Clothes make the.....

I'm fat and sassy, holding a nice, big paycheck for a week's worth of work. Barely a week into this job, I've already encountered my first hurdle. The personalities of the Elementary School staff. I expected this.

After the first couple of days at the elementary school, the principal took me aside to see how things were going, and to let me know that the name badge wasn't enough identification of my role while I was on school grounds. I figured something like this was coming, and being familiar with what OSHA has to say on this matter, I suggested I wear either scrubs, or street clothes with a white lab-coat. He (also being familiar with said regulations) said that would be just fine. He let me know that If I ran into any difficulty to let him know right away, and not let the fact that I'm technically outside of their hierarchy dissuade me from seeking his council. I was comforted by this, even though that was what I was expecting to do anyway.

The first two days, I wore the same brilliant set of blue scrubs that I wear to job interviews, washing them in the wee hours of the morning before my next shift. Yesterday, I went out and bought a lab coat at our local uniform shop. It was only 18 dollars, a little thin, with seams bristling with threads on the inside, but with plenty of pocket-room.

It was Halloween for the pre-schoolers, since they have a four-day schoolweek. I pushed my client along in his chair, he was one of two students whose parents elected not to costume them for school. As I pushed the kid's chair on my way back from gym, some school employee I had not met looked at my white coat and the pediatric stethoscope draped around my neck and said "Oh, look, he's dressed like a doctor!" As neutrally as I could, I stared at her levelly and said "I'm a registered nurse".

"Oh! Shouldn't you have one of those little hats then?"

I kept walking and pushing.

Before I had even returned to my client's home, someone from the school called my client's mother, telling her that I must only wear scrubs while in the classroom, in direct opposition to what the Principal and I had discussed earlier. This stressed out the client's mother considerably, since she was put in the position of having to relay information from the school to myself.

Something stank about this right away. Had something changed since I spoke to the principal? If so, what's the rationale behind preferring scrubs over a labcoat? Furthermore, who's calling up my client's mother to give her these kinds of instructions instead of simply telling them to me themselves? The mother's lips were sealed, saying she didn't want to "get involved". Understandable, she shouldn't have been called about this in the first place. Only now that I sit down to write this have I started to wonder if she was called at all.

When I told the client's mother I was going to call the principal and sort this out with him directly, she immediately got defensive, saying that doing so would be "very unprofessional". She explained that all of her nurses in the past wore scrubs. As impressed as I was with her dedication and knowledge in the beginning, her petulance and lack of self-awareness were starting to grate on me a bit. I patiently explained to her that lots of nurses in the hospital wear professional attire under a white lab coat. She continued to protest, saying that nurses "always" wear scrubs. I told her that, in fact, very few of the nurses I saw in the hospital wore scrubs.

"Oh yeah? Which hospitals?". Oh boy. I recited the list of facilities I had worked on over the past two years. She's only familiar with pediatric units, which might explain things somewhat, I didn't think to mention this, I was too taken aback with her sudden hostility.

"Do you have a problem with how I'm dressed right now?" I'm wearing a nice sweater, black pants, and $270 dollar shoes. I'm confident pedia-sure comes out in the wash just fine.

"No...as long as you keep wearing a belt. Can't have your pants around your knees." I didn't have the heart to tell her that I haven't once worn a belt in her presence and she hasn't noticed. I wear pants that -fit-.

She kept on the defense, saying that she already called my agency and they had scrubs they could give me. She said her concern was that I would be dismissed by the school if I didn't conform to their dress guidelines. I assured her that I had already discussed this with the Principal. I pointed out that I was dressed almost exactly the same as the School Nurse.

So anyway, I left a message with the principals office and headed over to the retirement community to do some HR orientation. I walked through the front doors about 10 minutes late, dashingly attired in a gray sweater, black pants, $270 shoes and a white lab coat. I felt so at home there! I had nice relaxed conversations with people with decades of experience at what they do. As it happens, many of the nurses at the facility practice reiki alongside technologically complex wound-care.

My intake orientation took place in a small office off the hallway of an elegant five-star dining area, where a medieval fair was taking place for the benefit of the residents. There was a palm-reader, gourmet food and a fully stocked bar in the hallway. The HR representative introduced me to some of the administrators and nurses who wandered by, wearing festive period clothing.

After I was done there, I got a short walking tour and was deposited with the woman who schedules the shifts. She's an LPN, and going to a community college in the area for her RN. She scheduled me for three orientation shifts (four hours each) next week, followed by a full 12-hour orientation shift on the weekend (what will be my regular shift). During this process I learned that I'm being hired as a nurse manager, with a very nice rate of pay.

Now, I realize to some extent that I'm getting put in this position because there's a couple of LPNs with 20+ years of experience each (one of which is usually charge nurse) who are really running the show, but the law (or insurance, whatever) requires there to be an RN in the facility. Usually the Director of Nursing fulfills this function, but they need someone on certain shifts so people can fulfill family obligations or whatever.

That's not going to stop me from getting everything I can out of this job, though. They told me I'll get the chance to do lots of wound-care, EKGs, venipuncture, all sorts of fun stuff I was afraid I'd miss by not getting into Med/Surg. Everyone there is super nice, so what if they just want me around because I'm someone who won't make waves and do their best to get along with everybody? I'm sure it won't be without it's hazards, but I'm excited to be there.

The similarity between these two different situations (the elementary school and the retirement community) is that the only other Males around are administrative types.

The elementary school principal called me back as I was strolling the lushly carpeted hallways of the health center in the retirement community. He told me that yes, of course, the lab coat and street clothes are just fine, and that yes, the four adults involved in that classroom said that this was just fine. Funny, that. When I told him the client's mother wouldn't tell me who called her, he lamented the uselessness of that decision. I sympathized with him, and I'm sure at some point we had thought bubbles floating over our head saying "...women".

Either someone at the school decided to make an end-run around the Principal to harass my client's mother directly, or the client's mother is making this up for reasons that aren't clear to me.

This should be interesting.


it's a tough job, but...

I've got a week of this private-duty gig under my belt (plus a couple of days) now, and things are falling into a regular rhythm. The elementary school I follow my client to in the mornings insisted that I wear some kind of uniform while I'm there, so I'm sporting my brilliant blue scrubs until I can find a white coat with sufficient pockets (where do you buy your white coats? Please respond).

I'm surprised by my own alacrity this week. I can slap on a pair of gloves and suction the kid's trach out in an instant, rinse off the catheter and power down the suction device before the preschool teacher even gets a chance to glare at me. If the kid throws their therma-vent (artificial nose) on the floor I can whip a sterile one out of my pocket and replace it so fast the para will still be reminding me to do it after it's done. I've got the diaper-changing routine down, the tricky part was positioning things so the kid doesn't grab poo and start smearing it on things (things that may be uncomfortably close to the trach). Feeding is still the trickiest part. On a good day, I -wont- spill pediasure and/or gastric mucous on something (most likely myself), but that's only happened a couple of times. I'm going to strive to have a good -week- in this regard, starting next week (too late for this week!).

The routine at school is much more relaxed now that a parent isn't coming with. Having them around is immensely useful at home, but at school they aren't allowed to do anything but observe, and their presence strikes fear into the hearts of the school staff. The parents are pretty blase about this, they're not there to critique the teachers, just to make sure their kid can go to school.

The kid only gets 15 minutes of ASL instruction a week, it's hard to imagine much getting done in that span of time, especially considering all of the interfering stimulus in the classroom. A tutor comes to the house once in a while too, but that's also infrequent (and temporary). The mom, unsurprisingly, taught the kid all of the sign they know so far.

I had resolved to use more sign while interacting with the kid, but I guess when it comes down to it I don't know what I'd even say. When it's time to suction, I suction. When it's time to feed, I feed. The rest of the time, we play. The kid's favorite stimuli as far as I can tell are vibrational. All the favorite toys vibrate or impart some kind of repetitive tactile stimulus. I can almost always elicit a smile by lightly drumming with my fingertips on their sternum, or causing my hand to vibrate using the muscles of my arm if the kid's latched on to it. I've had some small success using the sign for "look" to direct attention to something or someone specific, and I try to remember to always greet the kid by pointing to myself and making the gesture for "nurse" (gesturing by taking my own pulse briefly), which I've adopted as my name-sign on the advice of the tutor. Honestly I'm so language inept that I don't see myself getting very good at it. When I had clients who signed in the past, they only had an abrupt, truncated vocabulary of 5 or so signs, which is more or less where my current client is at.

Fun fact about me: I've trained my local bartenders to bring me water when I sign "water" at them (it's too noisy to do anything else)

I'm really happy with the agency I'm working for. I haven't gotten much in the way of clinical nursing support from them so far (I hear that will change in the coming months when clinical educators will visit me and do some skills training), but in every other way they've been very supportive. I swing by the office frequently, since it's walking-distance from my current place of residence. I'll stop by to fill out a time-sheet, pick up some gloves, catch the manager up on my client's situation. I mentioned off-hand that I had been planning on getting a pediatric stethoscope but wouldn't be able to until the next paycheck. The next day the guy just handed me one, no forms to fill out or anything. They're keeping me ankle-deep in gloves and hand-sanitizer. I keep running into more and more nurses who work for this agency, some people who are LPNs and going to school where I graduated, one RN who's the mother of an old elementary school classmate, a random acquaintance at a wedding, weird things like that. The RN-mother-of-former-classmate invited me to do flu clinics with her next winter (finally, I'll get to do some intra-muscular injections!).

This week I have orientation at the skilled nursing facility, looks like all my ducks are in a row.


Audiobook Casting Call

A couple of weeks ago, in a sleep deprived and addled state, I thought it would be a good idea to make an audiobook of Roger William's Novella/Serial Passages. A long time ago I planned on making an audiobook out of a story I liked, but none of the books at hand seemed suitible, and being the perfectionist I am, couldn't find the time or manpower to pull it together. Now that I'm (very) gainfully employed, now seems like the right time to do it. Plus, this story made me want to make an audiobook of it in ways that other stories have not.

If that sounds like fun to you, read AT LEAST ONE but PREFERABLY ALL of the stories below, and post a comment indicating the part you would like to read. If you don't have an audio recording device better than a hand-held voice recorder, I'll arrange for your equipment. Feel free to add to the notes as well if you think of something after reading one or more of the stories.

The biggest role I'm going to do myself, partly because it's too big a task to foist on someone else (as the main role is the narrator for 3 out of the 5 stories), and partly because...hey, it was my idea. These rolls are any character named "Tom", and all machine intelligences except the "Borden AIs". There are male and female rolls, some large, some small, many of which I'll be adding filters to with the kaoss pad later (one of the stories involves a transition from a character being a human pilot to a machine intelligence hundreds of millions of years old).

Here are the chapters:

Passages in the void
1 machine (bringer of minerva)
1 adult male
1 child male

The Passage Home
3 machines (bringer of Minerva, controllers of Tristan, controllers of Sol)
Last Leader of Reykjavik
Captain Marla
Heretic (dorn)
Captain Dana

Rite of Passage
1 machine (bringer of minerva)
Blue Army sentry
Blue Army commander (scott)
Big Keep Trader
Orange Army Soldier

Mortal Passage
Dr. Ieyoub
Director Adley
Borden AI

Revelation Passage
Bringer AI
Borden AI
Borden Maker
Descendant Minervan Bringer AI
Tom from Alpha
Tom from Alpha's Wife
Prince Alex of Loki
Princess Anne of Minerva


Omit ", I said ; , He said" ?

Machine dialogue should use similar but noticiably different filters for dialogue and narrative. Borden AIs should have more machine-like voices.

Mortal Passage - Morse code+text how?

Mortal Passage - Smoothly transition voice from unfiltered voice to bringer of minerva throughout story

Mortal Passage - Tom's Revisions:
1.0 ca. (what's ca.?)
2.6 ca. +10 years
2.7 ca. +12 years
3.1 ca. +15 years
4.5 ca. +20 years
3.67 ca. +23 years
7.2 ca. +40 years
22.70 ca. +210 years
306.47.12 ca. +5830 years
1467.92.811 ca. +6490 years
1711.12 ca. +9700 years
1711.17 ca. +65000 years
1711.22 ca. +115000000 years
1.01 ca. +1220000000 years

I'm also interested in recording an audiobook of The Metamorphosis of Prime Intellect (by the same author) but have not developed a casting list yet. Let me know if you're interested in that one as well.



I got my first paycheck today, sorta. I got a paycheck for 10 hours of testing, paperwork and assorted bureaucratic tasks that occurred before my first shift. The pay rate for this kind of thing is 1/2 pay, so after taxes I proudly deposited a cheque for a little over one hundred US dollars in my badly abused bank account.

"Maybe now I can keep a positive balance for more than a week!" I quipped to the bank teller.

He laughed. He's a jolly fellow.

Even better, my physical for the nursing home gig is tomorrow and the hiring paperwork is going down this weekend, so I am in full $$ mode. I'll only have 6 days off per month for a while (maybe less if I take extra homecare shifts on the weekends), but after not working for so long (almost 2 years!) I'm looking forward to socking some money away, paying off some debt and contribute to my sister's education fund. No more scrounging for quarters to buy beers and coffee!

Most of all, I'm looking forward to spending money on myself again. I haven't had what you'd consider "disposable income" in quite some time, so the possibilities for my new $1200+ per week income are fun and exciting to think about. Let's brainstorm a bit, shall we? In no particular order (except for the first one).

1) Computer upgrades: Number one with a bullet. I used to upgrade my computer every six months and PRN, but haven't continued this practice in quite some time. Thankfully I'm crafty with my upgrade schedule and have managed to keep my computer serviceable through routine software maintenance and wise hardware choices. A while back, however, I noticed that my computer couldn't even run some of the latest games (the last high-performance game I could run smoothly was Oblivion with some of the settings turned down). Time for that AMD XP 2800+ and Geforce 7800 to go! It'll require a new motherboard and new RAM in addition to the CPU and GPU, which is why I've held off for so long. Storage is running low, too, A measly terabyte doesn't go very far nowadays.

2) Medical gear: Now that I'm really getting in to (and starting to dig) home care nursing, there are some exigencies that I'd just love to pack into a bag and carry around with me. I wasted a lot of money on equipment I'd never use back when I started nursing school, now that I have experience under my belt there are a few toys I want to snag, which include; temporal artery thermometer, new stethoscope (the electronic littman served me well but it's time to get the littman cardio with pediatric bell), glucometer, pulse oximeter, ambu-bag....hmm, what else? What other non-invasive non-drug goodies can you think of to carry around? As soon as sequential-multiple-analyzers-on-a-chip hit the market, you can bet I'll be first in line to snag one.

3) Console Gaming: I grew up with video games, since the days of black and white Ultima 3 and Captain Magneto on my hard-driveless all-in-one black-and-white macintosh with 128k of RAM. The current generation of game consoles are unique in that for once, I want ALL of them. There are some games on Xbox360, PS3 and Wii that aren't available for one reason or another on the others, so I'll just get them all. Unfortunately, between work and aikido I'll have far less time to play video games than I did while I was a slacker of a Student Nurse, but I guess that's just how it goes.

4) Lodging: I'm glad I decided to stay at my parents' house as long as I did, it gave me a chance to develop an adult relationship with them (and my sister) I might not have had otherwise, and it's a comfortable situation; having the only room on the ground floor, able to have scores (literally scores) of people over until sunrise, inhabiting a splendid house on a lake in a nice suburb just 3 minutes from town...there's a lot of plusses. On the other hand, I am getting to a rather unseemly age to still be living with my parents (I turn 28 next year), and girls tend to look at you funny when they hear you still live with your parents (some people apparently have such fucked up relationships with their parents that they can't imagine anyone WANTING to live with them), no matter how pleasant a situation it is. On the OTHER other hand, they graciously extended the offer to continue living there for $350 a month in rent, in a place that would probably cost me 7-8 times that amount to inhabit alone, when utilities are figured in. On the OTHER other other hand, for however long I still live in this corner of the world, the idea of living within walking distance of my favorite coffee shop and favorite pub is very appealing, and having more personal space than just a room would let me set up the turntables and other music-making equipment on a more permanent and less cluttered basis. Additionally, my sister is chomping at the bit to take on the curator role of my Library (a series of bookshelves that cover nearly every vertical surface of my room).

5) Gassless personal transportation technology: A drunk-biking accident claimed my trusty $50 wall-mart special road bike many years ago, maybe now's the time to get back into biking. Driving a hybrid helps, but the cost of driving is still unreasonable, and I'd still feel that way if gas cost half as much as it does now. Maybe I can get something spiffy and plug-in electric, like these battery powered assist bicycles or just the modules themselves that one of my bike-making friends could mod into a bike.

6) Glyconutrition: Earlier this year when I went to the NSNA convention in Grapevine, Texas, I ran into some marketing agents for a company called Mannatech. They talked a good game, and pointed me towards some research suggesting that most of the food available in our supermarkets and restaurants are missing several key glyconutrients, the lack of which may have a hand in the rising incidence of cancer and auto-immune disorders. Maybe I'm particularly gullible, but it made sense to me, to the point where I'd be willing to shell out a couple hundred dollars a month for their nutritional supplements. Admittedly there are some shady things going on with the company, like not subjecting their research to the peer-review process (a process I'm more than a little cynical about anyway) and some sharp criticisms of the underlying glycobiology (from famous glycobiologists, no less), but I'm willing to give it a shot for a few months anyway to see what happens. Hell, it's basically just powdered cactus, kelp and aloe (and some other whole food products), what could go wrong?

7) New laptop: This one should probably wait for a while, since upcoming advances in battery, display and microprocessor technology would most likely make whatever I purchased in the near future painfully obsolete in the slightly less near future. Still, though, my venerable Alienware is on it's way out. I've already replaced the motherboard once, and I'm still getting thermal-failure events when I try to play a video or game full-screen.

8) New goban and stones: I have a few gobans and a set of stones, but frequent use and carrying it around in my trunk has resulted in dents and cracks in the boards, as well as many cracked or lost stones (which were cheap anyway). I'm thinking something like This and These. Purely for the home, not for carting about in the trunk of my car.

9) New mobile phone: My HTC 6800 was working great until I dropped it and cracked the screen, reducing the working area by half. I don't want to cash in on the insurance and go without a phone for 3 days, so I might as well just plop down the obscene amount of cash to get a new one un-subsidized. As soon as an Android phone comes out for the Verizon network, I'm there. Don't make me laugh with your iPhone piffle.

10) Aikido equipment. Mainly bokken and jo. Maybe four or five of each so I can practice with friends outside the dojo.

11) Reiki lessons: I got turned on to several good teachers in my area, I just lacked the customary biosurvival tickets to exchange for their services. I think this would have a great impact on my Nursing practice. As an added benefit, there's an opportunity to get an attunement from an old friend, which I think would complete a rather protracted cycle of hurting and healing.

12) Health care services: It's been way too long since I've had health insurance, and a combination of my Family History and my age suggest I should get on participating in some diagnostic studies sooner rather than later. I'm thinking colonoscopy and chest x-ray for starters, then there's the whole back-pain issue (which started during nursing school).

13) New DJing gear: Although my schedule wouldn't permit me to go back to DJing for quite some time, some things need to be replaced to practice/create at home. Specifically my Scratch Amp, which lost the functionality in a couple of the line-level inputs (some rather important ones). Rather than a simple replacement, I think an upgrade is in order. Also, my Korg Kaoss Pad 2 is getting a bit worn down, and the upgrade (the KP3) has been out for an embarrassingly long time for me not to have one. Not merely DJing gear, this device is a powerful performance tool all on it's own, probably my favorite musical instrument next to the Trombone (which would also benefit from a trip to the repair shop).

14) New MP3/MP4 player: I loved my Archos dv700 dearly. Despite it's ungainly size, the fact that it sported a 100GB capacity, a 7" diagonal widescreen and video/audio in/out ports allowed me to wave it in the face of foolish iPod users with glee. Having a device that allows me to play or record any audio or data format to or from any device is something that I've grown accustomed to, and the past 6-8 months that mine has been broken have been difficult to bear. Fortunately, in the meantime, the technology has improved. I'm thinking this one.

15) Miscellaneous: On the internet I come across at least 5 things per day I desperately want but can't justify buying, many of which are on ThinkGeek. A light-up LED shirt that plays drum samples when you touch the picture of the drum-kit, for example. A Kaossilator. A titanium spork. I could go on and on.

Afterthought: There are a few things, now that I think of it, that I want to buy for other people. For a bunch of the faculty back at the nursing school (say, maybe 9 or 10 of them), some thank you cards with personal notes in each, ranging from short to embarrassingly long. For my former classmate's RN brother and his father - who put up with my bullshit for two semesters while I crashed there in between clinical shifts, a letter and something nice. An expensive bottle of exotic liquor maybe.

My horoscope at freewill astrology says:

"Write the number ten followed by eleven zeroes. Our Milky Way Galaxy has that many stars. Write a ten followed by twelve zeroes. That's the size of America's national debt in dollars. Now promise me that for the next month, you will avoid absorbing any scary, overwhelming data like the kind I just threw at you. Worrying about the big financial picture would not only be fruitless, it would also distract you from your main tasks, which are as follows: Regard the crisis as an excellent opportunity to shed materialistic obsessions and live more humbly and creatively. Sublimate your buy-ological urges into biological urges. Stretch yourself to get into closer touch with your spiritual core."

But I say,

fuck that guy.


I woke up last night in a cold sweat. Wait, this was two nights ago. Weird dreams. I was lying in a hospital bed about to get a tracheotomy. Everything seemed huge and weird and incomprehensible. There was a doctor sitting next to the bed, he told me that I felt strange because of the drugs. "What? I don't understand you!". But I did understand him. He adjusted something, and everything seemed weirder. The effects of the drugs intensified. Later, I was in some kind of auditorium. There were lots of doors off to the side that lead to small service businesses. A doctor's office, music lessons, random things like that. There were people dancing in the middle. The way they danced was awe-inspiring. Not because of the dance moves, but because as they stomped the ground with their feet they made different musical tones, which seemed to map out the outer reaches of my auditory sensorium, which was spherical. The sounds were full of stereo delay and phasing. Later, I had to drive a scooter to take home the sister of the drummer in one of the bands I'm in. She appeared as a three-year-old instead of her actual age. Her brother wanted to drive, but I insisted on driving and having him ride the scooter with us, figuring I'm the better driver but he's the tai chi master (someone was planning to ambush us on the way back). We were all able to fly by pushing off on things, as if there was no gravity. As we were getting ready to leave, I noticed I left my copy of Medical/Surgical Nursing on one of the cafeteria tables set up in the auditorium. As I went back to retrieve it, one of the bartenders from the pub I frequent killed me by spraying aerosolized lysol down my tracheostomy tube. There was more but this was yesterday and I rarely remember my dreams. It only seems to happen when my sleep schedule's disrupted or transitioning.

It was four in the morning. I'd probably slept for less than four hours, and I had four hours to go until my homecare shift started. I couldn't get back to sleep, I was totally awake. I kept myself occupied with the latest NPR podcasts. Internet Go. I made myself a bowl of steel-cut oats for the first time. They took 30 minutes on the stovetop but I had time to kill.

When I arrived at my client's home, I discovered that they were ill. They only slept for 1.5 hours. Frequent sneezing fits caused bright yellow mucous to gush out of the tracheostomy tube, necessitating frequent suctioning and resulting in vomiting episodes that threatened the airway and wasted precious calories from feedings. The parents weren't too concerned, saying the yellow mucous is a common occurance, and that they go to the doctor when the discharge is green, red, tan or brown. Since I'd never seen the kid this sick, though, I decided to be ultra thorough. I pulled out an infrequently used oximeter from the bedroom (they used to do continuous monitoring but it isn't needed anymore) and got a nice, high value. Breath sounds were just a little more rhonchorous than usual (although I'm finding it hard to tell with all the noise from the trach, on the advice of one of my paramedic buddies I'm going to get a specialized stethoscope for this client), no nasal flaring, no retractions, no lethargy or restlessness. Just sneezy.

So, off to school we went. The van ride to school always seems like it's the worst. The parents say the client isn't any worse than usual when they ride in their car, but while the client's in that van they sneeze more frequently than ever. Maybe it's the time of day and not the van, but I'm not sure.

Everything ended up going fine, and I got to see some interesting physical/occupational therapy. Watching the other children interact with my client is also interesting. Overnight the client spiked a temperature that was resolved with acetaminophen, then the next day their temperature climbed again and one of the parents gave acetaminophen again. They explained that they no longer allow home-care nurses to administer medication to their child, after an LPN gave their child a 10x overdose of acetaminophen/codeine (!!). The client's temp was back to normal within the hour.

For me it was a stressful couple of days. For the parents, it was just another day in their life of caring for their child. A good warm-up, maybe, for when things get really bad. A reminder that I'm not only the child's nurse on days when they're healthy. I'm still learning a lot from the child's parents, I'm glad they've decided to keep me around.


Nursin' fo realz

I'm finally working full time as an RN! The nursing home job hasn't kicked in yet (still waiting to take my physical for them), but I have some shifts under my belt for the 1:1 pediatric homecare gig.

Since I'm new on this case, the parents are coming with me to school and helping me out after school's out for the last four hours of the shift. In about a month or so, the client's mother says, she can use those last four hours of my shift to sleep and get ready for work.

Being in the classroom for half-day preschool sessions is...interesting. It's difficult to say if any of the other students have special needs, maybe one or two of them do. My job is simply to stay by the client's side, watch 'em like a hawk, and manage the airway.

And manage it I do! For some reason, the mode of transportation that takes us to school causes the client to sneeze for most of the ride. This is a problem, because once they get up to three cough's/sneezes, they vomit, a potentially serious occurrence in the presence of a trach. This is most likely due to his Wrap, a surgical treatment for GERD. I got a chance to manage a couple of these episodes so far. The client needs to be suctioned very frequently to prevent this, since timely suctioning after the first cough will usually prevent the next one, thereby preventing the vomiting episode. The tricky bit is that suctioning TOO much is bad, too, since over-suctioning an airway can dry it out, increase ICP (and I'm not talking about the band), or make them gag. The client requires a LOT of suctioning, maybe 30-40 times in 8 hours, sometimes as often as every five minutes. Thankfully it's a cuffless trach and they can still breath through their mouth.

The classroom has a teacher's assistant and a paraprofessional in addition to the teacher, thankfully, so I have another pair of hands when it's time for diaper changes (the client can get a bit "wiggly"). The people at the school have been nice to me, so far. The physical therapist is absolutely wonderful with the client, and watching PT for special needs children has been interesting so far. The client also gets 15 minute visits from a woman who introduced herself as "Teacher of the Deaf". Not much seemed to get done, since she came during snacktime and there was a lot of distracting activity in the room, but she assured me that it was fine to do in that environment. I look forward to picking up some sign! I picked up a little bit back in the group-home, but everyone there used heavily personalized and modified dialects of ASL, and books on the subject were completely useless to me due to my spatial relationships deficits. Picking up some sign from an actual teacher should be interesting too.

Sometimes I feel a little bad about disrupting the class, the portable suction gear is LOUD and always distracts the class from their current activity. Still, when I gotta suction the airway, I gotta suction the airway, I can't wait for the teacher to finish the line of the story she started reading. It seems to me that it should be possible to implement a portable suction solution that doesn't drown out all the other noise in the room, don't you think?

The school nurse is wonderful, too. I'll be seeing her at least once a day, I think, since I think I'm the only RN following a patient the entire time they're at school. I got a tour of her office and she briefed me on emergency procedures and safety protocols, like making sure I have a radio whenever I'm outside the building with the client. Both of us have to be there for my client to be permitted at school.

I got to use a little of my critical thinking skills today, as well as having the opportunity to advocate for my client. The stroller the school provides was definately not safe, so I instructed the para to roll out the orthotic assistive chair (or whatever the hell it is) instead. The stroller they have has two plastic boxes on either side, far enough away from the head to -seem- safe, but close enough for the client to slice open a temporal artery during a sharp side-to-side movement. I caught one of these movements and reflexively caught the side of the head with my hand. The sharp edge of the ragged plastic cube dug into the back of my palm and that was the end of that. The assistive chair, although clumsy and complicated, is at least padded and made of rounded corners. I consulted with the physical therapist and the school nurse, and we agreed; the stroller was no good. We'll get a new one.

Everyone's been supportive of my presence there so far, but I was warned that this may not last, and that I should "watch what I say" around them. Heck, it's no different than nursing school; a coven of middle-aged white women who take their job very seriously. All I have to do is My Job, and if someone gets in the way of that they'll have to deal with the wrath of a very mature young mother who treats impediments to her child's care and education the same way you might imagine a bear would treat a dancing, shouting rag-doll full of sausages.


the warm-up

What a hectic day!

I woke up early to get to the home where I'll be doing 1:1 pedi and spent four hours or so learning about the daily routine and how to provide care to the client. Mom showed me what my morning routine would be. Empty the humidifier's collection reservoir, refill the humidifier with sterile water, break down the feeding bag, wash the g-tube connector (they only get one per week so it gets washed and lavaged between uses), hang a fresh feeding bag for the evening, and help the client get ready for preschool. I got to suction the client numerous times (the client needs to be suctioned frequently, I think the longest I saw the client go without suctioning was 20-30 minutes) and spent a lot of time playing with the client. Next in the routine I help get the client ready for school. The parents do a -lot- to make this job easier. They pack all the supplies, make sure his portable suction kit is outfitted with extra trachs, suction catheters and gloves. They pack the feeding kit and pre-mix the formula (mixed with liquefied hard boiled egg-yolk), get them bathed and dressed and keep all of their supplies well-organized.

I'm consistently impressed by the level of skill and organization that they exhibit in caring for their child. So impressed, in fact, I was startled when I learned they aren't even drinking-age! Far more mature than most people my age, but then I'm told having a special-needs child can lead people to grow up fast.

I learned a lot in those four hours, got briefed on the school routine and received a lot of insight into the client's personality and preferences. I also finally learned what the Dx is. SLOS. The client exhibits an easy affect, and playing with them and getting a feel for the level of mobility and stimulation preferences/thresholds in the relaxed home environment was a good intro to being responsible for them in the school environment.

When I was done, I swung by the office to fill out a timecard and picked up a bunch of flowsheets for the charting, since my first full day on the job is going to be soon. When this happens, another agency nurse will stop by after we get back from school to do an intake/admission assessment, which will be instructive to watch. Eventually I'll probably be able to do these as well for the agency.

While I was at the office, they noticed I hadn't gotten my PPD yet, I was planning on getting it done during my physical, but that wasn't soon enough, since it was scheduled for the same day as the admission assessment. The Boss told me to swing by a local pharmacy where other Agency nurses were giving out flu shots. I swung down to the pharmacy only to find that the RN giving the shots is the mother of someone I went to high school with! She was happy to see me, and even happier to find out that I was the RN she got the phone call about to give the PPD. She didn't even know I was an RN! One of the CNAs employed by my agency there also just started the clinical program I graduated from. If that wasn't weird enough, I met ANOTHER nurse from this same agency at a wedding last night! Small world.

Somewhere around this time we all realized my physical (scheduled by my nursing home job) conflicted with the pedi case, so I called up and canceled the physical, planning on rescheduling it for a later day. The HR manager from the home care agency called me back and told me -not- to cancel it, because the later date was too late. So, I call the occupational health center and un-cancel my physical. I call back the agency only to find that they wanted to pay for me to have a physical TODAY, and that I did, in fact, have to cancel the physical and reschedule.

When the dust settled, I had left three contradictory voicemails with the desk of the HR representative from the nursing home, who's out of the office until after the pedi admission assessment. My head was spinning! I was extremely apologetic in the last voicemail, hopefully this doesn't screw up the nursing home gig (they're going to teach me venipuncture, damnit!)

I've been running around all day, it's nice to finally be able to settle into my seat at the coffee shop and just veg out for a bit. I guess this is a taste of things to come, now that I'm about to go from not working for almost two years to working 52 hours a week (and making over 60k/yr)!

Oh, before I forget, any of your nursey types out there who have 1:1 pedi experience, share your insight!


Search Round-up

Here are some of the latest hilarious search strings that have lead people to my blog.

"what does ETOH stand for in speech pathology"

-probably the same thing it stands for everywhere else. Either speech pathologists don't have to take chemistry nowadays or some befuddled patient just figured out their therapist is calling them a lush behind their back.

"2nd grade government concept map"

-what kinds of governments are 2nd graders throwing together these days? Maybe they can assume control of our treasury.

"concept map" continues to be my most popular search string, with maybe 85-95% of searches leading to my blog containing that phrase, further evidence that concept mapping is rediculous obscure makework porn for Education types who desperately want to avoid teaching.

"cholyangiopancreatography strangely"

-i get why someone might want to look up cholyangiopancreatography, and since I mentioned it in a previous post it doesn't seem strange...but "strangely"? Are they looking for strange versions of the procedure or accounts of alien abduction experiences during the proceture or something? I don't get it.

"a student nurses clinical experience account of hanging IV piggyback meds"

-Oh brother/sister, the stories I could tell YOU about hanging piggyback IVs as a student! Oh, wait, I did already, that's why that search string worked. There are other stories, though. Horrible stories. I'm not typing them here. So there.


-this is another popular one, since I posted about this I get maybe one or two hits a week for this string.

"nursing symptom concept map"

-if you have a stethoscope around your neck and you spent all day administering drugs to people, it might be a symptom that you've come down with a case of nursing.

"concept map metabolism"

-Just order the biochemical pathways wallchart from roche. Better yet, here's a colorful web version.

"generalized anasarca"

-that's cute. Since anasarca is generalized edema, that's like saying "automatic ATM", or "military soldier". How many can you come up with? Please respond.


-whoa. two things. one, that's crazy, and two, stop yelling at my blog.

"foley catheter anatomical drawing"

-someone has a weird fetish.

"concept map 5th grade math"

-ohhh, I get it now. when educators are training other educators how to educate they come up with some of the WORST IDEAS EVAR!!!!11111one

"graphs about RNs"

-are you serious? I guess I can see why one of our faculty members gave us homework to do on how to formulate search queries. yeesh. See this chart here? This is a bar graph illustrating the relationship between the numbers of hour per week RNs make compared to the number of pastries they eat. Note the "uncanny valley".

"nursing educator photos"

-now that's just creepy

"how do they fix a csf leak after craniotomy"

-I'm sure kleenex is involved

"concept map of string instruments"

-ok, seriously now. Are people really making concept maps of classes of musical instruments? This is getting way out of hand. We need a desperate return to the days where people were educated through insightful lecturing and reading books. fo reals.

"good concept map"


"nursing concept maps for hopelessness"

-you said it, sister.

...and that about brings us all the way back to where we were last time I posted on this subject. This was just a hand-picked selection out of 200-300 search terms in the past few weeks (excluding image search).

In the past seven days:

4 searches for "yawngasm"
11 searches for various types of concept maps
72 image searches, nearly all of which lead to my concept map post.

In the past thirty days:

7 searches for "yawngasm"
41 searches for concept maps that occured more than twice for the same search string
365 hits from image search.
51 hits from google web search
10 via twitter


Adventures in Temporary Industrial Nursing

I think I may have mentioned this before, but I have a bad habit of staying up/out too late the night before something important is supposed to happen. I've always had difficulty initiating sleep, but some times it's more acute than others.

Two nights ago, I woke up at 6 in the evening. Realizing that in two days I would have to wake up early to drive to the temp job at the home improvement store, I decided to stay awake through the night, figuring I'd go to sleep early the night before the job and get a decent night's sleep.

Reality always has a funny way of intervening, sometimes there's a glimpse of intention behind the random events of my life.

Each time I felt tired and thought I'd throw in the towel and go home, something got in the way. Running into friends. Conversations with bandmates. The request of a pretty girl. Finally, by the time I got home, the final distraction. Left-over southern style ribs and grilled corn on the cob.

When the dust settled, I had three hours to sleep before my first paid gig as an RN.

Needless to say, I was pretty dysphoric when the alarm went off, but by the time I was halfway through my forty minute drive to Lowes I felt halfway competent, without coffee or anything.

The first thing that I thought was somewhat odd was that this building, once I found it, was HUGE. Take a super wal-mart and quadruple it. It was that big.

The second thing was that the parking lot with all the cars had a sign that said "employee and visitor parking". Hmm. That's strange. Calling your customers "visitors" and insisting they park in the same place as the employees.

The final oddness straw was the fence. It was tall and topped with barbed-wire, interrupted only by a guard outpost.

I walked into the guard building, through the door that said "truckers only". I didn't see any other door. Wearing brilliant blue scrubs, the woman behind the counter noticed me immediately and smiled at me past the truckers filling out some form or other.

"Can I help you?"

"Yes, I was trying to get to the front entrance of the store. Is this the right way?"

"Oh, no, sir, this isn't a store, it's a distribution center. Would you like directions to the nearest store?" Her response was smooth and practiced, with a Corporate accent. My sleep-deprived brain took a moment to adjust.

"Uhhh...erm....no, I'm working here today as a Registered Nurse."

"Oh!" Her polite smile had turned into a cheery grin. "You must be filling in for Shelly. Just head right through there and you can sign in".

After a short trip through a metal detector I'm on my way into the actual building with a temporary badge around my neck. I find the reception area, just past a sign that proudly proclaimed "002 DAYS SINCE THE LAST REPORTABLE INCIDENT! 022 DAYS IS THE CURRENT RECORD! SAFETY IS NO ACCIDENT!". Niiiice. I would have liked to see the -average-, not the high score.

After introducing myself around to the friendly office staff, they summon someone with a key to the area I would be working in.

There was a moment of panic, as my sleep deprived brain tried to assimilate the fact that THIS was where I was working.

The nurse I was covering for is a board certified APRN and family NP! I'm a new grad from a 2-year RN program (but the temp agency told me not to tell -them- that because it would make them nervous)!

I calmed down a bit when I remembered that the temp agency said all I would be expected to do is provide first aid and activate EMS in case of an emergency.

"I can open everything but the drug and filing cabinets" the employee told me.

I glanced up at the cabinets, labeled with their contents. Pretty run of the mill stuff. Acetaminophen, diphenhydramine, epinepherine, aspirin, albuterol, stuff like that. The fridge was full of ointments and influenza vaccines. Oddly (to me), no Insulin to be found.

"Hey, maybe I'll come back later and you can give me a breathing treatment"

I laughed, I thought he was joking. I looked up at him and saw he was serious and gesturing to the nebulizer. I opened the housing and found an incentive spirometer and instructions.

"Oh yeah, I know how to use one of these.." I muttered to myself absent-mindedly. I knew these devices well, as I child I regularly depended on them for bronchodilation. The employee wished me luck and left.

I rifled through the emergency supplies and found that they were armed for Bear. The big orange bag you can see in the picture is apparently something similar to what Paramedics take with them (it was emblazoned with the paramedic symbol on the front). Most of the advanced cardiac life support meds I learned about in critical care, a glucometer, glucose paste and glucagon, IV kits, protective gear, a self-contained pulse oximeter, sphygmomanometer, you name it. The AED hung on a hook next to the bag, along with 3 tanks of oxygen. Except for the ACLS medications and vein access gear, I was confident I could use all of it in an emergency (I'm not ACLS certified and I've never performed venipuncture).

I got lost in the supply closet for a while, marveling at the fact that it had pretty much everything I would have found in the clean utility rooms on any of the med/surg units I had served on, just in smaller quantities. Bags of lactated ringer's solution, IV gear, a plethora of bandages and gauze, suture kits, etc.

When I finally emerged I noticed that there was an entire additional room in the Health Center I was to occupy for the day. I walked through it on my way in but was distracted by the exam room. The office had a desk, a few chairs, a filing cabinet and a computer. I called the off-duty APRN to see if I could get the password to the computer, but, alas, I could not.

On the desk was a small packet of printed instructions for Per Diem nurses. Apparently the company that is contracted by the home improvement company to provide health services occasionally deploys per diem nurses when the APRN is off-duty. I idly wondered why I was placed there by a temp agency instead of one of the company's own per diem nurses.

The instructions were pretty clear and I got oriented to the documentation routine right away. I inventoried the emergency medical supplies, noted the expiration dates of the ACLS meds and antidiabetic agents, examined the epi pen, checked the battery on the automatic external defibrilator and made sure all of it's supplies were there. This took me several trips walking back and forth between the desk where I had set out the documentation and the closet in the exam room, but I figured the motion of walking back and forth would help perfuse my abused, sleepy vasculature. I recorded the ambient room temperature and the temperature in the refrigerator. Last was the calibration of the glucometer, a process I was thankfully familiar with after all those shifts in med/surg.

I reviewed all of the emergency procedures and administrative protocols, and completed all of the required non-care documentation. The office was still quiet and there was nothing to do, so I set out some things I thought I might need later (alcohol wipes, tape, gauze, penlight, all the things I would fill my pockets with on med/surg) and gently cleaned the earpieces of the stethoscope with an alcohol wipe (hey, you never know).

The clock by the door indicated that it was only 1 hour into my 8 hour shift. I was sorely missing the internet, now that I was out of things to do. I tried to convince the IT department I needed internet access in case I needed to google something, but they apologized and told me that wasn't possible. Oh well, worth a try.

Nothing left to do but sit and wait for patients! I settled into the uncomfortable chair at the desk as well as I could and started reading "Principals of Emergency Medicine" by various authors (it was a good read, contained a condensed version of basically everything we had learned about every body system in nursing school, plus some juicy clinical pearls I resolved to save for later in my cranial vault. By the end of the day I had read all 798 pages, skimming past some of the review material I was already familiar with).

My first patient encounter happened around Noon. An older man with thick glasses and a grizzly beard shuffled into the room, wielding an inventory-control gun. The coffee I had acquired in the cafeteria was starting to kick in, so I snapped into assessment mode immediately. Shuffling gait, favoring one of the lower extremities. He sat down heavily in the chair opposite mine and told me that he had pain in his leg.

I sat forward in my chair, squaring my shoulders off with his and making eye contact.

"Go on," I said "what's up with your leg?"

He pulled up his pant-leg to reveal a tightly wrapped elastic bandage.

"I got these ulcers on my leg 'cause of the diabetus. It's 'out of control' 'cause I don't do anything about it. I just came back to work today after two months, 'cause my doc said to stay off it for a couple months. I used up all my PTO (paid time off), so here I am. Doc sez I should only do half-days at first, but the boss says no. I can't work with my cane and we don't have sit-down jobs here."

My mental data collection continued. Assessments stacked up in my mind until nursing diagnoses and probable comorbidities emerged like a crystalline fungus in an alien compost heap. Peripheral vascular disease. Non-compliant with therapeutic regimen. Betcha anything he's hypertensive, too. Clear speech, positive affect, appears euthymic. I'm always suprised and amused when people come right out and say that they're not attempting to manage their serious medical condition, but I don't let it show.

"Well," I say cautiously, "I'd think your employer could accommodate you somehow, seeing how you have a condition and all that."

"Hah! Not at this place." Ah, the time-honored tradition of insulting your employer behind his back. It's universal. "I'm going to see my doc tonight, but I just don't think I can work the rest of the day, you know?"

I nodded sympathetically. "Why don't you hop on the exam table so I can take a look at that leg?" I was eager to get more objective assessment data, and I figured the time we spent in an examination would give him more time to rest his leg.

"Oh, no, you don't need to do that, I want to keep the bandage on. It hurt like this while I was taking my time off, like when I went grocery shopping with my wife, I just need to rest it for a while, rest and tylenol, that always did the trick."

I nodded again, in a way I thought might be interpreted as supportive. "I'd say rest is probably the best thing for you." I was glancing at his chart now, noting his antihypertensive medications and previous records of diabetes management, trying not get the info I needed without seeming like I was ignoring him.

"Soooo..." I figured it was time to rephrase and regroup. "You're going to see your doctor tonight, we just need to figure out what we're going to do for the rest of this shift. What do you think we should do? I don't work for your company, I cant exactly tell your supervisor what to do, you know?"

He threw up his hands. "I have no idea!" He seemed to get a little agitated, maybe that was a misstep on my part.

"How about this," I said as soothingly as I could, "I definately think it's in your best interest to rest that leg for a while if it will relieve your pain. If you want me to explain that to your supervisor, I would be more than happy, just have him call me or stop by. I'll be here all day. I'd give you tylenol if I could, but unfortunately I don't have a doctor's order for it (I had searched everywhere for standing orders for PRNs but they were nowhere to be found). The nurse I'm covering for can prescribe medications, but she's more advanced than I am I'm afraid." I smiled weakly.

He nodded, thanked me, and shuffled out of the room. I didn't hear anything else from him or his supervisor for the rest of the day. I charted everything I thought was salient in SOAP format (a requirement of this particular company), and made sure to include that he declined an assessment, would follow up with his PCP and returned to work.

The hours stretched on, then a bunch of people stopped by right in a row towards the end of the shift. One man just wanted to weigh himself to see which of his buddies was winning the "who could lose the most weight" game, I praised his weight reduction efforts and gave him some diet/exercise tips. Another man came in looking for the regular nurse to update her on what was going on with his upper-extremity paresthesia, which his PCP thinks might be the result of a stroke. He asked me what I thought it was and I politely and cheerfully reminded him that I was not a physician and could not give him medical advice.

Another man stopped by and asked for something for heartburn. I didn't think there was any antacids in the exam room and was still not too keen on the idea of administering ANY substance to ANYONE while I was there (since I'm just supposed to be doing first aid and I couldn't find any orders), so I invited him to sit and tell me about his heartburn. He was a younger guy, around my age.

He said it would be brought on by eating certain foods, and that once it happened it would last for "like a month". I asked him if he had seen his regular doctor about it and he said no. I counseled him that he should as soon as possible, since it might be something serious and relying on antacids all the time can cause other health problems.

Looking back on the day, there was so much that I was paranoid about. I walked away from the health center feeling energized about the experience, finally getting a small, limited taste of the experiences like the ones I'd pour over in blogs like "What school doesn't teach you about being a nurse practitioner" and "The nurse practitioner's place"...but then I started thinking...what if that diabetic guy was forming a deep-veinous thrombosis? I should have insisted that I took that bandage off even though he said he didn't want me to! What about that guy with heartburn...what if it was something more serious!? I should have at least auscultated him..hell, I could have even hooked him up to the EKG (never done that before but there's a first time for everything)!

I'm just there for first aid, I kept telling myself. The best thing for those guys is to go to their doctors, and they said they would. I'm only there for work-related injuries. Still, I'm an RN, though, and I should be applying the full spectrum of my abilities that my scope of practice allows, shouldn't I?

Anyway, as boring as the day was, all in all, it's an awesome thing these NPs do, even when it's in a sterile corporate/industrial environment. An awesome thing that I am totally not yet qualified for.

It was nice to keep the seat warm for a day, though.


Semiotics, Extopia, and Gaming as non-metaphor - The four endings of Deus Ex: Invisible War

I recently came across an excellent book published online called Gamer Theory. It's a bit dense, a bit academic, but worth reading if you have the ability. Each "chapter"; Agony, Allegory, America, Analog, Atopia, Battle, Boredom, Complex and Conclusions; uses a different game to illustrate the chapter's central point.

The chapter that lead me to this work was the one titled "Complex", as it was linked to in a discussion about one of my favorite video games of all time, Deus Ex. The chapter in this book focuses mostly on it's sequal, Invisible War, a tragically flawed failure of a game that came as a big letdown to fans of the original.

That's not what the chapter is about, though.

I'm basically reproducing my understanding of this chapter because I feel it's significant somehow, and in my sleep deprived state I figure the best way to wrap my head around this is to share it.

I'll spare you the full intricacy of the plots and skip right to the endings, which -is- what the chapter is about. At the end of the game, the player can choose between four different endings, by following the advice/orders of one of four different factions. These four groups of people give you conflicting orders throughout the game, but it's only at the end where this really changes anything.

The backdrop is a future world in which nanotechnology is widely used to augment human physiology and create synthetic biological life-forms. A crisis event is the situation at the end of the game, as an artificial intelligence seeks to unify humanity.

It's tempting to cite parts of Gamer Theory in this explanation, but I'll try to stick to just pulling the quotes out of it that are by other people, cited in the book.

The first group is called the Templar. By choosing their ending, you kick off a holy crusade in which all synthetic life forms and nano-augmented humans are killed. Once they do that, they find some other crusade to go on.

The second group, the antithesis of the first group, is the Omar, who seek to use nanotechnology to create a sort of hive-mind of heavily modified humans. Their ending involves basically making sure that -all- of the factions fail. The war that ensues destroys all life on earth except the humans who were modified heavily enough to survive on the ruined earth, now hardy enough to survive the perils of space colonization.

The first and second groups set up two particular extremes, in the -personal- relationship between the individual and technology. Either complete rejection of the merging of humanity and technology, or embracing it fully. Either "Separate" or "Merged". This is more than merely two possible endings to the interactive story playing out, it's a cleverly crafted breaching experiment in which the player is exploring his own relationship to The Game, not just the game they're playing, but the larger game that games themselves aren't merely metaphors for.

So next, in addition to the antithetical states of "Separate" and "Merged" in the first two endings, there are two additional endings that represent "Not-Separate" and "Not-Merged". On this axis, it's not the individual's relationship to Technology that's examined, but society's.

The third ending is the victory of the Illuminati ("Not-Separate"). In this ending, the fantastic potential of artificial intelligence and nanotechnology are used to create a "perfect" human world, governed by the old tried-and-true methods of authority, surveillance and data analysis. The systems of control are preserved by relatively dumb AIs guided by human overseers from orbit. Hundreds of years of peace ensue. The objective of the fourth ending is foiled.

“The delusions of paranoiacs have an unpalatable external similarity and internal kinship to the systems of philosophers.” -Sigmund Freud

The fourth ending was the only ending I saw when I played the game, because it was the only one that appealed to me. The significance of the four endings was lost on me, because I didn't experience them.

In the fourth ending ("not-merged"), a plan set in motion by the protagonist of the first Deus Ex game reaches fruition. At the end of the first game, the protagonist of that game merges his consciousness with that of an artificial intelligence that evolved from the government's attempt to use AI to monitor communication traffic for terrorist activity (the AI then classifies the government as "terrorist activity", which creates the "Crisis" of the first game that the recent film Eagle Eye blatantly ripped off"). The purpose of this hybrid human/machine intelligence is to reach an understanding of how humanity should be governed. The fulfillment of this plan (dubbed "ApostleCorp") is the creation of a kind of "cyber-democracy", in which each person retains their individuality (a point that is lost to many people in analyzing the four endings, in a sort of emerging cyber-luddite-ism that may eventually become a real problem when we reach this bridge for real), but many things are managed directly by the AI distributed throughout everyone's consciousness. Decisions on law and legislature can be truely democratized, for example, but decisions on economic production and environment are given over to the machine intelligence. A compromise, Helios says (that's the AI's name, you know, like the SUN), that is in everyone's best interest (obviously, the other three factions vehemently disagree with this viewpoint, in fact Helios has few potential allies besides the Player).

I have to say, watching all four endings, it's clear that this was the one the Designers of the game favored as well.

“One cannot go into exile in a unified world.” -Guy Debord

So we have these two axes, "merged versus separate" and "non-separate versus non-merged" The first deals with the individual's relationship to technology (panic versus euphoria), while the second relates to society's relationship to technology (paranoia versus extopia) ...but it goes even deeper than that.

“You played yourself.” -Ice T

In the "merged versus separate" conflict, we see a conflict that the person playing the game experiences every time they play a game. Are you separate from the game, mearly a player? Are you, through the act of playing the game, truly and wholly your avatar? Neither is absolutely true, that's why it's an axis, and the truth is generally somewhere in the middle.

In the "non-seperate versus non-merged" axis, we see a deeper level of conflict and paranoia. Are you really the player of the game? Maybe you're a non-player character in someone else's game? Maybe the game's playing you? On the other hand, the game can be whatever we make of it. The possibility exists of transcending all of these limits and abolishing the distinction between "gamer" and "game".

“The schizophrenic is the universal producer. There is no need to distinguish here between producing and its product. We need merely note that the pure ‘thisness’ of the object produced is carried over into a new act of producing.” -Deleuze & Guattari

The "game" we're playing now is a game of meaning-making. The outcome of the story as influenced by the player's decision is only a placeholder. What does it -mean- to you?

“Perhaps out of a desire for intelligibility, we can imagine that, in order to achieve the construction of cultural objects (literary, mythical, pictorial, etc.), the human mind begins with simple elements and follows a complex trajectory, encountering on its way both constraints to which it must submit and choices it is able to make.” -A. J. Greimas

There's a fifth ending, the significance of which I'll leave you to read Gamer Theory to work out for yourself, I'm still wrapping my head around it. Basically, it's an easter-egg in which members of all the different factions are partying together in a night club, having conversations that are actually the developers talking to each other through the bodies of all of the characters in the game.

“The prospect of becoming posthuman evokes terror and excites pleasure.” -Katharine Hayles

The relationship between merged, seperate, nonmerged and nonseperate can by represented by a Greimas Square, a tool for analysis in Semiotics

Compare that to another Greimas Square the author presents in the same chapter, relating "player versus worker" and "non-player (gamer) versus non-worker (hacker)"


Meetn' & Greetn'

The Meet-and-Greet with the pediatric home care clients was postponed until today because the agency director had a cold and couldn't be around the child. I showed up a couple minutes late, after driving past their house a couple of times. Doh! I was about to walk out the front door when my mother pointed out "you -do- realize you're wearing all black on your way to meet a three-year-old, right?" Oops. Old habits die hard.

It went alright, I think. Mom was there, the child was sleeping fitfully in a floor-chair. I glanced over whenever I heard his trach gurgling. Dad was at work.

This was the first time I met the agency director. He was smartly dressed in a suit and tie, and had a look and voice modulation pattern that was familiar to me after spending time in commissioned sales. We both sat on the couch while Mom sat on the floor and talked almost non-stop for a good hour or so (it was extremely informative, I knew mothers of special-needs children were practically nurses in their own right, but I'd never seen this in action before). She's around my age, maybe a little younger. Pleasant, articulate, and extremely knowledgeable about her child's care and condition.

She talked about their daily routine, their trips up to the children's hospital in our state capital, and the bevy of specialists that they see on a weekly basis. Cranio-facial, feeding team, neuro, surgery, the list went on for about 10 specialists I thought. The agency director intentionally didn't fill me in on what the child's diagnosis is, and when the mother mentioned the name, it slid right out of my mind. It was two words, very long, very difficult to pronounce correctly. I'll learn more once I start the clinical orientation with the current RN on the case.

Having learned a little bit from previous "interview" experiences where the principal interviewer seems to be doing all the talking, I jumped in with some questions for her about what she thought constituted good nursing care from an RN, and what previous experience has taught her about the difference between someone who's doing a good job and someone who isn't.

"Professionalism", she said. "RNs are more professional than LPNs". This caught me off guard, I was expecting something about clinical competency or maybe familiarity with developmental needs of special-needs children. She went on to explain that in the past, she's had problems with LPNs chatting about their home-life to people at their school, using the mother's make-up and leaving feminine hygine products lying around their bathroom.

I started to do that thing where one eyebrow creeps up.

"Lemme just piggy-back off of that for just a moment" the director jumped in, now. "Most of the problems we've had with home care nurses aren't clinical in nature. We want our nurses to feel comfortable while they're caring for someone in their home, but sometimes when people get TOO comfortable, we have problems."


The mother went on explaining the daily routine and nursing responsibilities, and it looks like I'm not even going to have to do any of the things a Para would do, they're going to get a para in ADDITION to an RN. Basically I'm going to ride with him to preschool, hang out and play with him, and be on hand to suction and deliver a bolus dose of feeding solution through his g-button. She also mentioned I'll probably be spending some time playing playstation with her husband while the child's asleep. Rock.

There are some privacy issues with this case that I'm going to have to spend some time reflecting on, specifically vis-à-vis blogging. Since I've written about hospital patients on this blog before, I've obviously put some thought into obfuscating my location and name, as well as the details about the people I've cared for. I've had a lot of great role models in the health care blogging community for how to go about this, and I'm confident that I have and can continue to do so responsibly. Since this is a 1:1 assignment, however, I have to make sure that I don't get -so- comfortable that I write something that could potentially identify my charge. The family has had some issues in the past that have resulted in them being very concerned about their child's privacy and safety. They know HIPAA backwards and forwards, in addition to everything else.

Since what's being proposed is basically welcoming me into their family, if I get the job maybe I'll write a test-entry and run it by them to see what they think of it. The best thing to do, I think, would be to focus on my own experiences and reflections on my own practice and stay away from the slice-of-life descriptions of "how my day went".

Tomorrow I'm supposed to call into the skilled nursing facility mentioned in a previous post and inquire about the status of my application. If I get both of these jobs, I'll have 40hrs/wk doing home care and 12 hours every other week in the nursing home (paid for 20). Both of these jobs together, before tax, would average out to be 1290USD per week. It's a pretty good combination of jobs, since the nursing home job will give me experience in wound-care, EKGs and IV therapy, while the home care assignment will give me steady work and pediatric experience (which is hard for associate-degree RNs to get in my neck of the woods). The pedi trach experience might later on be leveraged into critical care, which is what I'd like to be moving towards. Back in school I identified emergency/critical and pediatrics as two fields I wanted to explore (along with psych), so maybe I'm on the right track, even if I'm not in the hospital.


Casualty night

It was cold tonight. I was huddled outside the bar, attending the CD release party of a band some friends of mine are in. There was something odd in the air. Too many ambulances. I was broke, had cancelled all of my plans today for a band rehearsal that didn't go down, and couldn't come up with anything better to do with myself than alternating between the coastal chill of the street and the noisy isolation of a packed bar.

The drummer I jam out with on the weekends got kicked out twice, fortunately he had the good grace to buy me a beer before getting thrown out, obviously over-intoxicated. I briefly considered driving him home, until I remembered he mentioned that in situations like that he sleeps it off in the passenger seat of his truck, which he needs to get to work in the morning anyway. He sat on the ground, slumped over, in an alcove just out of sight of the main entrance. The police were kind enough to let us deal with him rather than dragging him away to sleep it off behind bars. The bartender suggested letting him get a taste of the cold air before trying to move him.

After some time went by, I walked over to see if I could rouse him enough to get him into the car, and my phone started going off in my pocket just as I was prodding him to get him moving. The voice on the other end was another friend involved in the health care field. She was calm but her tone Meant Business. She said she might need to call an ambulance for one of her housemates and she'd like me to stop by either way. In retrospect, I should have asked her what was up, but isntead I rushed over to my car and to their house. The drummer, I reasoned, was surrounded by people who knew who he was, and had a car nearby to sleep in.

With no idea what to expect I walked into the room where the friend who called me was tending to my other friend, who was obtunded and sitting up against a bed.

"Hey, look at this guy!" I bellowed with a practiced grin on my face. He wasn't moving, or opening his eyes.

"Heartrate's 100, resps are 5", my friend said as I knelt down on the other side of our friend. She's been a CNA (now pre-nursing), and this wasn't the first time we've "worked" together unofficially like this.

His eyelids and cheeks had a bluish tint to them. I drive my knuckle into his sternum and start shouting his name, and get a shallow, grunting snore for my efforts. I hadn't checked yet, but I would have bet anything his pupils were constricted.

"...tried that", she said, she was standing beside him now, cellphone in hand.

"is the ambulance coming?" she hadn't called them yet. "Call them now". I said that a couple of times, I think. I wondered for a moment if the paramedic would be anyone I know.

While she worked the phone I kept rubbing his sternum and got one of the other housemates to bring me a flashlight. Yup, pinpoint pupils. My continued painful stimuli was rewarded with maybe 8 or 9 shallow respirations per minute instead of the 4-5 he was running before.

It hasn't even been a year since I'd lost a friend to this, damnit.

In maybe a minute flat, there were..I dunno..3 EMTs, a paramedic, 3 firefighters and what looked like a barely pubescent volunteer carrying gloves. Me and my friend got out of the way and answered their questions as best as we could. Yes, he drank a lot today. Yes, he does that frequently. No, we didn't see him take any drugs besides a couple tabs of LSD. No, we've never known him to take heroin or any other opiates. On a hunch, I asked one of his housemates of they were missing any klonopin. They weren't.

The EMTs slip in a nasal endotracheal tube and connect it to oxygen, and after seeing his pupils the paramedic draws up a dose of narcan. At this point it was hard to see what was going on, the firefighters were crowding around the door, standing on tiptoe to get a better view for when the narcan kicks in. He woke up smoothly, opened his eyes and started answering questions, and walked himself to the stretcher waiting for him outside.

The police asked us a couple of the same questions, but just hung out by the doorway without coming in. When my friend the nursing student said she didn't find anything in his room while she was looking for his ID, the younger of the pair shrugged and said "well, if you find it, flush it before he gets back".

Just as fast as they came, they all departed. I hung around for a while to smoke a cigarette with the housemates and listen to everyone decompress and return to normalcy.

Right around closing time I went back to the bar to see if the drummer was still passed out next to the bar entrance. He was gone. A couple of our friends loaded him into the passenger seat of his car, just like I thought they would.

Standing outside in the cold again, I caught just for a second the sight of that same ambulance, running lights and sirens, turning towards the club around the corner.

One of those nights, I guess.


Home care interview

Another interview today, this time at a home care agency. Despite the stern warning from a VNA nurse that entering into practice in home care would be "one of the biggest disservices to yourself that you can do"; I balanced that against the experiences of the home care nurses who came to speak in our last semester of RN preparation, who held the opposite opinion.

The office is within walking distance of my current residence, in the same building as one of the anchor stores in a nearby shopping mall. The office was one large open space with four computers clustered around the center. There were cardboard boxes stacked against one of the walls, and a lonely looking couch off in the distance. The space had a "just-moved-in" feel to it.

I was greeted by two young, attractive women, an HR agent and the recruiter I had spoken to on the phone. The recruiter reminded me of someone..she had a Norwegian lilt that placed her somewhere near Wisconsin.

I was expecting an interview, but one didn't take place. After filling out the usual employment paperwork, I was given four tests to take. Metrology, pediatric vents, pediatric tracheostomy care and pediatric G-tube feedings. The tests themselves were easy, and I was provided with learning modules to get through all of the tests except metrology (which was easy, even compared to the easy metrology tests I took in nursing school).

The two employees in the office were...overtly friendly. They acted like I had the job already, pending my background check. The HR agent complimented me on my driver's license picture (in which I looked more than a little sullen and disheveled, due to the circumstances surrounding the capture of the image). After a little less than an hour, most of which was spent filling out forms, the recruiter told me what great feedback she got about me, even from the then-absent administrator, who I spent all of 3 seconds talking on the phone with yesterday.

Next I was told about the assignment they had in mind for me, which they all thought I would be a "perfect match" for. At this point I feel I should point out that I haven't met anyone in this company besides administrative types so far, no RNs, clinicians, etc.

Alarm bells started going off in my head, loud and clear like a ventilator klaxon. The assignment was an 8 to 4 shift on weekdays, getting a three-year-old client ready for school, staying at school with them, then staying with them at home for four hours. The client has a tracheostomy and a gastrostomy. When I asked about the orientation process, I was told I would accompany the nurse currently assigned to the client for "a couple of weeks" before taking the assignment over myself.

There's a couple of issues with this: The practice act in my state suggests that RNs taking care of pediatric clients have a four-year education, and I have two. Granted, the shortage here and everywhere else results in ADNs finding work on pediatric units, but that's generally in hospitals with comprehensive clinical support and supervision. Tracheostomy care, although something I've been trained to do in my clinical rotations, is also somewhat advanced, especially for pediatric clients. I'm confident I could pick up the skills with one-to-one instruction, but just the thought has me scrambling to earmark my old nursing textbooks for relevant information. Gastrostomy care, at least, is something I'm confident I can do with minimal further training, since I got a lot of experience with that in clinicals.

That said, I'll accept the position if they offer it to me. It's a risk, to be sure, but a risk I'm willing to take. I'd have the weekends off, so I'd still be able to take the bailer shift at the skilled nursing facility I mentioned in the previous post. The home care job pays 25USD/hr, slightly more than I'd make in the hospital. Maybe risk-taking behavior is just a feature of my gender, but I think I could make it work. I've always enjoyed taking care of children, and the consistency of the one-patient assignment may ameliorate some of the inherent risk-factors of the assignment.

If I get offered the positions, I'll visit the family and the client for a "meet-and-greet", and if both the family and myself find the arrangement acceptable, I'll start the orientation process. Otherwise, they'll select a different assignment for me and the process will start over with a new "meet-and-greet" with a different household.

What do you think? Bad idea? Acceptable risk threshold? If I pull it off, it will be a good resume builder, I think, especially for someone who would like to eventually get into emergency and/or pediatrics.