and out, in and out.  I'm going to press my ear to his chest and listen to his heart: beating, beating, beating, beating, beating.

Interesting

I just wrote out a detailed description of a situation at work in which I made a dumb, beginner's mistake (paged a specialist without having all my information lined up; in this case, paged an orthopedic surgeon without having had radiology give me the exact degrees of angulation in a fracture, which is something you need to determine whether you need to do an operative reduction or not).   It was a stupid mistake which made the surgeon's life harder and made me look justifiably like an idiot.  I was furious with myself--still am.  But I wrote a fabulous post about it--so funny! so rueful! so accurate!.  Then, when I went to save the post, it disappeared into the ether.

So, I felt all bitter.  Yes, the universe is against me, etc.  Until I realized that perhaps that was the point: I wrote it down, I thought it through, I threw it away. 

OK.  On to the next mistake!

One day. Just one day.

That's all I want.  Just one day when it stops for a second.  No toddler hollering at six am.  No preschooler wanting to play with trains at seven.  No beds to be changed, no laundry to be done, no cats to be fed, no drainboard full of last night's dishes to be emptied.  No breakfast to make while two children cling to my knees and whine with hunger.  No breakfast to serve, or clean up.  No fights over trains to break up.  No, "Leave your brother alone!"  No, "Give that back!"  No organizing the diaper bag and filling the everlasting sippy cups.  No getting clothes on and diapers changed and shoes on and sunscreen applied.  No wrestling everyone the door.  No loading up the van, no clicking into carseats, no driving to playgroup or preschool or library or park or gym or doctor or dentist or vet or grocery store or co-op or mall or church or friend's house.  No  unloading at the destination, no shepherding into  building, no wrangling of children for minutes or hours in grocery aisles or waiting rooms or children's rooms or living rooms or play areas.  No collecting and reorganizing and persuading and coaxing and ordering and carrying and stuffing back into carseats and van.  No unloading the van with weeping toddlers and hungry preschoolers and stuff everywhere.  No dumping stuff in the front hall.  No fixing lunch and snacks and bottles and having none of it eaten.  No cleaning up, no reading, no diaper changing, no singing and rocking and walking and singing and rocking some more to get the goddamned nap going.  No snatched moments to prep cook dinner and fold laundry and call the idiot satellite TV company that keeps charging us for a service we haven't had for eighteen months.  No getting horribly drowsy and trying desperately to stay awake and generate the energy to start the afternoon post-nap.  No diaper changes, no snack-providing, no repeating the morning's entire sequence from shoes to car to road to mall or wherever to in to out to car to home.  No scrambling to make dinner with two cranky hungry whiny clingy kids hanging all over me. No finally getting dinner on the table and having kids fling it to the floor.  No cleaning up the kitchen.  No cleaning up the playroom.  No organizing everyone to get upstairs for baths.  No stripping kids, running tub, dealing with multiple meltdowns.  No heaving kids into the tub. No drying tears when heads get split open on the faucet.  No washing hair while children scream bloody murder.  No handing off one screaming child to husband who has just now walked in the door from  work in perfect time to rev up the bed-ready children for another hour.  No cleaning the bathroom.  No reading to the older one while husband puts the younger one down again and again.  No fetching of snacks and water and stuffed animals and trains before the final good-night.  No sitting in the room while the child goes to sleep because his father started that trend while you were away working three nights in a row and now it can't be broken without an effort you are just too damn tired to make at 8 pm.  No finally getting finished with children after fourteen hours, then spending another hour listening to your husband recite HIS day.  No falling into bed and hoping your husband goes to sleep before you so you can just READ A BOOK IN PEACE WITH NO ONE WANTING ANYTHING FROM YOU FOR FIVE BLESSED MINUTES.  No drifting off to sleep just as the toddler wakes up coughing.  No repeating it all six hours later.

Just one day.  That's all I want.  Just one.

Meanwhile, Back At The Ranch...

So the last two days I've worked, someone's come in unresponsive every evening.  Which, you know, it's an ER, so fine.  The thing is, can you guess what I've been doing while the doc's have been running codes?  Ear Wax.  They're down the hall saying things like, "Can you get a line in there while I intubate?" while I'm in an exam room hauling chunks of gunk from some guy's external auditory canals and saying, "Can you pitch this?" as I hand a wad of same, wrapped in gauze, to the nurse.  Sheesh.

Sheesh anyway, because what's up with emergency ear wax?  And, two nights in a row?  Yes.  One night we did the left ear, and the next night he came back for the right.  I tried recommending he use Debrox drops for a week or two, then follow up with his regular physician (at the VA where he can go and get free care, hello, why are you here in my expensive ER where you have to pay for the prescriptions yourself, never mind the honking bill?) but no, we had to remove the wax RIGHT NOW.  OK, said I, it's going to hurt.  And I trotted off to get a metal curette from the ENT room down the hall.

It did hurt, and not because I was being vindictive.  It's just, when you dig around in someone's ear, it hurts.  I will give the guy credit: he literally sat on his hands so he wouldn't grab mine while I worked, and he sucked it up until I got every last scrap of cerumen out of there.  And then the next night he came back for more. 

But still...ear wax?

Gorked Gomers and Frequent Flyers: An ER Lexicon

One of the things I enjoy about medicine is its ability to rename absolutely everything.  The inside of your elbow becomes your antecubital fossa, walking becomes ambulating, and something as simple as panting becomes labored respirations.  Why say what you mean when you can say so many other things besides, and make yourself look smart while you do it?  I'm sure you've noticed this, especially if you've had an encounter with a physician who doesn't back-translate the terminology and treats you to a long string of polysyllabic and incomprehensible words which, while supposedly an explanation, actually leave you feeling like you've just been hit with the Oxford English Dictionary and its accompanying magnifying glass.

So, in the interests of demystification, I present a partial glossary of common and highly technical ER terms for your edification and increased erudition.  (What?  You say it's not alphabetized?  You ask an awful lot of a stream-of-consciousness blog, now, don''t you....)

Frequent Flyer: Someone who appears in the ER over and over and over and over...and over.
Gomer: Short for Get Out Of My Emergency Room.  Surprisingly, often a rather affectionate term for an old buzzard who is also a frequent flyer, usually malodorous, always intoxicated, and medically completely impossible.
SOB: Not what you think.  Abbreviation for "short of breath."
DRT: Dead Right There.  Used by medics to describe a patient who expired at the accident scene, as in, "She was pretty much DRT."
Gorked: Out of it.  Can be the result of a stroke or head trauma, or of being heavily medicated.  "She got so much morphine that by the time we took her up to the floor she was way gorked."
Hanging Crepe: Readying a patient or patient's family for bad news.  "You keep doing CPR but I'm going to go hang crepe for the family."
Flail: Noun describing a situation which involved many unsuccessful attempts to get something accomplished in a rather urgent context.  "We used up every piece of equipment in the trauma room trying to get her intubated; total flail."
Goat Rodeo: A flail involving a lot of people.
Fascinoma: A case which is wierd and, well, fascinating.  "Man, we had a real fascinoma this morning--lady with cat scratch endocarditis and an iguana bite."
Incidentaloma: Something found on testing which you weren't looking for and which is worth noting but not particularly serious. 
Aunt Martha: Term used by radiologists to describe something that shows up on Xray which you can identify because, well, that's just what that looks like.  You don't see someone coming across the room at the family reunion and think, "Five-five, brown hair, glasses, big hips...must be Aunt Martha!"  You just look at her and know who she is.  Ditto certain things like uterine fibroids which have a very distinct signature on Xray.
Line: An IV. "Could you get a line in her?"
On board: In the bloodstream.  "She's got an awful lot of Dilaudid on board already, are you sure you want to order more?"
Crump: To go downhill clinically.  "Get the doc in here now, she's crumping on me!"
PPP: Piss Poor Protoplasm.  Someone who's just debilitated in every direction and can't heal well.
Celestial Transfer: Death.  "They worked on her for a long time but she ended up a celestial transfer."

A partial listing, to be sure.  Do you know of others, or does your own profession have its code words, its little phrases which inject an inappropriate but often helpfully leavening humor into intense daily situations? 

How Not to Use the ER

Friday night, during the usual nine o'clock rush (why nine at night? for chronic knee pain or a rash? if you know the answer, do please tell me), I was discharging a patient who'd slammed her finger in a car door last week (and again I say, huh?).  "OK, you're all set," I told her, ushering her toward the exam room door.  "Let me show you where to check out." "Oh," she said, "I'm just going to go down the hall here to my daughter-in-law.  I came with her."  "OK, said I,trying not to seethe visibly. "I'm going in there next, so I guess I'll see you there."

It's a family affair these days, going to the ER.  More and more often I'll see either three patients in one room, all from the same family, or two or three patients in a row who turn out to be related.  Bobby Sue has knee pain, so her Aunt Rotunda gives her a ride to the hospital, and while Bobby Sue is in triage Aunt Rotunda decides what the hell, let's check out this elbow of mine which has been bothering me for the last six months, though not enough for me to actually go to the doctor and take care of it during office hours.  So Aunt Rotunda checks in, and whee, it's two for the price of one. 

Sometimes it's even more for the same price.  Mom comes in and brings all the kids, everyone with matching colds, and that's always interesting too, as I try to take three histories, two of them pediatric, and perform three exams, while the smaller members of the family bounce on the bed and try their best to brain each other with reflex hammers.  Then, after they leave, I sit in front of the computer trying to chart and thinking, "Wait, who had the otitis?  And was it the right or the left ear?"

Then there's the folks who come alone, but with an agenda so big it fills the exam room, an agenda usually called I Need A Note Because I Didn't Go To Work Today (or Because I Don't Want To Go To Work Tomorrow).  Usually the Noters present with a problem which, it becomes clear, is puzzlingly mild, at least for an ER visit.  A knot under the shoulder blade (About which, hello?  Don't we all always have one?), or a "sprained wrist" which moves really rather nicely, or a bumped knee from the week before which, if I squint and hold my head just right, could be said to have a fading bruise on one side.  I do my thing, of course--you never know, you know?--but when everything looks like it's going to pan out just fine, with reassurances and Motrin prescriptions and Ace wraps all around, the request comes in: "Oh, and I need a note for work."  Yeah, don't we all.

I don't mean to sound too callous here: most of the folks who wander in to the ED are sick, or hurt, and I am there to take care of them, and I love my job.  But I confess that if I get enough of the above in one night I go home thinking, "DAMN, people, it's the EMERGENCY ROOM.  It costs well upwards of three hundred dollars for you to step in the door, so how's about you think twice before checking in to get your paper cut seen."  (And yes, I have had people come in with Worker's Comp paper cuts).  I mean, have YOU ever gone to the ER with someone else and decided to get seen yourself at the same time, just because you were there?  Right.

Oh, I feel so much better now.  Every now and then a girl just needs a good rant, you know?  And, rant over and air cleared, I can now remember the other thing that happened Friday, which was that I got to mess around with my sign language for a deaf gentleman who was having chest pain.  I am a lousy signer, but I did my best and bumbled through something approximating a history, and the patient was very, well, patient.  Of course, I was interpreting, if you could call it that, which honestly you couldn't, for one of the doctors, and I kept having to remind myself to let HIM ask the questions, but I did rein myself in pretty successfully.  And I managed to keep from laughing when the patient asked me, "Is that guy the doctor?  Is he any good? He's so young!"  (Though I couldn't resist telling the doctor about it afterward; he was very good-natured and said that yeah, he did wish he could grow some facial hair). 

While I was whanging away at the sign language, the nurses ran an EKG, and we stood there, the doctor and the nurses and the techs and I, watching the results roll across the screen.  "It's good," I told the patient (forgetting to wait for the doctor to say so), and he looked relieved.  And as I walked out of the room, I realized that moment epitomized what I love about my job.  I love trying to communicate with people about what they're feeling and where they're hurting, then figuring out the right tests to run, and interpreting the results back to people.  I love moving information around the board, getting it to the right places, where it can stop pain and start healing.  I love being an interpreter of...come on, you wouldn't be able to resist it either...maladies.

Except, of course, when the maladies are that someone doesn't want to work tomorrow.

How To Read A Chest Xray

I spent the day at a medical conference, but before I get to that, a quick Visiting Mama update.  I know I said I'd have more information on how to come to her legal aid, cash-wise, by the weekend, and I promise that I have not been shirking, and that I do talk to her regularly, like daily.  But I don't have a place for you to send aid yet: she's working on it, but it's not quite squared away.  I tell her of your good wishes, and remind her that she has a lot of friends, and she always asks me to relay her thanks.  So...thanks!  She'll tell you herself someday, I'm sure, but right now she has closed her site, and she doesn't have much internet access.

As to her situation, it's a bit in flux.  Keep her in your thoughts.  She needs them, and you.  And I thank you too.  Oh, and also for the comments on the last post!  They were wonderful, and really helpful!  Y'all are excellent; keep this up and I'm going to make you write the novel.  Did I mention, thank you?  Because thank you!

And by way of thanks--you know, as a special treat--I offer you Bihari's Quickie Guide to Chest Xray Interpretation.  Basically, it all comes down to this: do the lung markings look cloudy and patchy, or lacy and cobwebby?  Answer that, and you're well on your way to a helpful diagnosis.  See how simple and elegant?  Oh, and as to abdominal Xrays, just keep this in mind: is the gas a) in normal places in normal amounts, b) in normal places in abnormal amounts, or c) in abnormal places?  Figure that out, and you have your key. The gas is all.  Now, aren't you glad you stopped by?

Actually, seriously, it was good to spend a day or two sitting in the dark watching PowerPoint presentations about this and that, and scratching some bothersome professional itches.  I have been practising for twelve years now, and though my clinical intuition is good (i.e. I can almost always answer the biggest question--sick or not sick?--accurately), the underpinnings of my practice have started to get a little soft in some spots.  Termites have nibbled at the formerly solid supports labeled, "Anatomy and Physiology of the Normal Kidney."  There's dry rot in the Cardiology and Pulmonology areas.  And though I hate to admit it, Orthopedics has suffered from shoddy construction right from the very beginning.  So it's good to sit down now and again and have someone remind me, or just flat-out instruct me, about why you always err on the side of caution with suspected scaphoid fractures, and how you can best identify peribronchial cuffing.  I mean, a girl's got to know these things if she wants to get ahead, don't you agree?

TTD is lying next to me on the bed right now and sorting through his charts for tomorrow via computer. ( Isn't it great that we can work until ten o'clock at night right in our own bed?  Gee whiz, what fun!)  He just turned and looked at me and said, "I'm looking forward to this one: the chief complaint is listed as, 'Itchy from poison oak.  Or something.'" 

Here's hoping it's not, "or something."

Fibromywhatcha

The other day, one of the nurses handed me a joke of sorts.  It was a piece of paper absolutely covered, margin to margin, with an obsessive, single-spaced medical history, including contact numbers of specialists, long lists of meds, and even longer lists of surgeries.  The nurse allowed me a cursory glance, then snatched the paper away and said, "Quick, without looking any more: does this patient have fibromyalgia?"

The answer, of course, was yes, the joke (of sorts) being that almost every patient who brings you an exhaustive list like that DOES have fibromyalgia.  By their lists shall ye know them.

I thought about this today because I went into a room to see a patient with back pain and the minute she answered my first question I thought, "She's going to tell me she has fibromyalgia."  And sure enough, she did.  She didn't have a list, but she had a lot of other cues: a certain body type, a soft voice, and a kind of cloud-like presence which enveloped the exam room and me along with it.  Taking a history from her was like sinking into one of those overstuffed sofas which invite you in, then swallow you whole, so that finally with a sinking heart you realize that you are never going to be able to lever yourself out from amongst the cushions. 

This being the ED, in the end I did lever with moderate success (in both directions: she felt better when she left and so did I), but the whole encounter got me thinking about fibromyalgia.  I've done some journal-reading (New England, thank you, not Redbook) and talked to bunches of rheumatologists, and I've certainly treated my share of patients, but I remain mystified by this one.  On the one hand, I absolutely believe these people are in distress; SOMETHING is hurting them all over.  They really are in pain, they really are having trouble.  I respect that, and I want to help them. At the same time, I have treated enough patients with fibromyalgia to be curious about the number of common denominators.  For instance, almost everyone I've ever seen who carries the diagnosis is female, somewhat overweight, depressed, and soft-spoken.  Most of them are very smart; all of them have done their own research on the condition.  They've been through the treatments which don't work, and the treatments which might, but few of them have tried the one treatment which actually has proven effective in clinical trials: serious exercise, like an hour a day.  They see a lot of their doctors, and when you look at them it is abundantly obvious that they are not bouncing with bright-eyed health.  Their bodies as well as their words say they're in pain; when you touch them almost anywhere, they wince.

What to make of this?  I don't want to be dismissive of people in pain, and I want to offer them the most helpful treatments I can find.  But the only really helpful treatment anyone's found is getting on a treadmill and going for it, and to a lot of people with fibromyalgia that sounds like an impossible task (and for the ones with knee replacements and disintegrating joints, it is). Do I think some of the syndrome is emotionally and intellectually driven?  Well sure; show me the physical syndromes that AREN'T.  Do I think that people who get really invested in their medical problems and make them part of their identities have longer courses of illness?  Yeah, from what I've seen, and from some of the research I've read.  Do I think that experiencing chronic pain can cause depression?  Absolutely.  Do I know which is the chicken and which is the proverbial egg here?  Are you joking?

So I'm curious as to what you think.  It's easy to dismiss people, to say, "Get a life and get over it," but that doesn't seem useful, practical, or kind.  It's also easy to get lost in a maze of pathology and load people up on pills, treatments, therapy, and really medicalize their situation, and THAT doesn't seem too productive either.  I want to retain both sympathy and perspective when dealing with patients who have the physical pain they describe, and the emotional distress of not knowing what's really wrong with them.  I want to display a modicum of professionalism and compassion here, and at the same time I don't want to enable when I should inspire (or kick butt, whichever).  In other words, I don't have a clue.

So...do you?  What say you?  Does anybody out there HAVE fibromyalgia, and if you do, what's helped?  What hasn't?  What has the medical profession done that's helped?  That's hurt?  That's pissed you off?  Enquiring minds want to know.  Think of it as a public service: the education of Iowadrift, NP.  Future patients everywhere could benefit.

Who Gets A Gunshot Wound in Cedar Rapids?

Urp has an endless ear infection and must spend every waking minute on my right hip (he doesn't like the left one, though personally I think it's marginally more padded, so he should love it). He woke TTD up at 6:15 this morning and screamed throughout TTD's shower, even though I was holding him--he wanted TTD and no one else, which is often the case. After TTD left for work, it took me an hour to get breakfast on the table because I was doing it one-handed, and Urp kept needing to be read to, and then as soon as we sat down to eat ("we" being me and the boys--and usually we quite enjoy breakfast, particularly the part where they drink their water and juice and I drink my tea, then we all put our cups down and go, "AAAAAHHH," in unison), Urp began the arch-and-shriek in his highchair and had to come to my lap and get his hair in my waffle syrup. Then I tried and failed to get Urp down for a nap. Then I raced around to try to clean the house before the cleaning lady came. Then we zoomed out the door, and actually made it to Bunny's gym class in time, oh frabjous day.

Every day, no matter how fraught, has its bright spots, and gym class was today's. Bunny does a little tumbling class at a local children's gym, because I thought it would be fun for him to run around and meet other kids and also useful for him to get used to being in a class before he goes to preschool. And in the course of six weeks he's gone from clinging to me in a corner and absolutely refusing to have anything to do with any kind of program, to marching off in line, without me, to his class and doing the whole forty-five minutes without so much as checking the window for me. I am ridiculously proud of him, actually, and if I weren't riding herd on Urp the whole time I'd have my nose glued to said window while I drank in the amazing sight of my child learning a new skill or two on his own, without me. He's a person! It's so thrilling! (And no, I'm not being sarcastic. I think watching someone you love do his or her thing is one of the most enjoyable pastimes there is. I find working with TTD to be very sexy, for instance; I love it when he does that Doctor thing).

Anyway, that was a good hour. Then we came home, Urp refused to nap again, Urp and I fought over the refusal, I decided that I didn't want to spend the last half hour of my time at home fighting and brought him downstairs, and we got in a little cuddle time with Bun before the Miraculous Babysitter (we have two, you understand; Gorgeous M,W,F, and Miraculous T,Th) arrived and I hightailed it for the ED.

Where the shit, literal and figurative, hit the fan. I'd been gone for two weeks (the trip to Dallas) and I was weak and out of practice, but did the patients display any sympathy? Hell, no. They were lined up five deep when I got there, and for the next ten hours I had all five of my rooms full and about seven people in the hall, all the time.

Now, I work the Fast Track, which is where the quick-sick patients go: my job is to patch 'em up and get 'em out so we can get some more in. So when I'm stacked up, it's not like people are bleeding to death in my exam rooms. They're just sitting there looking glum with ice packs on their ankles, or pacing with toothache, or curled up in a ball with a migraine. I mean, not JUST; it sucks to have a broken bone or a migraine (I've had both). But it's not like I'm desperately choosing who to save on the battlefield. Still, the feeling of having so many people waiting on YOU to DO SOMETHING to FIX them tends to color the atmosphere with a certain urgency, especially since I know the doc's tend to keep an eye on the computer to see how I'm doing (i.e. how the turnover rate's doing). So it was a long night.

Actually, it was an INSANE night, and I know there's a lot of cap's in this post and I DON"T CARE, I FEEL CAPITAL LETTERISH RIGHT NOW, IT"S TWO IN THE MORNING AND I AM REVVED. Triage was total anarchy, with three stabbings who all came in, still fighting, at the same time, and some guy having a nosebleed all over the floor. An ambulance came in with a gunshot wound to the head and was promptly sent down the road to the university hospital, because we don't have neurosurgery (I asked the doc's, "What did you do with the GSW?" and they said, "We pointed to the floor of the driver's side of the ambulance and said, see that pedal to the right of the brake pedal? Press hard on that and go south."). I casted fracture after fracture after fracture after fracture. And the place was so full that people were circling in the halls like aircraft over Kennedy in the fog. I felt like Bruce Willis in Die Hard: "Yippee kai yay, motherfucker!"

I got out only 45 minutes late, with all my charting done (drumroll please), and arrived home to find Urp and TTD circling the floor. Urp had awakened at 11 and wouldn't go down. TTD, almost in tears with exhaustion, wouldn't let me take him and insisted on continuing to try to get him back to sleep. I got mad. Everybody cried. I went downstairs and broke a plate. TTD and Urp eventually collapsed in Urp's room. Now I'm blogging, because we don't have that many plates and we've got to eat the waffles off of SOMETHING in the morning.

But there's hope. It's already tomorrow! That means it's getting better already, right? And I found wonderful, fleece-lined cargo pants for Bunny at the Land's End online clearance sale, for a mere fraction of their proper cost. So no matter that my shoulder muscles are like iron, or that in ten hours I'll be back in the ED, or that TTD need s a vacation ALONE in the worst way: Bunny will be warm and stylish in November! So all's well that ends well.

And now I am going to bed, perhaps right here on the kitchen counter. Yes, I think this will do nicely; excuse me while I lay my head down here....mmmmm.....