The Witching Hour

0430...

It was hard to believe that less than two hours ago our 40-bed Emergency Department was nearly full. We managed to admit or discharge nearly all of our patients in that short time. Only two occupants remained: one was a 17-year-old habitual "cutter" who had gone off her bipolar medication; we had stitched her up and she was just waiting for Daddy to come get her. The other patient was a harmless professional drunk whom we named "Otis." Otis was currently sleeping off his two-bottles-of-Old Crow dinner and getting IV vitamins.

Nurses and ER Techs had been busy for the previous hour, putting the department back together after a particularly vicious night with a patient demographic chock full drunks, punks, and bipolar funks. Hooray for Welfare Check Weekend. Yay.

Having completed the tasks associated with my particular section, and having no patients, I sat down at my station, stretched, yawned obnoxiously, and pulled out my copy of Patrick O'Brian's The Golden Ocean.

The housekeeper (a truly endearing gentleman named Moe, who is believed to be around 800 years old) arrived in the department riding his Super-Awesome Floor-Cleaning Vehicle. The machine functioned pretty much like a Zamboni. It kept our special rubberized floors nice and clean- until, of course, we walked on them with our filthy-soled shoes.

The Zamboni was universally hated by the nursing staff, and rumor had it that the machine was manufactured somewhere in the lowest plane of Hell by the devil himself. As innocuous as the thing appeared to be (it kind of looked like a prematurely-delivered SmartCar), its true sinister origins were revealed by its noise. The thing emitted a constant, bellowing screech reminiscent of a skinned banshee with a pitchfork up its arse. Its nightly rounds created an environment that was about as therapeutic as trench warfare.

Moe drove his infernal steed with a great big grin on his face and a cold gleam of bloody-minded determination in his eye. No puny mortals would deter Moe from his mission as he screamed through the Emergency Department at the blinding speed of 0.5MPH. Moe made it clear that he would not waver from his intended course; we had best get out of the way and the devil take the hindmost. He emphasized his point by honking the Zamboni's horn.

Oh yes, it had a horn. It sounded exactly like one salvaged from a 1967 Volkswagen Beetle- specifically, a Beetle that had just been discovered after forty years of being buried in the slimy muck of a freshly-drained swamp:

Mmmmmmmmeeeeeooooooooooooooouuuuuuuuuuuuunnnnnnnngggggggghhhhhhhh....

It was a soft, plaintive, mournful sound that carried through the early-morning air and evoked from Otis a slurred "WazzahellizZAT!?"- immediately after which the Sirens of Bacchus recaptured him with their wine-fueled song and returned him to snoring, slobbering, farting oblivion.

Having completed its infernal rounds, the hell-spawned steed with Moe at the reins retreated to the black pit from whence it came. A traumatized silence, similar to that which is experienced after witnessing a bad accident, ensued.

0500...

The change in the atmosphere was palpable. Staff slowly drifted towards the two large resuscitation (or "thrash") rooms that remained active- to one of which I was assigned. I put away my book, got up from my desk, went into my thrash room, and methodically prepared for a patient who did not yet exist. I pulled out a sheet and laid it on the stretcher, placed two disposable absorbent "chucks" on it, and elevated the bed to waist level. I pulled out an assortment of IV needles, skin prep supplies, and blood collection tubes, neatly arraying them on a stainless steel rolling table called a "Mayo stand." I brought out a Foley catheter kit, nasogastric tube supplies, and other sundry invasive instruments. I set up three suction points and checked for proper function. I pulled out a Bag-Valve-Mask and hung it over an oxygen flowmeter. One of the ER Techs casually parked a portable EKG machine outside the room.

This is the ritual of the Witching Hour.

The Witching Hour is what we call that period of time, roughly from five-ish to six-ish in the morning, when most heart attacks occur. It has to do with rising cortisol levels that occur during the body's sleep/wake transition cycle. It is unnecessary to go to great lengths in describing the pathophysiology behind the phenomenon. It can simply be explained thus: There is something about waking up that really gets a sick heart pissed off. And the heart, perhaps like no other organ, has a magnificent way of letting its owner know that it is really pissed off- especially if said heart has been abused by decades of overeating, smoking, substance abuse, and laziness. (Or sometimes it's just crappy genetics. Ask Jim Fixx, a 1970s-era marathon runner who was in ludicrously excellent shape. Oh, wait... he's dead. Heart attack. I think his last words were, "Oh, crap. You gotta be friggin' kidding!")

0540...

The medic phone rang. The MD took report, handed the run sheet to Mindy the Charge Nurse, and returned to his computer. Mindy turned around and quite by coincidence (I swear, really!) ran into me.

"Howdy," said I.

"Gee, I know how you hate these things, but can I trouble you to take this one, pretty please?" Mindy asked with a flat and rather sarcastic tone of voice. She batted her eyelashes.

I drawled, "Well, okay ma'am, since you asked real nice and all..." and took the sheet from Mindy's hands with a wink and a crooked grin. She snorted, rolled her eyes, and walked away shaking her head and mumbling something to herself about "code junkies."

I returned to the thrash room to recheck my preparations. I turned to my colleagues and recited the details from the run sheet: A 46-year-old man woke up at 0500 with crushing chest pain, nausea, lightheadedness, and cold sweats. He had no known medical conditions (until now). He was hypotensive and bradycardic (this raised a few eyebrows in the room). He was to arrive in 5 minutes. (Why medics choose to wait until they are only five minutes away to tell us they are enroute with a super-sick patient is a perpetual mystery to us.)

Having provided the background, I then gave each colleague a set of specific assignments to perform throughout the process. I would act as Primary RN.

The role of the Primary RN is highly management-intensive. My responsibilities as a primary nurse are to assign, oversee, document, and insure the completion of all nursing and tech-related tasks as long as the patient is in my care. Additionally, when a task was completed I must either provide a new task or release that RN or tech from the room in order to keep the area clear of all nonessential persons. I am to insure that the administration of all medications, the call times and arrival times of other specialists and departments, all interventions by medical and nursing staff, and the patient’s responses to those interventions are accurately and succinctly documented. Additional tasks for which the primary nurse is responsible include obtaining accurate information regarding the patient’s health and medication history and verifying any allergies to medication, the type of reactions, and the severity thereof. On top of all of this, the primary nurse is responsible for reporting all adventitious findings to the MD, carrying out preparation of the patient for transfer to the receiving department, providing an accurate ‘handoff’ report to the receiving nurses, and insuring that the patient arrives at his or her next stage safely and with all possible speed. I am also responsible for maintaining an environment that facilitates calm and clear communication. I do not allow cross-room talk, elevated voices, or needless chatter. While the physician "ran" the code, I ran the room; I was Chief of the Boat.

Because of the extreme depth of my involvement with the oversight of those matters, I typically will not lay a hand on my patient for the first time until five to ten minutes after arrival- and sometimes not at all. I do try to introduce myself at the soonest opportunity, ask the patient how he feels, and explain what is happening. But until the patient has been stabilized, this will be the extent of our relationship. More often than not, I will slip unknown and phantom-like in and out of my patient's life.

0547...

When the patient arrived, we were gowned and ready. I took station off to the patient's side where I had counter space and could see the monitor and every machine in the room. The other RNs and Techs transferred the patient onto our stretcher, stripped him, gowned him, and covered him up. He was fully hooked up to the monitor and a full set of initial vital signs was written down in less than a minute. A second large-bore IV was started. The MD stood at my right side, and while we both listened to the medic's report, I kept my eyes on the process.

Something about the patient's EKG was just funky. Clearly, the man was having a heart attack, but it wasn't the front part of the heart that was damaged. The MD looked at it, looked at the patient's monitor, and instructed the tech to perform a posterior-placement EKG. A minute later, it all made sense. The focus of the MI involved most of the backside of the heart- something we don't see all that often. It also explained the patient's bradycardia and low blood pressure.

This kind of MI really sucks for the patient, because all those great medications that would ease his horrific pain and protect his heart from stress (nitroglycerin, morphine, and beta blockers) would also cause his blood pressure and heart rate to drop like a cow off the high dive. So he was going to have to hurt for a little while longer.

0552...

The monitor alarmed. The patient went into ventricular tachycardia. CPR commenced while the defibrillator charged up. Per MD order, an initial shock of 300 joules was delivered. The patient jerked, sat bolt upright in bed and bellowed "Holy crap! What the hell...?" He blinked a few times, then settled himself back down.

"Well, that worked," Mindy said dryly.

The patient's heart returned to a perfusing (though still ominous) rhythm. Breathing resumed among the team members.

0605...

The cardiologist arrived in the room and received a briefing by the ER MD. He approached the patient and introduced himself.

"Sir, I am Doctor So-and-So. You're having a heart attack."

"Ya think!?" gasped the patient.

"We're going to take to look at which artery is causing your heart attack and try to unplug it so you can get better. There's a small chance that it could cause other problems like a stroke or a worse heart attack, but that doesn't happen very often. Do you consent to allow us to do the procedure?"

"Oh, what the hell. My dance card's empty. Sure."

The cardiologist looked at our documentation and walked out to see if the Cath Lab crew had arrived. He returned to the room and asked me if, rather than have the Cath Lab come get the patient, we could bring the patient so that his gang could complete setup. I told him we could. Mindy picked an RN and tech to package the patient up and get him going while I completed the documentation and made sure all vital signs were uploaded into the computer. I called the Cath Lab chief RN and gave her a report as my patient was wheeled out of the room.

The cardiologist found that a posterior branch of the patient's Right Coronary artery had occluded nearly 100 percent, and he was able to clear the jam. The patient stabilized immediately and was whisked up to CCU to begin a pretty rapid recovery. Door-to-balloon time: under thirty minutes. National standard: ninety minutes. (Does my team kick ass? Heck yeah!)

0630...

My thrash room was finally squared away, my documentation was complete, and after making the rounds to thank my colleagues I again settled down to my book. Once again a welcome silence settled over the department- broken only once by a single loud, lonnnnnnnnnnnnng belch, courtesy of Otis.

Road Fest Part Five: Leaving Kingman

Kingman, Arizona; 0800 (8AM for the rest of you) on day 4:

I awoke to the bewitching aroma of coffee, sizzling bacon, and Southwest omelettes. Melanie (ER nurse) and Kevin (ICU nurse)- the married couple who so graciously took this wayward colleague and his wrecked toe into their home for a day- had just arrived home from their shifts and were preparing what was shaping up to be a smashing breakfast.

I pulled the blanket from over my eyes and sat up on their couch, squinting against the brilliant sunlight that streamed in from the living room window. With some trepidation, I carefully lifted the blanket from my left foot and was relieved to see that my big toe had returned to normal proportions. While the bruising to my foot looked like hell, it had not extended; and I felt only very mild pain, although the ibuprofen had worn off at least two hours ago. I had good distal capillary refill and sensation. The perforated nail looked, well... perforated; but no signs of infection were evident.

I stood up tentatively, testing my ability to bear weight on my left foot. Standing was okay, and walking was... well, not so much; but it was quite bearable, and I could probably get by alright with ibuprofen and stops every two hours for ice and elevation. I tested my ability to withstand using the clutch pedal by putting all my weight on the ball of the left foot, and had no trouble. I was ready to hit the road again.

I hobbled over in my scrubs (which also serve quite nicely as pajamas) to the breakfast nook as Kevin turned around to greet me with a big mug of coffee.

"Morning, friend. How's the toe?"

"Much better than I thought, thank you. But if this ever happens again, I think I'll forego the digital block. How was your night?"

"Mine was uneventful," Kevin replied. "Mel's was busy."

"Nothing awful, I hope." I said, resting my elbows on the counter and lifting my coffee up for a sip.

"Nothing awful. Just your typical Sunday Night crowd. But every time we would discharge a patient, we'd get another one back there. We never really had anyone waiting in triage; they just kept coming in one or two at a time all bloody night long. Nobody had a break all night, and I'm starving." Mel emphasized her point by staring sad-eyed and waif-like (with a boo-boo lip thrown in for good measure) at her husband as he flipped an omellete.

"Oh, stop," Kevin retorted as he reached out with his free hand to ruffle Mel's Tinkerbell pixie-do. "You're going to make me cry and I'll ruin breakfast."

I snorted in my coffee. Mel snickered and handed me a paper towel to dry off my nose.

"Thanks," I said. "Listen, guys: I can't tell you how much I appreciate your hospitality. I'm glad I listened to you and stayed off my foot for a day. It made a huge difference. But I ran through all my crossword puzzles and I have to say that daytime television ranks a ten/ten on the Suck-O-Meter."

Kevin nodded. "That's one of the greatest benefits of working the night shift: sleeping through Oprah."

I nodded and sipped more coffee.

"So are you heading to Phoenix this morning?" Kevin asked as he placed a plate of bacon and eggs before me.

"No, I have to skip Phoenix. I already called my kin down there to let them know. I will be going to San diego today. My sister is graduating from nursing school at San Diego State tomorrow."

"SDSU?" Mel asked over her tea. "Didn't they just have a huge drug bust there?"

"Yeah. My sister told me about it. She said the bust has prompted the Administration to give up any pretense of dignity, embrace its licensious culture, and change the school's name to "SDEASU."

Mel laughed. I handed her a napkin to dab the tea from her nose.

Kevin asked, "When are you leaving?"

"Well, as soon as I help you clean up I'll load up Baby-san and be off."

"Baby-san?" Mel furrowed her brow. "Who is that?"

"My car."

"Oh, my God," Mel laughed and set down her tea. "You gave your car a name?"

"Yes, I gave my car a name," I answered with a childish defensiveness. "It creates a kind of bond."

"I gave our car a name," Kevin offered. Mel turned to her hubby with her hands on her hips.

"Oh, really? And just what did you name our car?"

"Squeaky," Kevin said with a grin.

"'Squeaky'? What inspired you to name our car 'Squeaky'?

Kevin answered in the form of a smirk and an upward roll of his eyes.

Melanie shrieked and punched Kevin on the shoulder. It was an odd, Newlywed Show kind of moment. I covered my face in my hands and cleared my throat.

"So Mel, would you like me to help you clean up the blood and hide Kevin's body before I head out?"

"Naw. I can take care of that," Mel replied as she launched a fiery glare at her imperiled husband (who laughed), and punched him again.

An hour later, freshly showered, I emerged wearing a pair of baggy shorts, wide-soled Keens, and a Hawaiian shirt loud enough to strip the paint off a Buick at fifty meters.

"Wow," Mel said as she shielded her eyes. "I guess I'll cancel my chemical peel now."

I packed up my things and got squared away for departure. After an exchange of telephone numbers and email addresses, Mel gave me a hug and a peck on the cheek and instructed me to call when I got to San Diego and let them know how the toe held up. I promised I would (and I kept it). Kevin shook my hand in that huge paw of his and wished me well. I told him I would pray for his safety, since upon my departure there would be no witnesses to his impending demise at the hands of his 5'3" powderkeg of a wife. He laughed and kissed his bride. She punched him on the shoulder again, but followed up with a kiss, so I guessed he might live to see another day.

After stopping at a market for more ice and snacks, I gassed up and headed west toward San Diego with a roar, a cloud of dust, and two new friends.

The ER: Stuff You Need to Know. Part 1: Triage

Introduction:

I recently wrote an article describing a variety of examples of poor behavior demonstrated by patients in the Triage section of my Emergency Department. While the article was written primarily to introduce the reader to some of the actual (rather than media-generated) challenges encountered by an ER nurse in a humorous vein (which is the modus operandi for all of my writing), my article evoked a tremendous negative response with regard to the readers' personal ER experiences. A majority of responders related their unpleasant experiences when they or a loved one was treated in an ER.

The most common complaint was that an extraordinarily long time was spent simply waiting: waiting to get back to a room while others who arrived in Triage later were brought back first; after arrival in a room, waiting for the nurse to come in and perform an assessment; waiting for the MD to come in; waiting for medication; waiting for tests to be performed; waiting for test results to come back; waiting for diagnosis or treatment; waiting for transfer up to a unit bed; or waiting for discharge instructions and prescriptions. Furthermore, more deeply entrenched in these woes was a complaint common to all: not being informed about what was going on with the process. These people were simply never told what was happening at any point throughout their ER experiences. (It is perfectly understandable that a person in that situation would feel forgotten and ignored, and thus become upset.)

After considering these problems, and at the suggestion of a colleague, I have determined to do something about it. I hope that this series of articles will inform and enlighten the reader regarding the challenges and intricacies of emergency medicine. I hold the firm belief that a well- and accurately- informed public makes for a great patient, because a better-informed patient is far better equipped to actively participate in the care process and is able to more effectively advocate for oneself. I have found that patients treated in this manner nearly always described a far more positive and satisfactory experience, even if an extended wait was involved. Thus, when I teach new nurses (and students), I pound into their minds the following adage:

Keep them SAFE, Keep them WARM, Keep them COMFORTABLE, and Keep them INFORMED. When a nurse does this, it goes a very long way towards making the patient feel cared for- which is the whole point of nursing, if memory serves me correctly.


Returning to the issue at hand, I begin this series where the ER process begins: Triage.

The Purpose of Triage

In the civilian sector, triage was adopted by emergency departments in the early 1960s when the demand for emergency services grew beyond capacity to provide everything to everyone at the same time. The process enabled overloaded emergency departments to quickly identify and treat the "super-sick" patient from among the crowds. (Interestingly, it also proved a useful tool in identifying malingerers who were inappropriately using the ER.)

With the advent of government-subsidized medical entitlement programs, emergency departments were rapidly overwhelmed with non-emergent and non-urgent cases that slowed the entire emergency care process down. The need for, and value of, an effective triage system became immediately evident. As a result, four-tier and 5-tier triage systems were developed. With either system, patients are classified by level of acuity (how sick they appear based on objective data such as vital signs, obvious trauma, or body system affected).

Level of acuity is generally classified as follows:

Level I: LIFE-THREATENING condition requiring immediate care. Not stable. Examples: CPR or intubation in progress, acute MI, major trauma, acute respiratory distress, or major burn;

Level II: EMERGENT but stable. Seen ASAP (within 30 minutes); Examples: Open fracture, kidney stone, testicular torsion, "hot" (surgical) abdomen, sickle cell crisis, frankly-ill child, neonate with fever, eye injury, narrow-angle glaucoma, suicidal ideation.

Level III: URGENT. Stable, no distress. Seen ASAP if no Level I or II patients ahead of them. Can wait up to one hour before being seen. Examples: Closed fractures, laceration without bleeding, Drug ingestion > 3 hours prior to visit with no signs or symptoms.

Level IV: NON-URGENT. Stable, no distress, can wait at least one hour before being seen. Examples: Typical migraine, rash (without fever), abrasion, anxiety, cough/cold.

Level V: DELAYED. Can wait four or more hours before being seen. Examples: out of medications, routine exams.

The patient is classified according to objective findings (abnormal vital signs, obvious distress, etc.) The experienced and astute triage nurse also develops a "sick sense" (being able to quickly visually assess a patient for the appearance of a life-threatening illness as they come through the door).

It is absolutely essential that the reader understand this system because it governs the entire flow of the emergency medical process. The patient is not merely classified randomly and arbitrarily by the triage nurse. It also provides the inarguable reason why one person may arrive first but be seen later than another person who comes in after them. While one person my have a migraine and be completely and undeniably miserable, if another person arrives with signs and symptoms of a higher-acuity condition, that person is going in first, and no amount of complaining is going to change this fact. Furthermore, screaming, crying, or otherwise acting out will never qualify a patient to receive a higher acuity "just to shut them up." It just upsets everyone else who has to endure the tantrum.)

Challenges of Triage

Triage is one of the trickiest, most challenging functions for the ER nurse. Symptoms of a potentially life-threatening condition can be subtle, and can even be discovered "accidentally" when a patient is complaining of a problem that would itself provide for a lower acuity assignment. In my career, I have had at least six patients who complained of abdominal pain without vomiting or diarrhea (which at face value, merits an acuity of II to IV, depending on vital signs). But every single one of those six made a seemingly-offhand remark, or described their pain in a particular way, that my "suspicion index" sent up massive red flares. In each case, acting merely on my suspicion through the simple act of looking at and feeling both legs revealed one being colder and paler than the other- and that the patient's pain was not gastrointestinal at all, but that he or she was suffering from a dissecting abdominal aortic aneurism, which merits an acuity level of I with an exclamation point. (Only one of those patients died, and that was because his aorta completely tore within moments of sitting down in my triage booth. When the aorta blows out, there is nothing anyone can do; death occurs in ten seconds or less- there often isn't even enough time for the patient to say more than a startled, "Oh!" (It happened once). He just said, "I can't breathe," and he was gone. But had I been less experienced, I might have missed all six.)


Traits of the Effective Triage Nurse

The effective and safe triage nurse demonstrates experience, awareness, astuteness, coolness under pressure, and razor-sharp critical thinking skills. Where I work, no nurse with less than two full years as a full-time ER nurse is allowed to go anywhere near triage- even if only to give the triage nurse a 30-minute break. It is no place for the neophyte or any nurse who is still in the process of gaining confidence of his or her abilities. As illustrated above, people live and die on the quality of the triage nurse's assessment. When a waiting room is packed and more people are coming in, and just when three rooms are opening up the charge nurse informs triage that three medics have arrived with Level I patients, the triage nurse has no choice but to hold the line.

I have had many nights like that in Triage. In some ways, it is more difficult than working in a Level I thrash. Instead of one patient, I have thirty or forty with variable levels of acuity. This, again, is where experience and calm is an absolute requirement. Nobody likes to be stared at; and the awkwardness is amplified when every one of the people staring at the triage nurse is not feeling well and has been waiting for hours. How does one cope with this potentially-volatile situation? The question introduces two more equally-vital traits of the triage nurse: empathy and compassion.

In my experience, it really does not take much effort to help even a miserably uncomfortable person endure a long wait. It is amazing how calming to a room full of patients it is to simply circulate around the waiting room periodically, offer a blanket or pillow, and say "I know you've waited a long time. Has anything changed? We are working as fast as we can. We haven't forgotten about you. As long as you are out here, you are my patient and I will look out for you."

When people see you actively following up on them and looking after them, they feel cared for. All it requires is one minute of time to infuse calm into a crowded, highly-charged waiting room. Granted, there are times when it may not help (a demented patient with "sundowner's syndrome," a belligerent drunk or drug user, for example). But otherwise, I have never, in all my experience, known this approach to have failed me in calming down a room full of upset patients.

In fact, the triage nurse is required to re-assess everybody waiting on a regular basis. Making rounds is a quick and efficient means of doing that.

Concluding Remarks: Doing Your Part

I cannot speak for the practices of every nurse, hospital, or emergency department. Many factors not mentioned here can create a positive or negative experience for the patient. But I strongly encourage you, the reader, to advocate for yourself or your loved one. This is not Cuba; our medical system is still driven by a free-market economy. That means if enough patients get upset, they can tell their friends not to go to that hospital, and so on. People will start avoiding that hospital. The hospital is a business. No patients means no revenue. State agencies will begin to wonder what is going on at that hospital. The hospital will either change, lose accreditation, go bankrupt, or lapse into backwater obscurity.

Here is what you can do: If there is a problem, speak up! If more than an hour has passed since you have been informed or have seen your nurse, speak up! If you have not been seen, gone to a diagnostic test, received results, been treated for the diagnosis, or received your discharge instruction more than an hour after being informed of the step, speak up! And if you feel that you are not being informed about any part of the care process, speak up!

You, the patient, do not exist for us; We, the Emergency Department, exist for you. If we work together as a team, we both will be the more satisfied and enriched for it.

How To Be Taken Seriously by Your Triage Nurse

Okay, I know this is a bit of a chronological jump, considering I was last writing about my recent odyssey. I'll get back to that soon.

I am back at work now, and since returning I have encountered an unusually-long parade of ER patients who have displayed, shall we say, less-than-sound judgment with regard to the way they chose to conduct themselves in ER Triage.

I am a man of great forbearance and restraint. I have never told any patient that he/she was a slack-jawed, mouth-breathing idiot before- even if the patient's actions clearly prove such to be the case. But some people make it very difficult to restrain the urge. Happily, only a rare few have ever caused me to fervently wish that dope-slapping was approved as a therapeutic nursing intervention.

For the sake of brevity, I'll cut to the chase:

To all of the exasperation-inducing patients described in Paragraph Two of this entry, and to all potentially-exasperating patients, I offer the following pearls of advice. If you follow these maxims, I guarantee that your name and the word "idiot" will never be uttered in the same sentence when you are mentioned in verbal handoff report by your Triage Nurse.

1: Do not come into the ER with a chief complaint of "high blood sugar" and then sit, in full view of the Triage Nurse, gulping down a can of Coca Cola and eating a candy bar.

2: Please do not use "I have (insert disease name here)," "Googled," and "My symptoms" in the same sentence.

3: Do not sprint full-tilt boogie into the ER from the parking lot (having been observed by the Triage Nurse for the 100 feet of your medal-winning dash), burst into the waiting area, and yell at the registration clerk in a full sentence that you are having a heart attack and need morphine.

4: Do not ask the Triage Nurse for any sample packets of Tylenol, Ibuprofen, antibiotics, the "Morning After Pill," Valium, Ativan, Zanax, Methodone, Oxycontin, Surgi-Lube, or medicinal marijuana.

5: Do not tell the Triage Nurse that you don't want to see a doctor but just want to have your blood pressure, blood glucose, lung sounds, or that "icky lump" in your bikini area (I am not kidding) checked by the Triage Nurse. You have to be registered before the Triage Nurse will listen to you say anything about that "icky lump" in your bikini area. Otherwise, go to the fire station or your clinic. And wash your "icky" frigging hands.

6: Don't get out of your car, walk ten feet to the wheelchair your relative provides for you, sit down in the wheelchair, and then go limp and pretend to be unconscious the remaining twenty feet to the Triage Desk. (Yes, I did see you peeking, you rascal!)

7: Don't ask for a five-gallon barf bag, be given one, pull your face out of it to spew all over the Triage Room, Triage Computer, Triage Floor, Triage Tech, and Triage Nurse- and then say, "Sorry, I missed."

8: Don't refuse to wear a mask if you are coughing or sneezing. If you do refuse, then don't be surprised if you are thus regarded on the same level at which any other mindless, disease-carrying vermin would be.

9: Don't talk on your cell phone while being triaged and tell the Triage Nurse to "shush!" for interrupting when you are asked about your migraine. And don't get angry when you are ushered out of Triage to finish your phone call and the Triage Nurse moves on to the asthmatic 3-year-old who just came through the door.

10: Don't walk in and tell the Triage Nurse you were involved in a rollover motor vehicle crash an hour ago when all you are really looking for are narcotics. You will be slapped into a cervical collar and duct-taped onto a very uncomfortable backboard faster than you can say "I'm never using this frigging story again." Just tell the truth. Honesty serves two purposes: 1) We can laugh at you without you having to go through all that unnecessary discomfort, and 2) You can haul your drug-seeking carcass over to the neighboring ER without any telltale patches of tape-induced depiliation on your head.

11: Please be sure to leave the ID bracelet from the neighboring ER that you just left on your wrist when you arrive at our Triage. This enables us to contact that ER and find out why you were dissatisfied with the service they provided.

There you go. Have a safe Halloween, think before you drink, avoid anyone who says "Hey, watch this!," and stay inside any moving automobiles.

Road Fest Part 4: Busman's Holiday in Kingman (Or, Melanie and the Toe of Doom)

The deep, exhausted sleep into which I initially fell proved to be woefully short-lived.

I was jolted awake around 1AM by the simple act of rolling over. My left great toe, which I had injured the previous morning when I struck it against a heavy chair in Susanville, was proving itself to be in far worse condition than I originally thought. I did not detect any deformation at the time of injury, and I could bend the joint fairly well. I had done everything that we would have done in the emergency department for this type of injury, and had been a good patient for myself.

Well, mostly good. There was this one little detail of keeping my foot down and using a clutch for nearly twelve straight hours...

I turned on the bedside lamp and swung out of bed to reassess the toe. I was shocked to find that the bruising had extended to above the toe and that the nailbed was an ominously-dark purple. I was unable to bend the thing at all. Of course! I forgot: I had been taking aspirin for the last four days to reduce the risk of getting blood clots associated with long-distance car trips. Aspirin reduces platelet aggregation, which means the initial bruising to my toe, which should have been fairly minor, was exacerbated by my inhibited platelet clustering as well as my keeping the foot dependent for so long. Thus was the unintended consequence of my diligent efforts to avoid taking rat poison (Coumadin) for a year or dying from a pulmonary embolism. Silly me.

I knew what I had to do...

Popping 600mg of ibuprofen and a gram of Tylenol, I hobbled to the ice machine to freshen my icepack. Returning to the room, I opened my "Hero Bag" (a first-aid kit modified for both survival and to treat traumatic injuries encountered outside the hospital setting) and looked through it for the tools I needed to perforate the toenail and relieve the pressure, which was the cause of my intense pain. As I rifled through the kit, which was contained in a surplus Army rucksack stuffed (and I mean stuffed) full of goodies, it slowly became clear that while I easily had enough supplies to perform an emergency cricothyrotomy, I could not find anything with which to puncture a damned toenail.

This situation rated a 9.95 on the Suck-O-Meter. I groaned a tired, "Aww, crap!" and propped my left foot up on a chair. As I glared balefully at the offending toe, I found myself on the horns of a dilemma that every ER nurse absolutely hates, hates, hates to encounter:

Do I stick it out a little longer and hope it gets better, or do I go on in?

Of course, I already knew the answer. The two factors of taking aspirin and having my foot down (and doing all that footwork on the clutch) for an entire day had combined to make my situation untenable. I was in so much pain that I was actually sweating and nauseated. I could almost see the toe pulsating. I resolved to grit my teeth and wait an hour, hoping that the ibuprofen, Tylenol, and icepack would win the day. One hour later, the ibuprofen, Tylenol, and ice pack handed in their respective resignations and trudged, under the black pall of defeat, into history.

I had to go in. Craaa-haa-haa-haaaaaap!

I consulted the phone book to find the number for a local hospital. Not knowing exactly where I was in relation to where I was calling, I rolled the dice and called the hospital with the most impressive-sounding name. The operator answered, giving the name of the hospital, and asked with whom she could connect me.

"Emergency Department Triage desk, please," I replied.

"Is this a life-threatening emergency?"

"Well, my toe is trying to kill me," I said with a grim chuckle. "Honestly, I just need to know how to get there from my hotel."

"What hotel are you staying at?" Asked the operator. I gave her the name and location. She laughed and said, "Dear, you are just around the corner. If you get in your car, turn right out of the parking lot, and turn right at the next light, you'll be at our ER in about thirty seconds."

"God bless you, Ma'am," I gushed. "I may yet save my toe." The operator laughed and wished me- and my toe- good luck.

I grabbed my wallet, my beat-up baseball cap (Toledo Mud Hens, in case you were curious), and cell phone, gimped to my car, and drove the shockingly short distance to the local Emergency Department. I arrived at about 2:30AM and limped into the waiting room, which was encouragingly empty. I trekked over to the information desk to get things started.

"What brings you in this morning?" asked the young woman at the desk.

"Left great toe injury," I said flatly, displaying the horrible-looking appendage.

"Ouch! Let's get you started, then." The young lady quickly registered me, and I took a seat. Five minutes later, I was called to the Triage booth. The Triage RN also cringed when she saw my toe.

"I know it looks bad, but it's actually merely horrific," I joked. The Triage nurse quickly finished with me and I was escorted into the main Emergency Department and placed in an examination room. The nurse gave me a fresh ice pack, a pillow, and a very sympathetic (not to mention cute) pout. After another few minutes, my nurse came in.

"Hi, I'm Melanie," she said as she pumped a glob of Cheap Scotch-scented hand sanitizer into her palm. "I'm your nurse tonight." She directed her gaze toward my toe and her eyes widened. "Holy cow, man!"

"Holy cow indeed, Melanie."

"When did you hurt it?" Asked Melanie as she gloved up, pulled up a stool, and began her assessment.

"Yesterday morning. I found furniture in the dark." Melanie winced again, and was tentative with her examination of the toe, appearing quite reluctant to touch it. She probably suspected- justifiably so- that the merest featherweight of pressure would cause me to scream like a girl. I am so glad she spared me of that embarrassment.

"Ooh, I hate bonking my toe against stuff! Still, they usually don't get this bad..." The RN pondered as she examined the toe.

"They do when you have been taking aspirin to prevent travel-related pulmonary emboli and have your affected limb hanging dependent for twelve hours," I replied.

Melanie sat bolt upright and eyed me with suspicion. She tilted her head and flatly stated, "You know the terminology..."

Her eyes searched me, looking for telltale signs that would betray me as one of those Effing Know-It-Alls who try to impress or intimidate ER staff either by (a): spouting terminology, or (b): wearing some article of clothing with an EMS or hospital logo on it. I had taken great pains to avoid either of those.

"Well, yeah. Sorry," I said self-consciously.

"Are you EMS?" She asked.

"No. I'm a trauma nurse."

"Really," Melanie responded flatly. I pulled my creds out of my wallet and showed them to her.

"I'm the real deal- See?" Melanie observed my license, ENA membership card, and Trauma Nurse certification card. Relaxing visibly, she said, "I'm sorry. You know how it is."

"Oh, yeah," I said with a laugh. "My favorites are the family members of patients who come in wearing a shirt that says "[insert resort name here] SEARCH AND RESCUE" and they try to actually pass themselves off as EMS. I had a ratty old morbidly-obese, greasy-haired broad with three teeth- all rotten- try that on me once. She pushed her daughter into Triage in a wheelchair and started barking orders at me- (I imitated the broad's cigarette-ravaged, slobber-flinging voice): 'My daughter has a history of seizures and needs Ativan STAT!'"

"Oh, no!" Melanie said, covering her mouth in horror. "Please tell me she didn't really say 'STAT!'"

"Nope. She really said 'STAT'."

Melanie threw her head back and laughed. She had a really cute, bubbly, disarming kind of laugh. I continued:

"And all the while, my dear colleague, this beast was taking every opportunity to wave her grotesquely huge chest at me to show off her MOON VALLEY SEARCH AND RESCUE sweatshirt," I said with a chuckle.

Melanie laughed and slapped her thigh.

I continued: "The woman just came unhinged when I smiled at her and told her, with all my genteel Southern charm, that I had bought that same shirt when I went on vacation at Moon River Resort!"

Melanie let out a squeak, her face red.

"And, AND, the daughter was totally faking her post-ictal symptoms, and she was reeeeeeeally bad at it. She would pretend to be all limp and unconscious with her head lolling around and her arms hanging over the sides of the wheelchair- even though she had tucked her elbows in when coming through the Triage doorway- and then every once in a while I would catch her opening her eyes and peeking at me to see if I was buying what they were selling. I caught her every time, and whenever I did she would sort of jerk a couple of times and go limp again..." I finished with tears in my eyes and my gut sore.

Melanie shrieked with laughter and stomped her feet.

"Oh gawd, yes!" Melanie said, wiping the tears from her eyes, and finally exclaimed, "Oh, I have one! Listen to this: About a year ago, I had a well-known drug seeker come in when I was working Triage. I am not kidding when I tell you that she weighed maybe a buck with lead boots on, and was seriously cachectic from years of poly-drug use. If you took all the bad teeth in her mouth and put them all together, you might get the same aggregate mass as half of a good tooth. And she was wearing a GRAND CANYON SEARCH AND RESCUE tee shirt." Melanie broke into a fit of laughter, then continued: "This woman was so tweaked on meth that she practically vibrated herself to the triage desk."

"Yeah, kind of like those old football game toys where we would put plastic football players on a metal table and flip a switch, and they would vibrate across the table," I offered.

Melanie looked at me strangely. "Oh, yeah. That was before your time..." I said sulkily. Melanie patted my knee sympathetically and gave me an 'It's okay, you poor old demented man' look.

"Anyway," Melanie pressed on, "This woman came up to me and actually shoved her nasty old shirt into my face, and identified herself as a SAR team member. She then gave me this story about someone breaking into her truck and ransacking her first aid kit, taking all the morphine and demerol. She actually ordered me to provide a replacement supply!"

I dropped my jaw in shock. "No way! She really expected you to believe her?"

"I'm not kidding, sweetheart," Melanie said. "She actually thought that she could get away with it. And you know what the really funny thing was?"

"No, what?" I asked.

"She was in three days before that and told us that she was new in town and was out of pain meds. She's lived in this town her entire life! But she wore sunglasses and a black wig to try to disquise herself. And a few days after the SAR thing, she came in again using the same out-of-town story."

"Wow. That's really, really... sad." I responded with a twinge of empathy.

"Yeah, you're right," Melanie said with a sigh. "It's sad. But you know what? It's also really, really dumb. We give them all kinds of resources to get clean. Our social workers bang their heads against the wall trying to make something happen for these people. I don't know how they come up with half of the resources they find. But these people, the really hardcore ones, don't want to get clean. They abuse the system, they bounce from ER to ER, they make up stories, and they spit in our faces when we give them what they need instead of what they want. And then, they have the audacity to show up in Triage a week later. Doesn't it drive you crazy sometimes?"

"Yeah, sometimes it does," I replied. "But ERs are beginning to wise up. I don't know about this ER, but my ER began to address it about a year ago by way of a standing policy that requires doctors to cease arbitrarily giving narcotics to drug seekers 'just to get them out of there,' and dictates that the first-line treatment be through non-narcotic medications that have proven to be effective for the same types of pain. We have seen a huge drop in the number of chronic patients who used to come in sometimes seven or eight times a month fully expecting- even demanding by name- narcotics for their pain."

"Hey, we started doing that about six months ago," Melanie said. "Many of the 'frequent flyers' stopped coming because they got genuine relief from their pain without narcotics, and they went to their doctors with this information. We got a 'Thank you' note from one of them. It was really nice. The others stopped coming simply because we stopped giving them narcotics. Whatever the reason, that's one less major drain on our healthcare system, and that will help to make healthcare less expensive for the rest of us."

"Amen, sister," I said.

Redirecting the conversation, Melanie asked, "Speaking of pain: How bad is the pain in your toe?"

"Bad enough for an ER nurse to decide to come in and get the toenail drilled," I answered in total seriousness.

"Hmm, yeah. I believe you." Melanie scribbled some notes on my chart and stood up. "Is your tetanus up to date?"

"November of 1999," I answered. "I'll renew my subscription at home, if you please. Driving with a bum foot is one thing; Driving with a bum foot and sore arm is another."

Melanie laughed again. "Okay. Just don't forget."

"I won't. I promise."

"Okay. The doctor will be in in a few minutes to do the deed."

"Yay."

"I'll be back in a little while, friend. Can I get you anything else in the meantime?"

"A stunt toe would be nice."

"Hah, hah. Back in a few." Melanie spun on her heel and exited.

A minute later, the doctor came in with a thermal lancet and a vial of lidocaine.

"I heard that you are an Emergency nurse. So I assume you are familiar with this procedure," the MD declared. I eyed the vial of Lidocaine with honest trepidation.

Clearing my throat, I answered, "Yes. You will perform a digital block on the toe and then perforate the nail with the thermal lancet. I am to keep the toe clean and covered with a gauze dressing and observe for signs of infection."

"Okay. Let's do it." The MD drew 5ml of Lidocaine from the vial, cleaned the proximal metatarsal phalanx with betadine, and spoke the ritual words: "Okay, you'll feel a stick and a burn..."

Oh. My. GAWD.

Let me tell you: I have had fingernails ripped out by towing hawsers, dislocated my fingers, fractured my ankle, and broken my nose. That was all tickle torture compared to this. I was ready to confess to everything from the Lindbergh baby kidnapping to being Paris Hilton's publicist just to get this guy to stop. Lidocaine H-U-R-T-S! I bit my lip so hard it bled. I was not about to cry out. I had a reputation as a badass trauma nurse to uphold, after all.

When he was done torturing me, and once I had regained consciousness after my vasovagal reaction, the MD smiled and said, "That went well."

"Oh yeah, doc. Piece o' cake." My head plopped back down on the sweat-soaked pillow.

The MD pulled out the thermal lancet and said, "Let me know if this hurts" as he lowered the tip to my toenail.

"Doc, compared to the digital block, this is nothing."

I did not feel a thing as the lancet hissed against my toenail, and I could not even express relief when I knew that the pressure had been dramatically relieved. I just did not feel it. Talk about anticlimax...

Melanie returned and gently applied a dressing to my toe. I was then shipped off to x-ray to rule out a fracture. It turns out that I did break the damned thing. So Melanie again gently buddy-taped my great toe to my second toe. She did a fantastic job of it. Returning with the discharge instructions, she advised me to keep the foot up as often as possible. I laughed and told her that I was scheduled to be in Phoenix to see some family later today.

"Cancel." She commanded. "You'll be really sorry if you don't."

I pled my case (that is, I sniveled): "But Melanie, dear girl, I only have my room for tonight. Every hotel in town is booked solid today. I really have no choice."

Melanie paused for a moment, then said, "I'll be right back." She got up and left the room. Melanie returned a few minutes later.

"My husband says you can stay with us for a day."

I was stunned. "Are you sure? I mean, you don't even know me! And I snore."

"I have four older brothers," Melanie replied. "I know all about snoring. Besides, judging from that ring, you're obviously married. We both have pistols, my husband was a linebacker in college, and we outnumber you." Looking at my wounded toe, she concluded: "Anyway, we could probably outrun a broken-down old gimp like you on our hands and knees."

"Wow, I'm touched, Melanie," I said drily. Pondering my plight for a moment, I finally surrendered. "You know you don't have to do this. I really don't know how to thank you."

"No worries. I trust you and your wife would do the same for us if we were in the same jam."

"Yeah. You know, we actually would," I said with complete certainty of my wife's amazing generosity.

"Okay. Let's check you out of here. Go back to your hotel room and grab some sleep for a few hours. My hubby and I will meet you there when we get off, and you can follow us to our place. I expect you to keep off of that foot for a full day."

"Fair enough." I gave Melanie my hotel name, room number, and cell phone number just in case they changed their minds. I drove back to my room and zonked out until about 8AM, when Melanie and her husband (a Critical Care nurse)collected me and made me feel at home on their couch after stuffing me full of one of her husband's delicious Southwest omelettes.

God wraps His arms around knuckleheads like me, sometimes. And next spring, our dear new friend Melanie and her husband will be staying with my wife and me for a few days of Pacific Northwest sightseeing.

Ya just never know what the day will bring...

Road Fest, Part 3: The Drive Across Mars

Fallon, Nevada to Kingman, Arizona:

I have been all over the world, and have seen some interesting terrain in my travels. But the landscape of western Nevada was just, well... eerie. The outside temperature was 110 degrees and rising, and it was only mid-morning. I had cast a lot of glances out of the side windows for the first 100 miles of this leg, but as the environment became more barren and forbidding, and the atmosphere thinner and drier, I found myself retreating inward with a strange sense of isolation and vulnerability. And that only caused me to become more aware of my injured toe, which seized upon the opportunity and commenced to hurt like hell since it had no competing distractions.

I concluded that whatever it was that pressed down upon me and triggered my brooding thoughts, it was certainly not the sense of being at great personal peril. Having nothing better to do, and rather desperate to get my mind off that damned throbbing toe, I cast about for a single word that most accurately described the sterile nothingness across which I drove. Looking out at the vast, gray-brown, treeless valley over which loomed a jumble of distant hazy and sinister-looking mountains, I found the word: Desolate. All that was needed was a big sign that read: SAURON WAS HERE.

I nodded to myself. "Desolate" covered it. I sped up a little without really thinking about it, and yelped a startled Whoops! when I looked at the speedometer and found I had reached 110mph. I prudently curbed my urge at that point-I say prudently, because as I rounded a curve at a more sensible speed I passed a Nevada State Trooper going the other way- a trooper who was clearly giving me the Evil Eye as we neared each other. I guess a lot of drivers get a little "goosey" out here. I took a deep breath and shook off the spookies as I pulled into Hawthorne.

Hawthorne, Nevada: an idyllic paradise where one can find a girl behind every tree- provided one can actually find a tree. The place is notable for being home to a US Army munitions factory and depot. I imagined that its placement in the middle of frigging nowhere was probably due to the nature of the munitions being produced. Just a guess, mind you. But think about it...

I gassed up, grabbed some hot chow and high-tailed it out of town, eager to get to my next stop on this traveler's paradise: the teeming metropolis of Tonopah, home of the Fighting Muckers. (It's a good thing that the sign over their high school wasn't painted by a person with dyslexia.) Tonopah is basically Nome, Alaska at 6,100 feet above sea level: Dusty, tiny, and wind-swept. Except for being about a hundred degrees hotter, I could swear I was in Nome again. (I made a vow that the next time I saw Nome, it would be through a bombsight. But that's another story.)

I had droned through half of my day already, and I felt somewhat peeved that I still had a long, long way to go to get to Kingman. This would not do; it was time to push things a bit. When Tonopah had vanished from my rearview mirror, I decided to see if Baby-san felt as inclined to kick up some dust as I did.

She did, in fact, feel so inclined. I accelerated through to fifth gear and when I hit a long, long straight stretch, I gradually opened her up as fast as I dared. My engine has a rev limiter at 6,000 RPM, and I buried the needle at 120MPH before I hit 5,000RPM, and I was still accelerating. In this realm of her performance envelope, Baby-san's voice was no longer the sultry resonating rumble for which I loved her- it became a malevolent, tooth-rattling bellow that vibrated the mirrors and drowned out all thought. From this, I understood her answer to be It's about damned time, loverboy!

Having successfully scared the crap out of myself, I backed 'er down to just under 100 and started breathing again.

The Pirellis were loud as hell at this speed on the baking asphalt. They were nice and hot and sticky. Baby-san and I ripped through the gently banked curves and long straightaways, howling through unpopulated central Nevada like a hellbent banshee. I flexed my fingers around the wheel and, wearing a truly wicked grin, danced with Baby-san right along the ragged edge.

I reeled in my evil twin long enough to gas up and snack in Death Valley, and then let him out to play some more until a little north of Nellis Air Force Base. I droned on into Vegas at a sedate 90MPH, but sensed from the number of cars that passed me that I was actually being a little pokey. Still, I felt that I had tempted fate sufficiently for one day. Deafened slightly from the engine noise, I stopped to recover and eat at Vegas before heading to the second item on my list of Landmarks I Have Never Seen Before (Lassen Peak was the first): Hoover Dam.

It was really big. I took lots of pictures. My foot hurt a lot. Okay, time to go.

The drive to Kingman took place as the sun began to descend towards the horizon. The desert was a most incredible shade of red, the sky was clear, and my backside was ready to call it a day. My injured left great toe was beginning to throb from being in a dependent position, in spite of the ibuprofen and tylenol. I was ready to be done.

I pulled into the hotel, paid for the room, then went across the street to a Sonic Drive-In that beckoned me. I gorged myself on a coney, fries, sundae and root beer. I ate at an outside table, massaged by a hot desert breeze as I watched a distant thunderstorm light up the eastern sky, it's towering cumulonimbus clouds painted a shocking pink by the setting sun.

I hobbled back to my room and examined my seriously hurting foot. The toe was bruised and swollen. I took some more ibuprofen, applied ice, propped my foot up and I pulled out one of the bottles of a very potent Belgian ale I had stocked for the trip and pulled out my laptop to post my experience. At that point, I discovered that the infernal thing had decided to eat its operating system and become an expensive paperweight. Cutting my losses, I pulled out my summer book and was asleep within seconds.

Road Fest, Part 2: Beth, and the Entrance to Nowhere

I had not slept so well in years. It was the kind of deep and dreamless Rip van Winkle sleep from which one awakens with the impression that no time had passed at all. The first objective data to the contrary was presented by the merciless blaring of the alarm clock in my hotel room. My eyes snapped open and I fumbled hastily across the unfamiliar, darkened room with a single-minded determination to stop that damned bleating instrument of chaos and evil. It was during this effort that I encountered the second (and far more effective) means of ensuring that I was awake, in the form of the chair leg against which I struck my left great toe.

Oh yeah. I was awake now.

I held my afflicted foot and spoke the Official Ritual Chant for Toe Trauma (Ow, ow, ow, oh crap ow) for the prescribed minute, then tearfully crawled the remaining distance to the source of that hellish squawking. I dragged myself up into the chair whose leg had caused me such woe and sorrow, and with some trepidation turned on the light to assess the extent of the damage. I noted some stiffness to the toe and mild pain with articulation of the joints, and gingerly palpated along the digit to assess for deformity. While still exquisitely tender, the toe and nail seemed otherwise intact. I knew that even if the toe was broken, so long as no deformity was present the course of treatment was the "I-Cubed" method: Ice, Ibuprofen, and Immobilization. And if the toe continued to swell under the nail, I would do as we do in the ER: Puncture the nail with a sterile object, apply a sterile dressing, and keep the offending digit clean.

I hobbled to the ice machine with a sandwich bag, returned to the room, popped 600mg of Advil, carefully buddy-taped the first toe to the second toe (leaving a little room for swelling), put my foot up, and applied the ice pack. I spent the next twenty minutes cursing that damned chair and watching an inane infomercial about some device that promised to be the "next revolution in potato peeling." The product was all chromed-up and slick-looking, but I felt no compulsion to buy it. The man demonstrating the device was loud, and his behavior led me to suspect that he was on the manic swing of his bipolar disorder. The token well-endowed, mini-skirted female co-host, however, was serious eye-candy (if they were real, they were spectacular). Now if she had been demonstrating that device, I'd have been more interested...

Twenty minutes later, I reassessed the toe and became reasonably certain that I would indeed live. I got dressed, got my stuff together, checked out, and loaded up the slumbering Baby-san. She started with a throaty, popping snort (her way of saying, "What- already!?, I guess), but quickly warmed up to a low and pleasant rumbling purr that told me, "Alright, darling, I am ready for you now."

I pulled onto Susanville's main drag as the eastern sky was just beginning to pink up, and I made my way to an open local restaurant for breakfast. After being led to my booth by a tired man, I pulled out my map, calculator, notebook and pencil, and set to rechecking my route. Country music played softly in the background. It was the perfect soundtrack for the open road. I smiled to myself as a fortyish, suntanned, brown-haired, attractive woman approached me. She tilted her head, observing my navigational efforts.

"Hi, my name's Beth and I'm your server," she began as she gently placed a cup of seductively aromatic coffee before me. "Where ya goin'today, hon?" the waitress inquired with a cigarette-husky voice a la Julie London.

"Well, hello Beth," I responded. "I'm driving through Nevada to Kingman, Arizona."

"Wow. That's a lonnnnng day right there, hon."

"Yeah, I figure about twelve hours..." I replied tentatively. Beth stepped back, placing her hands on her hips as if to preparing to deliver a Great Truth.

"Ya got kids? Make it 14 hours if ya got kids," Beth advised with empirical certainty. "Kids always slow ya down..." she said, her voice trailing off. I looked up at her. She looked weary, and the lines around her mouth and eyes bore evidence of a tiresome life. Every human is a saga, I thought. I shook it off and decided to steer the conversation toward a more positive region.

"Actually, I'm driving solo," I said with a boyish grin.

"Are ya?' Beth asked with a frown as she scrutinized me down the length of her straight and narrow nose with searching eyes. She again placed her hands on her hips and concluded, "Hmph. One of those 'finding yourself' things, huh?" Wow. Cynical too, I thought. This may take some work.

"Not really," I replied with my best and genuine you are important to me smile. "It's more of a 'driving a fast car as far as I can go in two weeks' kind of thing."

"Ahh..." the cynical waitress replied as she scrutinized me again. Looking out the window, Beth jerked a long-nailed thumb toward Baby-san. She asked, "That your car out there?"

"Yes, it is," I answered with the enchantment of a twelve-year-old boy who had just discovered that girls are pretty damn cool after all.

"Niiiiiiiiiiiiiiice," she said with a slow, approving nod. She paused for a second and concluded, "Hmm. Make it maybe ten hours. Just watch out around the border and around Vegas, sweetie. They love guys like you."

"I'll do that. Thanks, dear girl." I gave Beth a sincere and wide smile and she seemed taken aback. She finally responded with her own quite lovely, warm smile and retreated with my order in hand and a stride that would evoke, from a single man, a Pavlovian drool.

I ate at a leisurely pace (while Beth doted upon me with her wonderful coffee and attention) and revised my fuel stops based on yesterday's mileage data. (I was pleasantly surprised with the discovery that in addition to being sleek of beauty and menacing of voice, Baby-san had herself some nice, long legs.) After finishing my breakfast and my calculations (remaining conservative on the issue of travel time despite Beth's assurances), I dropped a big tip on the table and walked up to the cashier's counter where Beth met me.

As she cashed me out, she offered her hand and said, "I'll be praying for your safety, darlin'. You be careful, you hear?"

I took her hand, shook it, and replied, "I promise, Beth. Thank you for your hospitality." She smiled a distinctly un-cynical smile, gave me a pat on the shoulder, and retreated to the kitchen with that drool-inducing stride.

Ahem.

The eastbound approach toward Reno on Highway 44 was a perfect warmup stretch. The highway snaked down from Susanville into the light-brown, gently rolling hills below and provided long straight sections and pleasant banked curves that were taken with ease. I suspected that this was a section of road worthy of Beth's warning, which called for a light foot on the accelerator. My hunch was confirmed by the good half-dozen hapless speedsters pulled over by CHP and NSP troopers between Susanville and Reno. Nodding in self-congratulation (and silently thanking Beth for her generous advice), I rolled merrily along at a prudent speed into that garishly-lit oasis that attracted so many seekers of unearned wealth, night-of-passion weddings, and morning-after divorces. Feeling neither the need nor the desire to stop at Reno, I pressed eastward on I-80, and then on alternate Route 55, toward Fallon.

At Fallon, I prudently checked the air pressure in the Pirellis and made sure that the engine oil, coolant, and belt tensions were all satisfactory. The prospect of having a breakdown along the next leg, which ran through a very hot and unforgiving bunch of real estate, did not appeal to me. I topped off the gas tank and stocked up on nonperishable foods and a flat of bottled water (just in case the unthinkable occurred). My cell phone had a full charge, I had a disaster survival backpack in the trunk (as I always do), and I was as ready for the run down Highway 95 as I would ever be. I felt a little knot of tension as I gave sober thought to the possible problems and incidents that provoked my preparation for the worst. At 0900 the temperature was already well past 90 degrees, and it was expected to reach 115 before noon along my route.

But at the same time, I felt a bit of that long-exiled, youthful adventurer awaken in my soul. It was that same thrill that drove me to spend nearly a decade on the sea just to see the sea. It was kind of like the old cliche of having an angel on the right shoulder and a devil on the left. I compromised between the two, pressing on with nervous excitement while taking every precaution. That's the nice thing about being my age; I'm young enough to stand on the edge, and old enough to know when to step back and just appreciate the view.

With a preparatory sigh, I strapped on Baby-san and launched with a roar, leaving Fallon- and civilization- far behind. Settling myself into my seat, I took a deep breath and let Baby-san go free. Cruising at 90MPH in 5th gear, the engine was barely touching 2,250RPM. The noise was deep, entrancing, and consuming. The car seemed to take the curves of her own volition, as if my control of her was merely an allowance. I surrendered to her as she enticed me into the barren, forbidding wasteland of Western Nevada...

McCain Selects Alaska Governor Palin as VP Candidate!

Those of you who have known me over the years also know that a couple of years ago I decided to avoid discussing politics on my blog. I do not regret my choice. I much prefer- and fully intend- to keep the tone of this blog as apolitical as possible. I am a staunch conservative (most ER nurses are), and I thrive on open discussion. I have learned far more from you and about you, dear readers, through my current format than I ever would have by maintaining this blog's former, confrontational.

But Senator McCain's choice of Alaska Governor Sarah Palin as his Vice Presidential candidate has really piqued my interest in the election, and I would like to share my thoughts with you and also to know your thoughts on the matter if you choose to share them. I promise that politics will not be a frequent issue of discussion here, and will return to the standard format after this brief interlude. So without further ado, here are my thoughts:

The selection of Gov. Palin was a shrewd move on Sen. McCain's part. He has just accomplished in one bold swipe what some say the Democratic party has just failed to do- create a ticket that can electrify and unify the party and boost support for a run to the White House. I disagree with most of Sen. McCain's ideas (McCain-Feingold, McCain-Kennedy, the Gang of 14, etc.), and I am not a fan of his, but I have to admit I think that that he and his staff have pulled off a masterful coup. I also must admit that before today, I had pretty much written off the Republican Party as a total loss. By choosing Gov. Palin as his VP candidate, Sen. McCain (of all people!) has caused me to wake up and pay closer attention to what is going on. That in itself is a good thing anyway.

The irony alone of Sen. McCain's choice is delicious. Follow along:

Senator Obama, running on the platform of being a Beltway "outsider," nevertheless picks one of the most notorious Beltway insiders to be his VP, publicly clotheshangs a popular female candidate, and exacerbates the division within his party in the process. Of even greater import is that Sen. Obama has never even been mayor of so much as an unincorporated hamlet, and yet he wants to become the most powerful man in the free world.

On the other hand: Sen. McCain, accused of being a Beltway insider (hard to argue that point) reaches over the crowd of established (and jaded) GOP old guard -who are viewed with distrust and even contempt by most Republicans and Americans after the Great Elephant Sellout of 2005- and plucks a ripe plum from the outer fringes of the orchard.

And two things are particularly striking about this choice: (1)Gov. Palin is decidedly NOT a Beltway insider; (2)Gov. Palin has far more executive leadership experience than Barack Obama has. Of much less material consequence, yet compounding the irony, is the fact that Gov. Palin also happens to be a woman. And did I mention that Gov. Palin is a conservative? Did I also not yet mention that Gov. Palin has accomplished what our Congress refuses to do- pushing ahead with opening up petroleum (natural gas) production and transportation?

Anyone- from either side of the aisle- who harps on Gov, Palin's "inexperience" forgets the fact that the Sen. Obama has (1)never even been a mayor; and (2)never governed a state. And I would wager that Gov. Palin has probably accomplished more to the benefit of her state constituents than Sen. Obama has for his own. It will be interesting to see how this plays out.