The Cure, Austin Music Hall

Despite a couple missed opportunities that are too ridiculous to go into here, I've previously only seen The Cure once. As a way to get fired up for the show, I made up a dream setlist as I drive to Dallas. As the encore began, I was struck with gleeful awe when I realized that they had played every damn song I wanted to hear! This is what I love about The Cure's live shows. They have a extensive career and dedicated fans, so play long shows with songs across their whole discography.

When my friend Dan heard that they were coming to Austin, and to the relatively small Austin Music Hall we were committed to going along with other friends. Tragedy struck when computer problems (?) or something prevented Dan from getting tickets for everyone and the show sold out. After seeing the setlists from this tour, I knew I couldn't miss out and so paid premium for ticket off eBay (grumble, grumble).

As the carload of friends drove to the show, we engaged in the witty banter that's a mainstay of our group (how frickin' self-agrandizing can I be? Ass). We speculated on the intricate goth outfits that were sure to be on display and then we rounded a corner to the sight of miles of black cloth and fishnets. As Chad put it, "Ladies and Gentlemen, Exhibit A."

Austin Music Hall has been extensively refurbished with more seating upstairs, a fancier entryway, better sound, and much improved intimate feel. After some nosing about, we set up downstairs about 30 feet from the stage. After a bland, boring opening act The Cure took the stage and blew us all away. Disintegration and Wish are about tied for my favorite albums and so opening with, well "Open" and then going right into "Fascination St." made me extremely happy. The show continued with plenty of songs from both albums with others sprinkled from across their career. It wasn't until they ripped into it that I remembered how much I love "Push" from Head on the Door (I re-listened to that CD later and rediscovered how great it is). "Catch" resulted in a happy emotional meltdown for Karen which was great fun to witness. During the show Dan and I confirmed out loud what was obvious, it had vaulted into our top ten concerts of all time.

Push from elsewhere on the tour


In Between Days


Sure Robert's put on a lot of weight and looks a bit silly with the make-up and hair at his age. This was balanced out by Porl Thompson ripped physique (how nice to have him back in the fold after years away and just killing on lead guitar) and the fact that Simon has not aged in 25 years. Jason the drummer isn't as good as Boris but I'm not complaining. They were in fine form. One of the coolest thing about the show is that they had no keyboards. All the synth lines were played on guitar by either Porl or Robert. I think The Cure uses keyboards very well, but it was invigorating to hear the songs without them.

From previous shows, we knew there would be at least two encores, but we still clapped and called for more. "M", "Play for Today" (and yes I sang the keyboard chorus melody), and "A Forest" just killed. Away to the wings, more clapping, and then back out for the highly anticipated run of seven songs from their 1st album. Even though I knew it was going to happen, it was still wonderful.

Jumping Someone Else's Train & Grinding Halt


After a 90 minute nap, I drove back to Austin tired but exhilirated for work the next morning. Absolutely worth the lack of sleep and jacked-up ticket price.

One last thing, coming so soon on the heels of the REM show in Berkeley it was inevitable that I'd compare the two. Both started off as "college" bands and broke into the mainstream before settling into the rock canon. Their best work is behind them but they both still write some good songs and play well. My estimation of these shows however is miles apart. REM played a good set to a rather flaccid audience who couldn't care less for older material. The Cure played a fantastic, almost three-hour show for a energetic audience filled with big fans. Blame it on the difference between Berkeley and Austin or the intimacy of the TX show to the outdoor venue in CA, or maybe the band themselves. Whatever reason, it certainly bumped up The Cure in my estimation.

The full setlist:

open, fascination street, alt.end, torture, the end of the world, lovesong, the big hand, pictures of you, lullaby, catch, the perfect boy, from the edge of the deep green sea, the figurehead, a strange day, sleep when i'm dead, push, doing the unstuck, inbetween days, just like heaven, primary, the only one, signal to noise, the hanging garden, one hundred years, end

E1: at night, m, play for today, a forest
E2: three imaginary boys, fire in cairo, boys don't cry, jumping someone else's train, grinding halt, 10:15 saturday night, killing an arab

REM in SF

The timing of my trip to SF was dictated by REM's tour stop in Berkeley. They weren't/aren't coming anywhere close to Texas and I always said my first trip after graduating from school would be to visit MidSav and Rob in SF, so the timing worked out well.

I've been an REM fan for a long time, but back in the late '80s I was deemed too young to attend the Dallas stop on their Green tour. After that they didn't tour for years. So I've only seen them three times, Monster tour, Up tour, and at ACL during a tour promoting a Best Of. All good shows, though the ACL one wins out because A) I was so close, B) I was surrounded by great fans, and C) they played plenty of old stuff (setlists from that tour). The one-two punch of "Finest Worksong" and "Begin the Begin" made me wish yet again that concert joy could be bottled to enjoy later. Still, I was bummed when I saw the setlist from Houston. Maps & Legends?!

REM's new album, Accelerate, has been hailed as a return to form which really just means that there are some loud rock songs and it's not so wan like that last couple records. That sounds like damning with faint praise, but I really do like it for the most part. Anyway, I was excited to see them again and especially at the Greek Theatre on the University of California, Berkeley campus. It's a open-air, tiered venue so everyone can hear and see well. I'd bought my ticket early but since I'd let my fan club membership lapse missed the prime seats right up front.

MidSav & Rob dropped me off outside and I hurried in as The National had already started playing. They were good, but really belong inside a dark club. Next up was Modest Mouse, a band with several songs I like and many I find tedious and uninspired. The show was OK. The best part was (finally!) seeing Johnny Marr play guitar. Even when I closed my eyes I could pick out his lines. That Smiths reunion will never happen but if it ever did, I'd get there some way. Marr stills play beautifully and Morrissey can still belt it out.

Then REM hit the stage to huge cheers. The three actual members (Peter, Mike, Michael) were supplemented by usual tour guitarist/keyboardist Scott McCaughey and new-to-the-fold drummer Bill Rieflin. Rieflin's a great drummer and I wondered if anyone else in the audience knew that he used to play drums for a long line of industrial bands like Ministry and KMFDM.

They kicked things off with a new song "Horse To Water" to a muted reception considering. Next song was "Little America" and I was all excited, "Yay old stuff!" and then I looked around and slowly realized that though a big chunk of the crowd was the right age to have been fans of REM when during their mid-80's IRS years, they didn't know this song. Third song was "What's The Frequency, Kenneth?" and the crowd roared its approval.

This sad pattern continued through the rest of the set and severely impacted my enjoyment of the show. Song on the radio? Big cheers. Not on the radio? Boredom and tepid response. Me all ranty in my head, "C'mon people, "West of the Fields"? "Wolves, Lower"?! They haven't pulled that out for almost a decade. But oh you'll finally start moving around when "The One I Love" starts up." Grumble, grumble, gnashing of teeth.

Best part of the show (aside from the lovely old chestnuts) was their reworking of "Let Me In" into a gorgeous acoustic-guitars-and-organ version. Even Rieflin came down off the drum riser to play guitar. Here's a recording from a different show:


With this wonderful version arrangement and the subject matter, I got all teary (wouldn't be an REM concert if I didn't at some point). The main set ended with "I'm Gonna DJ" which grates because it indulges Stipe's penchant for twangy hollering. Encore proceeded as per usual (when did encores for headlining acts become customary? The '70s? When did bands start intentionally putting popular songs in the encore rather than deep cuts or unpolished covers? A topic for another post) kicking off with the best song on the new album, "Supernatural Superserious". After another new one they started up "Driver 8" which sparked at least a little recognition in the audience before tearing into "Life And How To Live It"! I danced up a storm and focused on the band and the little group of superfans up front. Show closed as it often does with "Man On The Moon" which I've grown tired of, especially Stipe's silly hollerin' version.

La la la, get back to MidSav & Rob's place, talk about the lame-o audience, still enjoyed the show, go to bed.

Well, a little more to the story. REM sold out the Greek Theatre so fast that after I bought my ticket they added a second night. At the time I had thought about buying for that night (for which I was sure to get a better seat) and just selling my first night ticket, but I didn't. Sigh. After I got home from SF I pulled up the setlist for the 2nd night and was crushed. Leading up to my trip I'd been listening to a lot of REM, particularly my favorite album Lifes Rich Pageant. Four songs on that album I love particularly and are among my favorite in their whole career. The 2nd night in Berkeley they played three of them, "Begin the Begin", "These Days", and "Fall on Me". Oh the disappointment. Full setlists for the whole tour here.

The lesson I learned from this is that I will go see REM whenever feasible for back-to-back shows and I will do my best to be right up front with the superfans who love the old stuff too.

UPDATE: I found a note I'd jotted down during the show. After they played "West of the Fields," Stipe talked about the lyrics and how early REM songs were fairly impressionistic and didn't always make a lot of sense. It's well-known now that he doesn't have a great memory, even for his own lyrics and that's especially true for the early songs. When they started playing them more often live, he went online to find out what the fans thought they were. He was amused to see what many lyric websites had posted for "West of the Fields".

Stipe: Now, I wrote some bad lyrics when I was 21 and did drugs back then. But I never wrote, "The animals are strange, try to put it in."

Mills: What are the words?

Stipe: (mock testily) I don't know what the fuckin' words are. What were you doing in 1981 Mike?

Mills: Oh, this and that.

Stipe: Yeah. I have photographic evidence.

My trip to San Franciso, and overcast Berkeley

After working 12 hours, with a 2 hour nap under my belt, I left the apartment for my trip to San Francisco. I was glad that I found a bus route that goes to the airport, less enthused when I realized how many stops it made on it's way there. Oh well.

The flight was uneventful with a layover in Arizona only noteworthy for this odd, planes-circling-a-vortex carpet pattern in the terminal. Thankfully, SF/Oakland has a great metro system of trains and buses. I easily navigated from the Oakland airport to the Mission district where I met up with Middle Savagery and Rob. Though quite tired, their sparkling conversation and enthusiasm perked me up and we had a great time eating dosas at Dosa.

Eating round, flat things would turn into an unintentional theme for the weekend. Thursday dosas, Friday pupusas, Saturday pizza. I don't think Sunday's meal, Mission burritos, held true but MidSav argued that they were round and flat before being rolled up so they counted. Though all the meals were yummy, the pizza from The Cheese Board was phenomenal. Also a standout was the Bug Juice Ale at Triple Rock, a brew pub in Berkeley.

Most of my time in SF & Berkeley was spent eating, reading graphic novels late at night, walking, and window shopping. SF is stuffed with little shops selling cute things. I think we went into at least four stores along the line of Giant Robot, which we also visited. The best window display goes to DoublePunch. Despite all the browsing, I didn't buy much. A few things from Little Otsu and a pile of CDs from Amoeba Records Berkeley branch. I went into the main Amoeba records too, but after a few minutes I was just too overwhelmed to focus. I'll go with a specific list next time.

Saturday night I went to see REM, but I'll cover that in the next post.

On Sunday we hit the Castro generally so I could see the gay(er) part of SF, but specifically so we could see the new Indiana Jones movie at the historic Castro theater. See, MidSav is an archeology grad student and so we just had to see the movie. The theater itself was grand and it was great to have the curtain part and the movie start. No ads, no trailers. I went in with low expectations, yet was hooked in the first five minutes by Spielberg's fantastic use of mirrors and shadows. And then the George Lucas crap came in and those low expectations came rushing back. Best action sequence of the film? The motorcycle chase, which un-coincidentally had no (or at least subtle) CGI effects. Anyway, we laughed walking out.

The two best things I saw in the Castro was the sex toy shop, Does Your Mother Know? because I love inappropriate ABBA references, and the guys in pink bunny suits giving out free hugs and roses. On the way to eat, we passed an alley covered in impressive graffiti. Turns out it's the well-known Clarion Alley.

After burritos, we returned to find the vehicle gone. Towed. Suck-o. Well, we weren't parked legally, just had followed others illegal lead. Between the three of us we worked out who to call and where to go to get it back. Sorry about that budget buster friends!

Monday I had some time to kill before my flight out so I rushed to the city and hit the SF Museum of Modern Art. I wrote some notes about the work that impressed me most, but I seemed to have misplaced it. I'm sure I'll come across it and then I'll just edit this entry.

UPDATE: The notes were found, though really it's just a list of works I liked.
Gerhard Richter - Lessende (Reading)
Lichtenstein - Rouen Cathedral Set V
Rothko - No. 14, 1960
Richard Serra - Boomerang

Oh yeah, we also went out to the beach, ate at a diner overlooking the ruins of the Sutro Baths, walked through Chinatown, drove through the Presidio, and got offered "nuggets" while walking through Golden Gate Park. MidSav, according to the DEA, love nuggets are marijuana, so now you know. At this point, I'm kinda tired of writing, so the activities of this paragraph shall not be expanded upon.

More trip photos here.

Fun night

I wasn't with my usual night preceptor one night, though I don't think the events of the night would have gone differently if I was. Night.

One of my patients had gotten out of surgery earlier that evening and was to remain intubated and on the ventilator all night. Usually we try to wean patients off the ventilator and get the tube out as soon as the anesthesia has worn off sufficiently. Though I don't remember the one time I was on one, it's clear that people mostly do not care for ventilators. Instead of gently sucking in air as usual, patients now have a tube down their throat that blows air into their lungs. Unnatural, uncomfortable, and often anxiety-producing.

This young man was prescribed medication to decrease his anxiety and surgical pain. They weren't really keeping up despite a couple calls to doctors for increased dose and over the course of the night he was getting increasingly agitated. His hands were tied down with soft wrist restraints as we usually do with intubated patients who are not yet calm and rational enough to not grab for their tubes and IV lines. This guy was clearly not with it mentally, yet had the presence of mind to try wiggling down in bed so he could get hold of something to pull on. Several times an hour I had to readjust his position because he was close to grabbing his Foley catheter or airway suction line. Through rubbing it against the mattress, he managed to slightly dislodge the line going into his radial artery (the wrist) that measures blood pressure continuously. While I was trying to re-tape it, he yanked back and it came out. Great. I bandaged the site and got an order to follow cuff blood pressures instead.

With all this, and upon the advice of my temporary preceptor, I called a doctor to get the patient started on a sedation protocol where we could adjust a continuous drip of medication to the desired effect, calm and not fighting the restraints. Unfortunately, the middle of the night is not the best time to request the needed medication pumps as the supply staff is only a skeleton and take forever to deliver items.

At one point, I had to reach across this guy and hold his arm down because he was grasping at his chest tubes. These are tubes that are inserted between ribs or under the sternum to drain blood and other fluid from the chest after surgery. They also help reinflate lungs that have been deflated either for surgery or because of a pneumothorax (good picture of deflated lung and chest tube there). I couldn't go around the other side of the bed to readjust and retie his restraint because I was worried that during transit, he'd grab and pull his tubes out. I said, "Sir, I cannot let you pull your chest tubes out." He looked right at me and vigorously nodded as if to say, "Oh we'll see about that!" The other nurse in my pod had gone to the supply room and my preceptor had stepped away for a moment. So there I was leaned over the patient, holding his wrist, craning my head around toward the hallway waiting for someone to walk by. It was kinda funny. Kinda. After only a couple minutes, another nurse walked by and quickly came over to help.

Around 4:30 I started to give him his bath. My temp preceptor, who is a large, strong guy, held the restraints while I washed down the patient. Despite doses of medication before the bath, the patient was still agitated. The medication pump had arrived, but we hadn't titrated the medication up enough yet to have the desired effect. At one point while we were concentrating on his upper body, he managed to get his Foley catheter tubing between his toes and yanked on it. Um, dude. There is a balloon inflated in your bladder to anchor that catheter. You do NOT want to be yanking on that. Can you say traumatized urethra? Well, not with that tube down your throat.

Toward the end of the bath he settled down though. I was just finishing up redressing his surgical incision when the patient jerked suddenly and I looked up to see a look of shock on my preceptor's face. The patient, moving quickly, had grabbed a chest tube and yanked it out. My preceptor covered the hole with his glove and called for help, I ran to the supply room for some gauze impregnated with vaseline which is used to cover the hole so air doesn't leak in.

A couple other nurses came over to help and I paged the resident on-call to come reinsert the tube or suture the hole closed. Woken up in the sleep room, the resident was groggy when he called back and at first didn't really get what I was saying. "Just come down here now please," I said as nicely but firmly as I could. The patient wasn't putting out much fluid through the tube and had another one on the same side so when the resident showed up fully awake, he just sutured it closed. While he was working, early morning visiting time had come and I tried to head off the family before they came on the unit. I caught the mom in the hallway and explained the situation, worried she was going to panic. Nope. "I thought something like this might happen," she said looking apologetic, "He's a pretty anxious person usually. I sorry he's giving you so much trouble." Oookay, then.

From there, we switched to a different, more powerful sedation med which worked well. The pulmonary doctor showed up soon after, thinking she was going to be extubating him. "What's going on here?" she asked innocently. I told her the whole story and she sympathized. I paused the sedation med so she could see his behavior (it gets out of the system quickly) and within five minutes he was back to pulling and wiggling. By this time we were at shift change so I reported off to the next shift nurse and went home to well-deserved sleep.

A couple days later I walked by the same pod and saw the pulmonary doc. She beckoned me over saying, "Look here." I rounded the curtain and there was my guy, sitting in a chair eating dinner. Thanks to the amnesiac qualities of the sedation meds, he didn't remember a thing.

Night shift and getting the hang of it all

I've been working nights for a couple weeks now and it's going well. My night preceptor is great and I've learned a lot from her. It was up in the air how long I'd be with her before I'm off orientation and working solo. At the end of last week, we both agreed that I needed more practice caring for unstable patients needing interventions such as vasoactive drip titration (regulating the dose of constantly delivered IV meds to keep heart rate and blood pressure within certain parameters) along with a second stable, but still critical patient. Managing both while still making and receiving calls, delivering scheduled medications, completing paperwork, and drawing labs, all within the alloted time, is a skill I've yet to completely master. Then of course I also have to be using critical thinking to work out what's needed when.

A beautiful thing

I laid down for a little cat nap tonight and unintentionally fell into a deep sleep where I had an incredible dream. It was late at night and a big group of my friends ringed a microphone set up in Mybloody's front lawn. We were playing a gorgeous song. Some had acoustic instruments: guitar, orchestra bells, viola, banjo, shakers, wood blocks; everyone was singing. It was a gentle, sweet song cut with a fair bit of longing and even though the words were sad, we kept looking at each other and smiling as we played on and on and on.

When I woke up to the roar of the A/C fan, I laid in bed stunned by how wonderful it all was. Then I scrabbled for a tape recorder, trying to hold on to the melody. Like many dreams though, it faded away and didn't make much sense when I tried to get it down on tape. I admit I teared up a little, both for the idea that my friends and I had made something so beautiful and out of frustration that I'd lost it.

I'm not convinced that dreams are a window into the subconscious, but this dream integrated two things I love very much, music and my friends, in a way I wouldn't have in my waking life. So friends, pick up an instrument today or just sing and try to catch a moment of joy or fear or sadness. I'll do the same.

The Art Guys - Nothing To It

After a work shift on Saturday 5/3, my preceptor dropped me off at the University of Houston so that I could see The Art Guys' show Nothing To It: An Evening of Itty Bitty Witty Ditties. Despite the trying-too-hard-to-be-humorously-obnoxious name, it was a lot of fun. The Art Guys are a Houston institution. I won't recount their biography, you can read that here. In brief, they are performance artists with an emphasis on the fun and funny rather than the dull and ponderous.

This show was a retrospective of their work performed in front of an audience that was clearly heavy on their friends, family, and ardent supporters. The first work sounded like a good idea, but in practice only partially worked. Called Future Music [In Three Movements], a projector displayed instructions that each audience member should, at a random time during the rest of the show, shout out one word. As soon as the description was up, people started calling out. The words were almost exclusively nouns like asparagus or chicken, you know "funny" words. And once the children got started, oh man was that annoying. Again, good idea for a piece, but when the audience is full of wannabe comedians and hyperactive, bored children, it don't work no good.

I won't go through every piece, just hit the highlights. A great work that worked was Kiss Piece where the two Art Guys applied lipstick and kissed every member of the audience. It was funny and sweet. Good friends and (I think) family got kissed on the lips, bald guys got kissed on the head, shy little girls on the hand. I can imagine that for a different audience it could be uncomfortable or even hostile (which would also be interesting), but for this hometown crowd it went smoothly. Kiss Piece was immediately followed by Guzzle A Beer - At Any Time - (For Tom Marioni). It's exactly what it sounds like. For the rest of the night, the director would intermittently flash up the title on the projection screen and the guys would crack open beers and guzzle them. Near the end they handed them out to some of the other back-up performers and even one guy in the audience. Seeing as the guys aren't really party animals, it was more to be endured than enjoyed, at least after the first round.

Inverted Karaoke was great. Jack, who cannot play, sat at a piano and attempted to perform "Bridge Over Troubled Waters" while listening to it on headphones that blocked out all other sound. Michael, equally horrible, "sang" along while also listening to headphones. It was cacaphonous and hilarious. Another mostly auditory work was Wrap Piece where the guys pulled out giant rolls of industrial-strength plastic wrap and proceeded to stretch it around rows of seats and handrails, working to express all the squeals and thrums they could. Plywood was a visual spectacle with dancers and chorus singing the praises of plywood. While fun to look at, this elevation of a mundane object to glory went on too long.

The last piece was also the most serious. Entitled For Martin, Jimmy and Bill, it consisted of Michael breathing audibly into a microphone while Jack slowly turned a rain stick. Sounds kind of lame, but in the near-dark, as a meditation on breath and the end of life, for someone like me that cares for people on ventilators every work day, it was beautiful and moving.

The whole show was filmed and will air on the Houston PBS station at some point. There are photos from the show on their website as well as clips from other performances.

Amorous RN, or how not to be accused of same

During a brief moment of live TV, where as I'm usually watching something recorded by my Tivo, the weekend weather guy for the Houston CW affiliate was doing his thing. I was a bit dumbfounded by his name, Casanova Nurse. Really and truly, that's his name. Unfortunately his bio does not reveal the provenance of such a unique moniker. I like that he (most likely) does NOT live the life that his name could have dictated, skillfully wooing then abandoning patients in an endless string of medically-based conquests.

On that note, last week I was advised that I should make sure a female nurse or patient care tech was present whenever I examine female patients and to leave bed baths to the female staff as precautions against allegations of impropriety, which have ticked up recently. With the pain, lack of natural light (and therefore cues to the time of day), dearth of quality sleep, medications for pain and anxiety, or just idiosyncrasies, patients who've been in an ICU for days can become confused and somewhat paranoid. For instance, even in my short time working I've seen several patients who think that all staff discussions are about them, including gynecological surgeries for men and imminent childbirth for elderly women. Good thing I have a psych background, it's useful.

It's rather annoying that I have to be so cautious as I have no interest in molesting my clients and I can't really imagine a nurse getting in to this line of work with that intention. Still, better safe than sorry or as we often say, CYA.

Up all night

I started working nights this week. My schedule in general is:

- Wake up at 5 PM
- On the bus to work at 6:05 PM
- Work 6:45 PM to 7:15 AM
- Home by 8:00 AM
- In bed by 9:30 AM

Soooo much better than waking up at 5 AM. On my days off I'll wake up and hit the gym, do laundry, and grocery shop before those places close at midnight, then enjoy the peace and quiet of the night. At first I'm sure I'll do a lot of reading and movie-watching, but I do plan to go on some photo excursions around my neighborhood and finally get out to the music clubs to see some bands. A social life would be nice as well.

I was going to advise my friends to avoid calling me during the day, but I accidentally left my phone on yesterday and didn't wake up despite three separate calls. Yay for the air conditioner/white noise generator in my bedroom.

Hectic day, but I did it

Started the day with two patients, both of whom were ready to transfer out of our unit. After getting the requisite doctor sign-outs and orders for Patient #1, I started packing up the his things when the monitor for Patient #2 alarms. I look over and see no blood pressure on the monitor, then flick my eyes over to the patient who is calmly sitting up in her chair, then to the blood on her wrist. Dang, the arterial line has come out. I ask another nurse to grab a blood pressure cuff while I get some clean gloves and gauze to hold pressure on the site of bleeding. Cuff goes on, site stops bleeding, secure it with tape, then toss the bled-on pillow.

Call report on Patient #1 (the one who didn't bleed) and move him upstairs. Back to the unit and my open spot is already assigned for a patient currently in surgery. Call housekeeping for a stat clean and start setting up for the admit. Intersperse setting up suction cannisters, tubing, monitor cables, etc. with prepping Patient #2 to transfer upstairs. Call report on her then hand off to my preceptor cause here comes the admit, a "pump case" - cardio-pulmonary bypass pump during cardiac surgery - who will be on a ventilator while recovering from anesthesia. These guys can be quite unstable and this one is initially very hypertensive. Treat that, have family back for a quick visit and status update, and then catch up on charting.

Now as Patient #3 warms up (they're chilled during surgery to reduce metabolic demand), he's vasodilating and dropping his blood pressure. Calls to doctors for fluid orders. Hang multiple bottles of albumin (yes the protein in egg whites and shampoos, though this version is human albumin) as an intravascular volume expander. Success! He's stable, which is good because now it's time to set up for another admit in the bed formally occupied by Bleeding Wrist Lady. It's not part of some cruel hazing, just happens to be the only spot open for an admit.

My preceptor helps me set up the spot while I keep one eye on still-intubated dude. Patient #4 rolls out and we're off again with stabilization, family update, and charting. While fetching a medication my preceptor says in passing, "Don't worry about the bloody sheet behind [Patient #3]'s head. It's all good. Just wanted to warn you so you don't look over and panic." I appreciate the heads up.

90 minutes later it's time to report off to the oncoming shift. Whew. Four patients in one day with two of them pump case admits is unusually heavy. Of course I had lots of help from the other nurses in my section as everyone pitches in during new admissions and nobody's going to let you (and the patient!) drown. I was most proud when a co-worker said, "I like that I didn't hear any crying over here."

Love my Car Olé

Another nice weekend in Austin. This time I came up to visit with my wonderful (but slightly misanthropic), adorable (yet occasionally menacing) friend and former roommate Carole and her sister. Both now reside elsewhere and it had been a while since they'd been back to Austin. I didn't join them for the requisite trip to Toy Joy and Momoko, but I did attend the night swim at Barton Springs. Sure the water is 68 degrees but if you just start swimming, the exertion keeps you warm. Getting out is mildly uncomfortable, though I find that vigorous towelling and thoughts of perhaps going to Kirby or Magnolia for pancakes soon resolves the shivering and goosebumps.

Lots of eating out including meatloaf at Hyde Park, Thai pizza from Flying Tomato, breakfast tacos at Tamale House, and a strawberry cheescake snowball from Casey's where we heard but did not directly witness a two-car collision. Thankfully everyone was OK and I didn't have to spring into action. It makes me nervous that I might be called upon to render medical aid outside my job and volunteer activities. Of course I'll do it as needed, I'd just rather not have the "opportunity".

Oh hey, I just realized that Carole, her sister, and I failed to convene a meeting of the organization we founded many years ago. BOTA, or Bring On The Asteroids, is dedicated to periodically becoming so frustrated by the general suckiness of people that we throw up our hands and welcome an asteroid bombardment that will wipe out humans and allow the rise of a new sapient race. Hopefully the bonobos who are generally groovy and prefer sex over violence.

Medicine on TV

So I was watching an episode of a TV drama and there occurred a medical emergency which played out so poorly, I shrieked, "WHAT?!" at the TV. A very fit young man is in the hospital after being beaten up. One minute he's talking, then suddenly the EKG monitor (which an assault victim with no history of cardiac problems would not have) alarms and IMMEDIATELY a doctor comes running in saying "He's crashing. Get me O2 and an ambu bag." The monitor completely flatlines (wrong) and a couple more staff members (nurses, possibly) run in. The MD starts totally ineffective, fake-ass chest compressions with the patient still up at a 30 degree angle in the bed. The nurse with the ambu bag gives a few breaths, then caresses the patient's chin. Huh?

Oh it was so bad. I'm sure police and lawyers get riled by horribly inaccurate portrayals of their professions too. A guy asked me once which TV shows were the most medically accurate. The best one is Trauma: Life in the ER but that's a documentary show so it really doesn't count. I haven't watched it in a while, but ER was pretty decent in that the actors had practiced doing fake intubations, chest compressions, and other procedures. I recall as well that the treatments they rattled off by and large were accurate for the patient's condition. Of course, like all medical shows, the doctors did tons of stuff that really nurses do.

Scrubs is rather bad, both in the wildly inaccurate depiction of medicine and in severely dropping off in quality after the third season. Don't even get me started on House.

And then there's my favorite quack doctor. No not Dr. Nick of The Simpsons. I'm speaking of Dr. Spacemen (SPA-CHE-MEN) on 30 Rock. A couple episodes back Dr. Spacemen (wonderfully played by Chris Parnell) rushes in to see an unconscious man who he instantly and correctly identifies as being in a diabetic coma. After some ineffectual bungling, Alec Baldwin's character says, "Couldn't you just, you know, inject something right into his heart?"

Dr. Spacemen, with a look of concern and pity, responds, "I'd love to, but we have no way of knowing where the heart is. You see, every human is different."

BWAHAHAHA! Thank goodness for Tivo so I can pause and rewind because they weren't done. Spacemen grabs the phone and says, "Is it 411 or 911? [pause] New York. Uh, diabetes repair I guess?"

Oh how I love, love, love Diabetes Repair.

A typical Monday of late, in that it involves work, frustrated desire, and something funny

I didn't make it to the dramatic presentation. I transposed two theaters when I was looking at directions originally and when I realized the mix-up it was too late to make the show. Oh well, there will be other opportunities. I'll just have to stay on top of what's playing and plan ahead. What I like about Houston is that classic and contemporary, much-lauded works get mounted here. Quite different from Austin.

Yesterday work was a study in contrasts. When I started the day, I took two patients with the plan being that I'd give them up at 9 AM to another nurse so that I could get more practice admitting difficult cases. Two hours to assess the patients, document, give medications, while also managing phone calls from family, updating doctors on condition, and providing comfort care isn't much time. I didn't quite make it and by 9:30 just ended up fetching one patient's meds for the relieving nurse to give. Dang. Then I found out that the surgery schedule started late because resident interviews had begun that morning. We wouldn't be getting the kinds of patients I needed till much later in the day. I kept myself busy helping others and studying a little till my manager called me up for my 90 day review. I'm doing well apparently and get a small raise. Yay.

At 3 PM (or 1500 as medicine uses military time) I took back one of my original patients and prepared for a fresh post-op case. He came out at 1700 and the race was on to do as much as I could get done before the next shift showed up at 1845 while also, you know, taking care of the patient. As I was saying to Mybloody last night, I once started to write a post about post-operative care of patients who required heart bypass during surgery but when it took three paragraphs just to establish the basics of hemodynamics, I deleted it. Too complicated and therefore boring for anyone that doesn't want to actually do it I think.

Anyway, I again didn't quite make it in the time allotted. Between assessment, calls and conferences with doctors, warming the patient, managing blood pressure, giving meds, and documenting I didn't get to some paperwork and a few of the less important medical orders. I was and am disappointed that, though improving, I'm still slow. My preceptor said, "You did fine. Are your patients still alive? OK then." To which I replied, "That is *not* the standard I'm shooting for at this point." I'll get there eventually but I'm not one to be patient with my own progress, grumble grumble.

On a lighter note, this made me laugh:

I was ready to be impressed

Oh Houston, I'm trying to like you but you're making it difficult. Last week I got excited because I found out about the Westheimer Block Party. Lots of bands and artists, free, and just a 20 minute walk away. It started at noon, but after a long week at work I slept in, read a bit with Muriel's Wedding on in the background, went to the gym, and ate a leisurely early dinner before heading down to the Party. Three hours later I was walking back home rather disappointed. Here are some notes I jotted down:

- This band would like to be the Strokes. Now they're playing Tom Petty's "American Girl". Huh.

- Bandana. Why?

- The painter of stylized rotund people is here.

- Shitty drummer for a jazz band. Saxomophones.

- Screw is still a going concern in Houston. [Reading the Wikipedia entry, it's still a going concern everywhere. Shows what I know.]

- Between song time > song time = no good + me moving on

- Suck.

- Nice guitar, belongs in better band.

- A song I like! Now sucking.

This was the most entertaining thing I saw.

I really should stop comparing Houston to Austin, but it's hard when the city you love to pieces is not the one you're in and the one you're in jabs you in the ear with mediocre to poor music.

Tomorrow I get my first taste of Houston theater. My cultural hopes are elevated yet wary.

Tiring, yet fulfilling week

Very busy at work this week, particularly today. My preceptor has almost completely stepped back, leaving me to handle things on my own unless I specifically ask her input on my plans or for a hand in boosting in patients in bed and the like. It's stressful doing the job without her help, but she and I agree that I'm ready and I best get as much practice handling the work solo because I'll be switching to night shift soon enough. After a couple weeks with a preceptor to get the hang of the work flow at night, I'll be on my own. Of course I can still ask the other nurses for help or input, but the responsibility will be mine with all the little mental freak-outs that come with shouldering it.

As I said, today was busy. I started the morning with one patient, admitted a fresh surgical patient, transferred the first one to the floor, admitted a third patient, transferred the second one out, then managed the third until shift change. Despite it being so busy, I had time to fall in love with my first two patients. Though their quite different backgrounds played a big part in why I was so taken with them, for confidentiality reasons I can't go into detail and changing the details to hide their identities just defeats the point. I can say that their motivation was a joy. Too often post-surgical patients just want to lie still in bed. These patients wanted to get better and followed the medical plan of care to achieve that. More than once I told one of them, "I wish I could shoot a video of you to show other patients how it's done!" I'll have to remember them both when I have the inevitable bad day.

I still really like my job. Yay.

A taste sensation?

A little Tex-Mex place near my apartment has a drink on the menu called Vampiro. It's a combination of orange, carrot, and beat juice [sic]. In rapid succession I thought of the following definitions for that last ingredient:

beat juice

1. the combination of blood and saliva that flies or leaks from the mouth whilst being pummeled: After he provoked those bikers, they extracted at least a pint of beat juice.

2. reputation for DJing skill: He's got massive beat juice.

3. semen: After holding off for 18 days, the masturbation session resulted in massive beat juice. At least a pint.

Beyond adding a deep red color and therefore justifying the name Vampiro, beet juice just doesn't sound all that appealing. Still, it's preferable to making a drink with definitions 1 and 3.

Anti-clotting med shortage

Though reports vary, it appears that there is a world-wide shortage of heparin. Heparin is an injected medication that prevents clot formation and extension. Where I work it's used to keep IV pressure lines and dialysis catheters from clotting off, to reduce clot formation until longer-term anticoagulation therapy kicks in as well as for the prevention of thrombosis formation in patients who have reduced mobility, i.e. lying in bed all the time. We got word that the normal supply was disrupted and so for single doses would have to use syringes that Pharmacy is preparing and distributing.

After some reading of wire reports, I think I got a handle on the shortage. Starting at the end of last year, there were reports of patients experiencing allergic symptoms such as difficulty breathing, rapid drops in blood pressure, nausea, and vomiting after single doses of heparin. In February, Baxter Healthcare Corp. issued a recall of heparin after many more reports of reactions including some deaths. Later Baxter announced they were suspending manufacturing. A couple weeks ago B. Braun Medical Inc. and American Health Packaging issue a voluntary recall as well.

Turns out that some of the ingredients were originally produced in China. In early March, the FDA found that the Baxter heparin had a substance called chondroitin sulfate in it that had been chemically changed so that it had a similar effect as heparin. Chondritin sulfate is much cheaper - shades of lead-based paint on toys huh? At first, the Chinese government said that quality control on the manufacturing of heparin should be carried out by the importers. They about-faced several weeks ago and issued new guidelines for stepped up testing and registering of suppliers.
Between this lax control on manufacturing and the Tibet crackdown, I'm a little peeved at China.

The Federal Drug Administration (FDA) publicly stated that there was no heparin shortage because of the recalls but, uh, when you've got three of five manufactures recalling it and hospitals practically rationing supplies, that's a problem.

St. Arnold's Brewery, an afternoon of beer

Yesterday I went to the St. Arnold's Brewery here in Houston with some friends. The brewery conducts a tour and tasting every Saturday afternoon. It was packed so the "tour" consisted of an employee with a mic explaining a few things about the brewery, which maybe 25% of the audience cared about. Then he explained the way the tasting worked, which I guess about 75% of the audience cared about (the other 25% were clearly veterans who knew quite well how it worked).

$5 gets you the speech, a souvenir St. Arnold's half-pint glass, and four tokens you redeem for drinks. Even the kids or teetotaling friends can join in as St. Arnold's has a root beer. If your kids are bugging the hell out of you I guess you could go half root and half real beer so they'll become sedated, or possibly belligerent. I kid of course, alcohol for children is a no-no.

I had two Lawnmowers and an Amber. By the time the final call came, I was too full from lunch and beer to use my last token. Next time I'll be more diligent. Click the above pic to go to Flickr for more photos, if you're into that sort of thing.

The South Park me

South Park Studios, where you can watch any episode from the series, recently launched. Following the lead of other animated program websites, they have an avatar generator.
This being South Park (with all that implies), you can chose from the basic body types of Female, Male, Canadian, 4th Grader, and Kindergartner. Skin tones offered are Hispanic, Caucasian, African, and Gay Tan. Yeah. I went with Male and Caucasian. The outfit is the closest I could get to scrubs, though the color is exactly right. Wish I had the Photoshop skills (and the actual program) to take out the "T" and add in a stethoscope and a pocket with pen, scissors, and hemostats. Still, fun!

UPDATE: Mybloody made my wishes come true. Picture now updated with stethoscope, pen, and hemostat. Thanks Mybloody!

My nursing assessment Part I

As I've written about before, patient assessment is a major part of being a nurse. Here's Part I of what I do within 30 minutes of getting a patient either when I'm coming on shift or they roll out from surgery. I was going to type up the whole thing in one post and then I realized how long it takes to write it all out versus just doing it. It's organized by body system and yes, we have a form to remind the nurse of all the things to check.

Neurological

Shine a flashlight in their eyes and watch for pupil constriction. Grade the size of the pupil (esitmated in centimeters) and the speed of constriction (brisk or sluggish). Grade their level of consciousness (alert, lethargic, obtunded, stuporous, or comatose). Grade their behavior (sedated, inappropriate, confused, agitated, or combative). Ask them their name, the day/date, where they are, and why they are there to judge how oriented they are. People who only know they're name are Ox1, if they know they're in a hospital and why and at least can get the month then they're Ox4. While they're speaking, grade their speech (clear, slurred, incomprehensible, or they have a breathing tube in and cannot speak). If they are aphasic, note whther they are having difficulty speaking (expressive aphasia), understanding what I'm saying (receptive aphasia), or both (global aphasia). Put two fingers in their hands and ask them to squeeze and release. Have them push against my hands with their feet and pull back their feet toward their knees. Grade their strength in these movements. Note if they have a drain or pressure monitor to their cerebral spinal fluid and if so the condition of the dressing over it, the level it's at, and the type of drainage (clear, serosanguinous, sanguinous).

Cardiovascular

Listen for heart sounds, note presence of S1 & S2 (the lub-dub sound) and any extra sounds. Check capillary refill at fingers and toes, grade brisk or sluggish (<>3 seconds). Note nailbed color (pink, pale, dusky, cyanotic). Grade the temporal, brachial, radial, dorsalis pedial, and posterior tibialis pulses (palpable, heard with Doppler, absent). Note chest tubes, their placement (pleural, mediastinal), suction applied if any, and what they're draining (clear, serosanguinous, sanguinous). Note pacemaker and/or internal cardiac debrillator and whether it is on. Note whether unused transcutaneous pacemaker wires are wrapped. Print a EKG strip and analyze it for the heart rhythm. Note or adjust the alarm settings for heart rate, blood pressure, and ST segment elevation or depression.

Note all IVs, their size and placement, when they were inserted, how the insertion sites look, and if the dressings over them are intact or due to be changed. If A-line (arterial line used for continuous blood pressure monitoring) and/or CVP (central venous pressure line used for monitoring that pressure as a measurement of right-side heart function and fluid status) present, calibrate the transducers and note how the monitor waveform looks and that the dressings over them are intact and up-to-date.

That's enough for now. I'll get to pulmonary, renal, etc. later. Is this boring? Should I spice it up with stories of things gone wrong?