Koru: Abuse, Incompetency, and Greed in the Healthcare System. a Memoir.

by Elize Kelly

Preface

I ended my 34 year nursing career at age 56. I always intended to work longer, well into my 60's. But the bullying and cruelty common in the health care industry eroded my passion for doing nursing until nothing was left. I share with you, dear reader, my memories, the vignettes of my life, piecing together the story of the last eight years of my career. I start my memoir by telling you about me, about who I am and how I react to life, so you can better understand what happened and why I made the choices I did.


This memoir is dedicated to Kent

Koru:

The Koru symbolizes the way in which life both changes and stays the same.

per The Encyclopedia of New Zealand

Quote Page:

" The unwritten rule I'd broken was a simple one: You really weren't supposed to write honestly about people in power. Especially those the media deemed untouchable....

You're supposed to keep the myths going."

from Michael Hastings' book "The Operators: The Wild and Terrifying Inside Story of America's War in Afghanistan"

"Truth is like poetry and most people fucking hate poetry."

overheard in a Washington D.C. bar by Michael Lewis, author of "The Big Short"

Disclaimer:

This book is a memoir. It reflects the author's present recollections of experiences over time. Names, characteristics, geographic locations and other identifying details have been changed, some events have been compressed, and some dialogue has been recreated. Any resemblance to actual persons, living or dead, events, or locales is entirely coincidental.

Koru: Abuse, Incompetency, and Greed in the Healthcare System. A Memoir.

I ended my 34 year nursing career at age 56. I always intended to work longer, well into my 60's. But the bullying and cruelty common in the health care industry eroded my passion for doing nursing until nothing was left. I share with you, dear reader, my memories, the vignettes of my life, piecing together the story of the last eight years of my career. I start my memoir by telling you about me, about who I am and how I react to life, so you can better understand what happened and why I made the choices I did.

Part One

TWO ROADS DIVERGED

I turned over in bed, my eyes slit open, and I realized that it was 23:59. As I blinked, the clock turned to 00:00. How many new days had I seen? In the blink of an eye, sleepless nights turned into years. As I stared at the illumination, it changed to :01. Then, :02. And I put my hand over my eyes to black the quiet room.

Life is a series of decisions. Even doing nothing is a decision. The familiar lines of Frost's poem "The Road Not Taken" came in my mind, and as I whispered the beloved words into the dark, my eyes moistened and my chest ached. "... I shall be telling this with a sigh somewhere ages and ages hence. Two roads diverged in the woods, and I, I took the one less traveled by. And that has made all the difference." All the difference indeed. As I finally fell asleep, I thought back over the last few years, back to a warm sunny autumn day in a land far away.

New Zealand

I turned southwest, the morning sun bright behind my left shoulder. I glanced to my left as I drove, watching the ancient volcanoes of the Banks Peninsula recede in the distance. I looked that direction as often as I could, not wanting to lose sight of them, not wanting the moment to pass. They rose majestically up from the rolling plains around Christchurch, up from the blue Pacific, and I smiled as I remembered that I was riding a bicycle on them just a couple of days prior. Now that was some ride, hilly and strenuous. I was pretty fit, but I had to stop a couple of times during that bike ride to walk it.

I had an appointment with the director of Human Resources the next day in Kauri, a smallish town along the coast. When looking online for nursing positions available in New Zealand, the director of Human Resources was the one who advertised to the world that he would consider foreign graduates. Not everyone wanted to hire someone from another country. I guess they worried that we would act like we knew everything; perhaps some foreign graduates thought that. Or perhaps they were concerned that they would not commit to staying. I didn't know. But my intention was to live in New Zealand.

Why New Zealand? Why did I feel drawn there, like new lovers to that first kiss? New Zealand first came into my consciousness about 15 years prior, when my ex-husband surprised me by saying that he would like to go on vacation to New Zealand. He said that New Zealand was the only country that he wanted to see. That was a big deal coming from a man whose idea of a vacation was traveling to the back yard with a beer.

But he and I never went, and I had always wanted to see more of the world. So after our divorce nine years prior, I decided to see what New Zealand was all about. I booked a five week trip, which included a couple of weeks on a bicycle tour of the South Island. For the other three weeks, I was just spontanoues, driving myself as many other places as I had time to go. I fell in love with the beauty of the country, and with the friendly, independent, outgoing people.

For the previous 20 years, I had been traveling regularly with family and friends, mostly sans husband. For the eight years after my divorce, I had been traveling continuously. For those eight years, I had been traveling in the United States for my work, and I had been traveling to foreign lands for fun.

Along the way, Kent and I met. I was not too long off the divorce when we met, so made it clear that I was not interested in a settled relationship. Our relationship started purely as friends, emailing, instant messaging, and calling. I figured he was at a safe since he lived far away in Canada. But as time passed, we decided we liked each other and wanted to be together more. Years later, we are still in our monogamous, long distance relationship. He is my best friend.

I had traveled all over, mostly with Kent but many times on my own, and of all the places I had been, I liked New Zealand the best. New Zealanders are also called Kiwis, nicknamed after a bird of the same name which is found only in New Zealand and which is their national symbol. I liked the Kiwi people, how they looked you in the eye when they spoke to you. I liked their honesty and their trusting nature. I liked that materialism did not seem to have the same priority with them as it did in America. New Zealanders seemed to appreciate people who worked hard, and I had always worked hard. I hoped I had some quality which I could contribute to their society.

I liked that in New Zealand there were less people everywhere. There was an outdoor, rugged feel to the country which reminded me of the frontier mystique that I admired. It felt familiar. I liked that the infrastructure was similar to America, which made me think that I would be able to function. I liked the wide variety of geography in the country, from the rain forests, glaciers, fertile plains, and mountains of the South Island, to the mud pots, fumaroles, mineral colored lakes, and volcanoes in the North Island. And the beaches! The beaches everywhere were stunning. I could live my life on a beach, barefoot every day.

It was also helpful that Kiwis spoke English. Learning new languages had never come easy for me. Although I had taken numerous Spanish classes, I laughed when I told people I remembered only enough Spanish to get me in trouble. And although I had taken a extended German language course, in Germany no less, I only knew enough to get around in Germany, picking out words and guessing at the rest.

New Zealand felt like it was growing, becoming, full of energy and enthusiasm, and I wanted to be a part of that. I wanted to live the rest of my life in a country that was young, where the air was as fresh as the fruits and vegetables. Where I had optimism and hope for the future. I had such a bleak view of America's future.

Why did I think I could manage the transition? I knew it was no small thing to move to another country, to pack up, pay the expenses, leave friends and family, find a new life in a new place. But I had been enough in Europe, Russia, and Canada that I had a good idea how to adapt to get my basic needs met. I had traveled to so many places over the last eight years, that I was pretty familiar with the emotional transition to acclimate to a new culture and environment. And, importantly, I knew how to take care of myself.

Was I afraid? Yes, sometimes, but not enough to paralyze me. So as I drove in the left lane to this interview on the other side of the world, I felt more excitement than anything else.

If I was concerned about anything, it was how I would be treated as an American. I knew the Kiwi philosophy of peaceful coexistence on this planet, and I knew of their opposition to American aggression. Would this antipathy be projected onto me? Would I constantly be harassed even though my views were similar to the Kiwi perspective? I wanted to be seen for what I was. I guessed, I hoped, it would be like the times when I worked in the northern United States. My southern roots were evident as soon as I opened my mouth to speak. Familiar to me was the northerner's perplexed face, as it's owner reconciled my southern twang with signs of an advanced education. But once people got to know me, they realized I was decent at my job. So would the Kiwi people stereotype me as a typical American? Probably so. It's human nature. But hopefully that would change once they got to know me.

Would I want to come into a place of employment and force my American view on it? Absolutely not. My goal was to adapt to, and to learn from, the local ways of doing things, as I always did when I went to work in a new hospital in America. If they wanted my help, if they wanted my ideas, I would be happy to pass it on. But I was not a brash and aggressive American, and I did not want to be seen as such. In fact, I thought of myself as having a gentle soul; I still do.

Every Heartbeat and Every Breath

What was my work that I could even think of such a change? I was a nurse, and most countries in the world, including New Zealand, needed nurses. And I was a locum tenen, Latin words which I personally thought sounded pompous, but which was the common way to say that I traveled for my work. And I was a Nurse Anesthetist. I had a background in Intensive Care, and had continued my education to become an Advanced Practice Registered Nurse (APRN) specializing in anesthesia. Specifically, I was a Certified Registered Nurse Anesthetist (CRNA). So to put all that together, I was a CRNA who contracted with hospitals around the United States who were short anesthesia providers, and who needed some temporary help.

Many types of APRN's exist in America and in the world. An APRN is a nurse who has gone beyond their baccalaureate degree to obtain postgraduate didactic and clinical skills. They use their knowledge, skills, and experience as a specialist or a generalist to improve patient outcomes through critical analysis, problem solving, and evidence based decision making. There are four basic types of APRNs: Nurse Midwives, Clinical Nurse Specialists, Nurse Practitioners, and, of course, CRNAs.

When I was in anesthesia school, I heard about locum tenen work, and immediately thought "That's for me !" I was excited about the idea, thinking how fun it would be to be able to work and travel at the same time. But while I was married, that lifestyle was not possible. Two weeks after my divorce was final, though, I started my locum tenen life, with my first contract being in Alaska.

In the divorce decree, my ex-husband got the house, the boat, the land, half the household stuff and furniture, and his car. I got $75,000 of his retirement, the other half of the furniture and household stuff, and my car. I put all the stuff in storage, and I sold the car. I figured some day I would settle down again, buy a house, and need stuff. I rented a climate controlled storeroom near where my parents lived. I set up the front of the storeroom with closets and my dressers so that between jobs, I could unfold my luggage and unpack. Then everything would be handy when I needed to pack up to be off again. Every year, I had averaged being "home" only about six to seven weeks. That was long enough to check on my aging parents without my being too much under foot. It was a good situation for all of us.

When I was in the United States, I contracted my anesthesia services to hospitals which were in need of anesthesia help. I had worked at 26 different hospitals, all around the country, so I had seen a lot of different ways of doing things. Thankfully anesthesia was anesthesia, and that right there was the reason that I could travel for my work. But saying that, there were some interesting regional differences. How things were done, the "culture", varied with different operating rooms and anesthesia groups. One hospital might prefer one muscle relaxant over anther. Some hospitals placed endotracheal tubes in all their patients, while others used a Laryngeal Mask Airway, or LMA, any time they deemed it's use was safe. Equipment varied, depending on the supply vendor. Some anesthesia groups had the latest anesthesia machines, with the most current technology, and others had machines which were so old you couldn't even get parts for them anymore.

Also, something which was amazing to me, patients varied in how they reacted to certain medications. In one part of the country, I needed less or more of a dose to achieve the same effect as in another part of the country. I had never heard anyone comment on this, and so I had no proof or research anywhere. Perhaps the only reason why I was unique in observing a trend is because I had given anesthesia in so many different locales. Maybe the reason for the variations was simply how the medications were stored in the different pharmacies, or how they were shipped to that hospital. I didn't know. But I had definitely noticed the difference, and so had to adjust my anesthetic doses accordingly.

Furthermore, certain regions of the country had a population who had more potential for unusual anesthetic complications. One example of this was a rare genetic condition called Malignant Hyperthermia (MH). MH is a hypermetabolic state which genetically susceptible people would experience when exposed to specific anesthetic gases and drugs. Patients experience very high body temperatures and muscle rigidity, and MH can be life threatening if not treated immediately. Thankfully, symptoms could generally be avoided if the patient made the anesthesia providers aware of either their familial disposition to MH or their personal experience with MH. One hospital I worked at recognized the increased genetic incidence in their community, so provided an anesthesia machine cleaned of all anesthetic gases. This anesthesia machine was kept to be used only for those MH patients. That was quite a commitment; anesthesia machines do not come cheap.

Nurse Anesthetists are trained in all kinds of anesthetic techniques, and work in any location where a patient needs anesthesia. We administer local, spinal, epidural, sedation, and general anesthesia, and we practice in physician's offices, pain clinics, outpatient surgery centers, small community hospitals, obstetric wards, large academic medical centers, the Veterans Administration (V.A.), and in public health.

Although many variations exist, Nurse Anesthetists generally work in three different ways: independently, in a solo practice; with other CRNAs, in an all-CRNA group; or in an Anesthesia Care team (ACT), with anesthesiologists. An anesthesiologist is a physician with advanced training in anesthesia. Even though Nurse Anesthetists are trained to work independently, the degree of independence between CRNA practices varies with each state's particular Nurse Practice Act or with military law.

The most common way Nurse Anesthetists function is in an ACT. In an ACT, the anesthesiologist "supervises" up to four operating rooms, with a CRNA in each room. I say "supervises" because the anesthesiologist is rarely in the operating room during the surgery. The anesthesiologist generally evaluates the patient preoperatively and comes to the operating room when the patient goes to sleep. Once the patient is under anesthesia, the CRNA watches the patient during the surgery and intervenes to keep the patient safe, but can call the anesthesiologist if they need an extra pair of hands.

Historically, the delivery of anesthesia in the United States was mainly a nursing function, with very few physicians training to provide anesthesia. But in the late 1950's and early 1960's, anesthesiologists came more into the picture. Anesthesia practice areas overlapped, and turf wars began between Nurse Anesthetists and Anesthesiologists. Physicians, amazingly, began to claim that anesthesia was solely the practice of medicine. To this day, they have continued to try to make it unlawful for CRNAs to perform anesthesia without the direct "supervision" of an anesthesiologist. They are perfectly happy for us to work, mind you, and to leave us in the operating room alone with the anesthetized patient, but they want to "legally supervise" us in that work, thus gaining a piece of our monetary pie.

It is important to note here that, currently, no state requires that CRNAs be supervised specifically by an anesthesiologist.

Licensing boards in America regulate professions, not activities. The Board of Medicine regulates anesthesiologists, not anesthesia, so when a physician administers anesthesia, they are practicing medicine and thus are regulated by their Board of Medicine. When nurse anesthetists administer anesthesia, they are practicing nursing and are regulated by their Board of Nursing. Similarly, when a dentist delivers anesthesia, laws state it is the practice of dentistry. The bottom line here is that there always has been and always will be overlaps in tasks between the different health care professions. A common example is the placement of a breathing tube into someone's windpipe, or endotracheal intubation. This task is done by dental surgeons, EMTs, paramedics, respiratory therapists, physician assistants, emergency room physicians, anesthesiologists, and yes, Nurse Anesthetists.

Law courts state that when they analyze whether a particular activity is within the scope of an individual healthcare profession, they focus on the statutory definition of that profession, and not whether the activity is included with other professions. Thus, If a task is within the scope of nursing, it is not important whether other professions are also permitted to do that task.

I often say that Nurse Anesthesia are one of America's most hidden professions. People know an anesthesiologist, but rarely do they know a Nurse Anesthetist. In fact, when a patient admits they know a Nurse Anesthetist, I am surprised and tell them so. And when those patients and family who are so inclined gather and have a "moment of prayer" before surgery, they ask God to bless the surgeon (always), to bless the anesthesiologist (almost as often as the surgeon), and to bless the nurses (often), but never, not once in my 20 years of doing anesthesia, has anyone asked God to bless the Nurse Anesthetist. I am not offended, mind you. After all, I am a nurse, so I am included in this prayer time. But it just goes to show how hidden my profession is from the greater part of an American's consciousness.

The ironic part of this is that over 45,000 Nurse Anesthetists administer approximately 43 million anesthetics to patients each year, according to a practice profile survey done in 2016. So the likelihood of a Certified Registered Nurse Anesthetist delivering a patient's anesthetic is high, but the patient doesn't know it.

When a layman asks me to describe my profession, I recite what I tell my patients when I work in an Anesthesia Care Team: "Hello. My name is Elize Kelly. I'm an Advanced Practice Registered Nurse with a masters degree and Board Certification specializing in anesthesia. I work with Dr. So and So, did you meet him? We do a team approach to anesthesia here at So and So hospital, so Dr. So and So and I will be working together to keep you safe during your surgery." I continue by explaining what a team approach is, saying that the anesthesiologist will be in the operating room when they go to sleep and would be available should an emergency should arise, but that "I will be with you every heartbeat and every breath".

The Traveler

So I was a locum tenen, locum for short. The locum life suited me then. I traveled to work, and I worked to travel. I liked to see the world, still do, to gain a greater understanding of its different cultures. I believed strongly that travel made you a better person, and I believed my traveling had made me a better person. I had a few favorite quotes about that topic:

The first quote, from St. Augustine: "The World is a book. Those who do not travel read only a page."

These two from Mark Twain: "Travel is fatal to prejudice, bigotry, and narrow-mindedness" and "Broad, wholesome, charitable views of men and things cannot be acquired by vegetating in one little corner of the earth all of one's lifetime."

This by Gustave Flaubert: "Travel makes one modest. You see what a tiny place you occupy in the world."

And another two by unknown philosophers: "Familiarity breeds myopia", which I often repeated, and "The clearest way to see home is to go someplace else and look back."

Truth, all of them. I had traveled so much, to so many places, that when asked where I had been to, I told people it would be easier for me to tell them where I had not traveled rather than telling them where I had traveled.

Jimmy Buffett's song "Changes in Latitude, Changes in Attitude" had become my motto song:

"I took off for a weekend last month

Just to try and recall the whole year

All of the faces and all of the places

Wonderin' where they all disappeared...

Reading departure signs in some big airport

Reminds me of the places I've been

Visions of good times that brought so much pleasure

Makes me want to go back again.

If it suddenly ended tomorrow

I could somehow adjust to the fall

Good times and riches and son of a bitches

I've seen more than I can recall...

I think about Paris when I'm high on red wine

I wish I could jump on a plane

So many nights I just dream of the ocean

God I wish I was sailin' again

Oh, yesterday's over my shoulder

So I can't look back for too long

There's just too much to see waiting in front of me

And I know that I just can't go wrong.

With these changes in latitudes, changes in attitudes

Nothing remains quite the same

With all of my running and all of my cunning

If I couldn't laugh I just would go insane

If we couldn't laugh we just would go insane

If we weren't all crazy we would go insane."

And I liked to travel around America. I had learned first hand that my country was a beautiful country, awesome in its grandeur and expanse, filled with different cultures and sub cultures. Cajuns of southern Louisiana spoke a French dialect similar to northern Maine-iacs. Northeasterners had a bewildering mix of kindness and turn-on-a-dime, in-your-face aggression. The polite genteel speech of a southerner became a cat spitting venom when a black person showed a hint of being " uppity". I had seen it. Racism is alive and well in America, my friends.

I liked to travel because I liked seeing what's around the bend, over the hill, around the corner. I loved to read, but I didn't want to just read about a place. I wanted to see it, hear it, feel it, breathe it, experience it. My first time seeing a glacier put a period on this, that you could not know a place just by reading about it. It so impressed me, that I then and there tried to write about it:

"First you notice the air; the air is pure. You know it is pure, pure like you have never known before. An ancient part of your genetic animal heritage recognizes the purity. The cold, the clean, the fresh, the gentleness flows around you, in your nostrils, in your ears, in your hair, down your coat collar, tickling your cheek. Have you ever seen such a blue? Maybe in the color of the rare person's eyes, or in the flash of the rare, clear, eastern sky, predawn, before the heat of the sun changes it. Then you hear it, and are almost surprised. It is alive, this mass of glacier blue. It creaks, groans, moans, then crashes to the ocean, suddenly, unexpectedly. It is moving toward you, but you wouldn't know this unless you were there, seeing the mountains of ice fall and crash, absolutely not caring what is beneath them. The pieces of ice, ancient ice that was last liquid thousands of years ago, flow away from its awesome power, crushed into slush or the size of small icy boats, returning to liquid again. The blubbery sea lions of these white icy boats laze in the sun, barely lifting their heads to recognize your presence, not caring, like the glacier beside them, of your existence."

Although I filled this description with flowery words and I humbly submit I did a decent job of trying to "put you there", reading about a glacier can not fully describe the experience of actually being in front of one. There are some things which the imagination is simply not equal to.

And I liked to travel not as a tourist, but as someone who lived there. I tried to do that not only when I traveled abroad, but also when I traveled in the United States as a locum tenen. I found where the best restaurants were. I was invited into the homes of "locals". I purchased a temporary membership at the gym. I rode the mass transit, took the bus, and drove aimlessly and spontaneously.

I saw the sights which people who had lived in one location their whole lives had not seen, their thinking they could see that sight another day. How many times had I heard, "Oh, you went to do that?! I've always heard it was pretty cool, but we've never gotten around to doing it." I did understand. I understood they were busy with their children, with taking care of a home, and with other everyday activities. I got it. But I couldn't help but think that they were missing out.

I set up my work contracts so I could be off for trips abroad, and I set up my trips abroad around my work contracts. It all fit together.... until it didn't. The hospitals hired me for my flexibility. They provided me a good hourly wage, a rental car, accommodations, and round trip airfare if needed. In exchange, I went when they didn't need me anymore. Generally, some hospitals had chronic shortages, so they kept me as long as I was willing to stay. Other times, they found someone local, someone cheaper, and so said bye bye to Elize. That only happened a couple of times though, thankfully.

I liked to work full time when I was not traveling to another country, and when a contract was cut short, it was quite inconvenient. It was pretty much impossible to find another job quickly; credentialing itself took forever, with the need for primary source verification on everything. Understandably, hospitals wanted to know that you were who you said you were and could do what you presented yourself as being able to do. They wanted documents from the source, and would not accept a copy of that document. So when a contract terminated before it was originally agreed to terminate, I found myself with no income. Since it didn't happen very often, it was not too much of a hardship. I had never lived beyond my means, depending on every paycheck. If I was dependent on every paycheck to pay my bills, I would not be a locum, that was for sure.

Long ago, I realized that people were on a continuum concerning travel. I had a favorite uncle who was far on one side of the continuum. He was born and raised, bred, fed, died, and buried in one county. He only went out of his home county a handful of times in his 83 years of life. He liked it that way, the comfortable familiarity of it all.

There are people on the far other side of the continuum, who wanted to do nothing but travel. They carried their few belongings on their back, traveling to different parts of the world as the wind blew them. Their guiding beacon was perhaps a quote from Tad Williams' book The Dragonbone Chair: "Never make your home a place. Make a home for yourself inside your own head. You'll find what you need to furnish it: memory, friends you can trust, love of learning, and other such things. That way, it will go with you wherever you journey. You'll never lack for a home, unless you lose your head, of course". I had been attracted to that guiding beacon, I could feel the lure of it in my bones. Wanderlust was strong in me.

But I was honestly somewhere in the middle of the continuum. And because of that, I had started to get the urge to settle again, to open boxes to remind myself what was inside, to look at my stuff again. It had been eight years since I had seen the back of my storeroom, and I was starting to forget what was there. Was New Zealand the place to settle and unpack?

One problem I had with traveling so much was keeping friends. Everyone had busy personal lives, and so it was difficult for them to find time to get together after work, to invest their personal time in someone who would be gone in a couple of months. And with so many people, proximity was key to keeping a friendship. Face to face interactions were essential. It was the rare person who could continue a friendship once the person was out of sight. Kent and I are two such people who could continue a friendship long distance, which was why our relationship had been able to survive, even grow, all those years. But for many people, the saying "out of sight, out of mind" fit.

When I traveled, I always met people with whom I felt a connection. Occasionally, despite their busy personal lives, we developed a budding friendship. But I would know that once my contract was finished, I would leave and it might be a long time before I saw that new friend again. Sometimes, I would never see them again. When I was new at traveling, leaving these new friends made me cry. I no longer shed tears. But I was feeling urges to make more long-term friendships again, and settling down in one place would help me do that. Was New Zealand the place to settle and make friends?

The major problem with my moving to New Zealand was that they did not utilize Nurse Anesthetists, which was quite a problem. In fact, no English speaking country in the world, except for the United States, utilizes Nurse Anesthetists. The United Kingdom, Canada, Australia, and New Zealand had based their Nationalized Healthcare Systems on the physician mode of practice, and APRNs were given a more minor role. And in the case of Nurse Anesthetists, they were left out all together.

I do wonder if these country's lack of fully utilizing APRNs was part of the reason why their nationalized healthcare budgets were under strain. You see, although we are some of the highest trained and highest paid nurses, we are still at least half the cost of a physician.

Anyway, I had made a good living during my 20 years of doing anesthesia. But I still had many more years of employment ahead of me before I planned to retire. If I did decide to move to New Zealand, I would move there not as an Nurse Anesthetist, but as a nurse, and my income will be fragmented. Also, it took a lot of money and was a lot of work, emotionally and mentally, to obtain my Certification in Nurse Anesthesia.

Besides, I honestly liked doing anesthesia. I loved putting all the pieces together to decide what was best for the patient. Anesthesia was like educated detective work, looking at the details and deciding a conclusion. For instance, vital signs, cardiac output readings, arterial blood gas levels, and electrocardiogram readings told me which medicines to give, how much intravenous fluids to administer, or what my ventilator settings should be. Or, the quality, color, and volume of the urine output indicated to me if the patient was dry, if they had good heart function, and if their kidneys were perfusing.

I liked doing anesthesia because I loved, after completing a long, deep anesthetic, seeing those beginning patient breaths without my help. I loved, as the patient woke up, to call their name and see their eyes open to focus on me. I couldn't imagine giving up anesthesia to go back to floor nursing, or to the Intensive Care Unit. Although I would have to give it up if I moved to New Zealand, I would not give it up lightly.

So I had been emailing people for months, planning the trip. I emailed about twenty New Zealand agencies, tying to find if there were any anesthesia jobs I could do. I emailed the Labour Department, the Board of Nursing, individual hospitals, the Department of Commerce, and several Medical and Anaesthetist societies. All of them said, without exception, that "anaesthesia is the practice of medicine, and is not open to nurses".

The only glimmer of hope was the contact I made with the Advanced Nurse Practitioner Society in New Zealand. The President of the Society said there were a couple of Nurse Practitioners who were willing to speak with me personally, to discuss ideas. So we had arranged to meet for coffee in Auckland the following week.

I did know that moving to a new country was like moving in with a person; you didn't really know if you would get along until you did it. You never really knew a person until you lived with that person. And so, you never really knew a country until you lived in it. I was a realist about that. So the trip to New Zealand was a fact-finding trip.

It was my dream to live in New Zealand, so I explored every option I could fathom to accomplish that dream. I decided I would first explore living and working as a part time employee, until I learned more about how my life would be in New Zealand. I thought I could possibly set up contracts in the States so that I only worked long enough each year to fulfill the requirements to maintain my Certification as a Nurse Anesthetist. Then work the remainder of the year in New Zealand.

I thought all those deep thoughts, and asked myself those deep questions, on my way to Kauri.

Spirits in the Air

Spirits were in the air the day that I arrived in Kauri. It was an intense, exciting day of magic.

I stayed in a hotel in Kauri which was located close to the hospital. The accommodations were very nice, with little kitchenettes, a washer and dryer in the complex, and quality construction. It kind of surprised me that such nice digs could be found in such a small town, but I thought the owners' market were those who needed a place to stay while a family member had an extended hospital admission.

I found the hospital easy enough, and went to find Tim, the director of Human Resources. He had temporarily stepped away from his desk, but the two people in the office were instantly friendly with me, and we were having a nice chat when Tim came back. Exchanging emails with Tim the last couple of months, I already liked him. He came across as professional, efficient, and intuitive.

Tim gave me the grand tour of the hospital. We saw the outpatient physical therapy services, the lobby area, cafeteria, etc. He showed me the intensive care unit (ICU) on the third floor, and I was able to visit with the nurses working there. I had been in a lot of ICU's in the States, and some were definitely nicer than others. But I was very impressed with how clean and professional everything was there, and how open the nurses were to my being there.

After leaving the ICU, Tim wanted to introduce me to an American physician working in the Emergency Room. The physician said she was contracted for a year in New Zealand, and was traveling the country during her time off.

Then we went to the Operating Theatre. Tim said another American was working there as the lead Anaesthesia Technician. First, we met the nurse manager for the Operating Room, who was from Scotland. She went to find Ron, the lead Anaesthesia Tech, to see if he was available. When he came, I asked him where he had lived in the States.

Ron said, "Alabama."

"Me too," I said. "Where?"

"Pulido. I used to work at the hospital in Pulido".

One thing led to another in the conversation so that I got a big surprise. Ron said he had first been a paramedic in Pulido, and had later taken a position as a telemetry technician, a person who monitors patient electrocardiograms in the hospital. I had been his boss ! He worked on the night shift during the time when I first became Head Nurse of the telemetry unit. We hadn't recognized each other, too many years had passed ! He said he had left the telemetry unit to go work in Saudi Arabia as a paramedic. There, he met a British woman, married, and they ended up in New Zealand. I was so amazed that I blushed scarlet.

After exchanging contact information with Ron, Tim walked me to the door of the hospital. I had told him before, but assured him again, that I was actively working to obtain my New Zealand Nursing License. We both agreed that it was a process, a process which took time.

As we were shaking hands in front of the hospital, he said, "Just let me know Elize what you decide to do. Anything you want to do, we'd love to have you here."

I decided to look around the town a little more before heading on with my trip. After driving around Kauri a bit, I settled at a coffee shop in the Central Business District, or CBD. I liked the feel of Kauri. It was busy during the day, and quiet at night. The town was tucked between the mountains and the ocean. It was a clean, medium sized town with an active sea port and with agricultural farmland and several large agricultural stations surrounding it. A station is basically a large farm dedicated to raising sheep and cattle.

I had a couple of spare days before my next appointment, and so I wanted to see if I could get to the very south of the South. That's the Kiwi way of saying the southern part of the South island. I hoped to make it to Invercargill, the most southern town in New Zealand.

But first, I wanted to visit the studio of a Maori artist who lived in St. Andrews, just south of Kauri. I had been to Peter's studio on my last trip to New Zealand, when my bicycle tour group had visited his studio high up in the Southern Alps, in a town called Otira. Peter had described to our group the histories and details of his Maori paintings. I had admired and often thought of one of Peter's painting, called "Ko Mauria", and I wanted to see it again.

Maoris are the indigenous people of New Zealand, and Mauria was a greatly revered Maori woman. I learned the Maori word "Ko" had no literal English translation, but Maoris often used the simple two letter word as before a proper name. When Mauria was alive, her nickname had been "Nanny".

The name Nanny was coincidentally the name my family had given to my dearly loved great-grandmother. Because of that unusual connection, I hoped to purchase a print.

His studio was right off the road. I could smell the ocean as I walked up to the door, although the flat landscape gave me no view of it. I was the only visitor in Peter's gallery during the hour that Peter gave me his attention; only one worker was present, helping Peter with the care of his studio. I did buy a print of Ko Mauria, of giclee quality, which was the only quality he offered. A giclee is the creation of high-quality reproductions using an inkjet printer. Peter autographed it, then dedicated it to me, with my name.

Then magic came into the air for the second time that day. He had some carved greenstone pieces for sale, created from New Zealand jade by a Maori artist in Hokitika, located on the west coast. I picked out a piece for a friend who had asked me to get a piece of greenstone jewelry for her. The piece I picked out had some white spots in it, and Peter had said that white in a Greenstone represented healing.

Then Peter noticed, "You're not wearing any greenstone."

I said, "No," and then I picked up a small Koru. I knew all about the Koru; it had been a huge influence on my life since the first time I came to New Zealand, when I first learned of the Koru's symbolism.

Peter continued, explaining the meaning of the Koru, "The circle of the fern leaves opening to the sun is represented in the shape of the Koru. It is a symbol of new beginnings, not just in a lifetime, but also in a day. The circle of things in life, the constant of new beginnings."

I told Peter, "I've always liked the Koru symbol."

He said, "Then I'm going to give this to you. For the Maoris, this is the way to give of themselves, for it to have meaning."

His giving me this gift so surprised me that my speech caught in my throat, and my eyes became teary. My hand went to my chest. I asked him to put it on me. He adjusted the leather necklace and put it over my head. He led me so that we were standing in front of the original painting of Ko Mauria.

Peter said, "Since you have been thinking of Nanny all these years, she had been calling out to you."

And then before I knew it, he held me with one hand on each shoulder. He put his left cheek to my left cheek, then lifted his head to put his right cheek with my right cheek. He then touched his forehead and nose to mine and stayed in that position, breathing softly. I had seen this Maori custom, called a Hongi, in photography, but this was all new to me. I was breathless with emotion. We kept this position in silence, breathing each other's scent. Then he released me and I was gone into the sunshine in a daze.

It took me about two hours to calm my heart after I left him. I remember that even hours later, as I sat on the hotel's lawn, I could still feel the intensity of it. As the stars came out that night, I saw that Orion was upside down, which reminded me of my first trip down under. Somewhere in the middle of the expansive Pacific ocean, in the middle of the dark, I had opened the window cover to be amazed that I could see Orion right in front of me. I know it wasn't a dream.

After I went back inside, I looked in the mirror at my Koru, at how delicate it was. I touched it. The Koru was only about a half inch diameter, and very thin. Peter had said it had to be fine quality greenstone for the artist to carve it so small. But what I thought of when I held the Koru, or looked at it, was how soft Peter's skin was against my cheek. The surprise of it, the warmth of it.

I smiled and gave my psyche a gentle shake. I remembered the bottle of New Zealand wine which I had bought that day, a Merlot, Cabernet Sauvignon, and Shiraz blend. The hotel room had a jacuzzi, so to end that spirit filled day, I filled the tub and enjoyed a hot spa bath. Afterwards, I sipped a glass of that marvelous New Zealand wine.

Untouchable, Touchable girls

"We don't let anybody touch our brains.

We won't ever, ever plug into the mains.

And we are overtaking on a single lane.

We're untouchable, touchable girls."

I had heard the Topp Twins before, so as I drove north to Christchurch, I sang along with them at the top of my lungs. My radio was turned up loud, my windows were open to the salty seaside air, and the wind was blowing my hair into a tangle.

"We're untouchable, touchable girls. Guurrls," I spread out the pronunciation, trying to mimic their Kiwi accent. "Girls.

We live in a world that doesn't care too much.

You've got to stand up, you've got to have guts.

Yeah, we are untouchable but we touch.

We're untouchable, touchable girls."

I never made it as far as Invercargill. Instead, I spent a couple of nights and one full day on the Otago Peninsula. After the interview in Kauri and the visit with Peter, I just flat ran out of time. I was sad about that; I really wanted to go from tip to tip during that visit to New Zealand, from Invercargill to Cape Reinga. But hey, I learned long ago that it's impossible to see and do everything.

I needed to be back in Christchurch for an interview in a little town near there, and to pick up Kent at the airport. I was going to be in New Zealand for four weeks that time, and Kent was joining me for two of the weeks. Kent had joined me because he and I both wanted for him to see the country as well, to get his thoughts on things.

The day on the Otago Peninsula was a wonderful day of viewing wildlife. I was out the door and heading over to Sandfly Beach, a nature preserve, by sun up. I hung out a couple of hours there, with no other sign of human life, soaking up the sun and sharing the beach with sea lions and red-beaked oyster catchers. Walking the beach alone, I gave the sea lions plenty of room, especially the huge males.

Then I took a boat cruise to the very tip of the peninsula, checking out the fur seals, black swans, blue penguins, shags, and tons of other birds. The captain went out as far as the lighthouse at the tip of the peninsula. The lighthouse sat on a towering jut of dark, almost black rock, which I figured must be volcanic.

I finished off the day at Penguin Place. The penguins which nest there are called Yellow-eyed penguins. Since they are special and rare, I really wanted to see them. The conservationists had dug tunnels so we humans could secretly go out to viewing platforms. The tunnels put us close enough to the penguins to see them without interrupting their natural routines. The sunset tour I went on was to watch the penguins as they literally popped out of the ocean onto the sand after a day of fishing.

So while the Topp Twins' singing kept me company, I drove to Christchurch and made it there by the evening. I stayed in the same little hotel as when I first arrived. The interview was for the next morning, at 9:00, and I was to pick Kent up the same day at 2:15. I knew he would be jet lagged and disoriented when he arrived, having flown literally halfway around the world, with layovers in Los Angeles and Auckland.

It had always been like a game, a fun challenge, to find a pinpoint in the world, and to go from where I was to that pinpoint. So I found the hospital for my interview easily enough. I watched the Kiwi people come and go while waiting in the hospital lobby for the Human Resources employee.

Most of the interview was taken up with her telling me about her American sister-in-law who had moved to New Zealand. The sister-in-law apparently frequently complained about her life in New Zealand, about how she could not get anywhere on her own, could not find anything, had nothing to do. I tried to reassure her that I was not like that, that I enjoyed experiencing other cultures, this one in particular. I told her I never had problems getting around, as I thought, "I'm here on my own, aren't I?"

But I could tell she wasn't listening. I could tell that she had set in her mind that all Americans were like her sister-in-law. All she offered me was a night position working as a nurse on the medical-surgical ward. I guess that was something, yes. The problem with her offer was that I had never been a night person. Even when I was young, and all my friends wanted to stay out until one or two in the morning, I was pleading to go home at ten p.m.

Kiwi Nurse Practitioners

A few days later found Kent and me having dinner just north of Auckland, discussing recent events. My brain hurt. I had been around super intelligent Nurse Practitioners (NPs) the couple of days prior, discussing deep, difficult subjects, and sharing deep thoughts. All of it was interesting, very interesting, but my brain was tired.

I met the two Nurse Practitioners with whom I had been emailing. Both amazing women were sharp, sharp as a tack. Our primary topic of discussion was how I could become a Nurse Practitioner anaesthetist in New Zealand. The task was daunting, if not impossible. The sheer volume of what I would have to do looked like a mountain, with several huge obstacles in the way. The obstacles would be dependent on the approval of others, thus totally out of my influence and control.

First, I would have to get approval from the Nursing Council to work as a Nurse Practitioner anaesthetist. To do that, to even have a beginning chance to be a Nurse Practitioner, I would have to write my Scope of Practice. The Scope of Practice would describe what I would do in New Zealand which would be above what an anaesthetist doctor did. The Nursing Council would have to approve my Scope of Practice before I could move to the next step.

The next step would be a four to five hour grilling by a panel of medical professionals, such a nurses and doctors. Each person would ask me questions to discern the competency of my practice. If they did not like what I said, they could stop me in my application anywhere along the line. If they agreed with my performance and answers during the panel discussion, then they could grant my approval to practice as a NP.

Once the Nursing Council gave me approval to practice as a NP, the College of Anaesthetists, the governing body for anaesthetic physicians, would not be able to stop me from practicing. The Nursing Council governed nurses, and if they said I could work, then I could. I told my NP friends that this approval to work was similar to how it was done in America.

The next big hurdle, the next big mountain, was to find a job. I would have to find a job with a District Health Board, or DHB, in a rural setting which had a need for anaesthesia providers. My Kiwi Nurse Practitioner friends thought it would be totally impossible for me to find a job in a city or in a private hospital. Those positions paid well enough so that there were no positions open.

So, two huge hurdles. Two huge mountains.

If I succeeded, I would be the first Anaesthetic NP in New Zealand. The Maverick. I was 48 years old, and I didn't feel like I had it in me to be a Maverick anymore. Twenty years ago, I was a Maverick, maybe even ten years ago. But at age 48? I knew I would have to think on that some more.

But my desire was to see it through, until I came to a point where I couldn't go further. I did know my personal preferences would affect my decision. I hated being grilled, especially by a panel, so I was against that. I could do it, had done it, but was reluctant to put myself in that situation again.

Paperwork, I could muster out, but defining my role would be difficult. Before I could define how my role as a Anaesthetic NP would be different from that of an Anaesthetic physician, I would need to know exactly what an anaesthetic physician in New Zealand did, which would be difficult to learn. All I so far knew were the basics, that a Nurse Practitioner's education and training was roughly between that of a nurse and a doctor's. The typical Nurse Practitioner received up to eight years of postsecondary education, whereas a doctor received an average 12 years of postsecondary education and training.

The two NP's and I also discussed the New Zealand Anaesthetic Technicians' Society, or NZATS, of which my American friend Ron was a member. If I introduced NP Anaesthetists into New Zealand, Anaesthetic Technician's (ATs) may feel that their role was being jeopardized. We agreed that Anaesthetic NP's may be a threat to their employment, vying for the same jobs. We did discuss the option of my training to become an Anaesthetic Technician, but they thought there would still be some resistance from the ATs to my doing that as well.

The idea came up for me to try to be a Clinical Nurse Specialist in Anaesthesia, or CNS, but they turned their noses up at that idea. A NP can function autonomously, where a CNS can not. A CNS has to work under a physician's direction.

"Why would you want to do that?" one of the NP's said, as we all laughed.

They agreed that physician Anaesthetists are the most vocal about New Zealand not having anaesthesia NPs. To give an example, they told the story of the struggle for NPs to obtain prescriptive authority. The point at which negotiations always became stuck was when anaesthetic drugs were included. The only way they could go forward with the negotiations was to exclude anaesthetic drugs from NPs prescriptive authority.

Also, and most amazing, they told me there were only 52 NPs in the whole country ! They then told me that NPs just came into being in New Zealand in the year 2000 ! I was astonished that NPs were so new to the country, and were so underutilized.

While relating to Kent over dinner the discussions I had with the NP's, I couldn't help but shake my head. Nurse Practitioners are such a viable, important resource for the health and well being of a country's citizens, but their presence and autonomy was actively excluded and blocked. It just seemed to me to make more sense to allow any qualified, trained provider the ability to work. There is room for all specialities! There are shortages of all health care providers around the world, and New Zealand was no exception. Why couldn't we all work together for the common good of the society ? I was no Pollyanna, I had been a medical professional too long to be a Pollyanna. The answer I felt, that I knew, was that it all came down to power and control. And money in the pockets of those with the power and the control.

I thought of a quote by Grayson Perry, from his book The Descent of Man: "I reiterate: men will only come on board when they feel that there is something to gain from change. A just balancing of power will feel different to different people: to some, it is fairness; to others, it will feel like deprivation....."

The Scoop

I wrote this email to a CRNA whom I had met while on an assignment in Pennsylvania. I had told her about my going to New Zealand to hunt for jobs, and she had said she would love to hear what I found. So I wrote her this email, which in the email I titled "The Scoop":

"Kia ora from Auckland.

Ok, here's the story so far, as I know it. I don't know for sure what you wanted to know about working down under in NZ, you just said to tell you 'everything'. So, let me know if you want to know more.

There's a lot to say. So I think I'll just tell you just how I had learned it.

First, to be an RN here, you just have to fill out a bunch of paperwork and submit a bunch of documentation and pay a bunch of money. It sounds to me a lot like getting credentialed in the U.S. They just want to be sure you are who you say you are and you can do what you say you can do. Also, there are English competency tests. They want to be sure you actually speak English. And I think there is a police record search.

To be an anaesthetic technician here, from what I can tell you from the brief emails with NZATS, I would have to enroll in an anaesthetic tech course, at an approved facility. I would have to do more clinical work, and probably more testing. I would have to pass their professional exams. Some of my anesthesia education in the U.S. would count here, but they were vague on it.

I've emailed anaesthetic techs here, and my emails have either been ignored, or the responses have been brief. I spoke with a Nurse Practitioner about it, and we both figured that they would see me as a threat to their role. So they're not keen on having me around, even if I came as an anaesthetic tech.

Also, from what I've gleaned from several sources, it seems the anaesthetic techs here function like an AA (Anesthesia Assistant) in the U.S., under the direct auspices of an MD Anaesthetist, but they can't give drugs. The NP I spoke with said she has some operating theatre nurse friends who say that the anaesthesia techs at some hospitals work alone in a theatre, with an Anaesthetic MD supervising up to 4 rooms. She didn't know if that was within their professional scope of practice, but she knew it was being done in reality.

The only inside help I may have, in case I pursue that route, is that the lead anaesthetic tech in Kauri, one of the hospitals where I interviewed, is an American. After talking to him more, we realized that I used to be his boss when I was Head Nurse for the telemetry unit. Imagine our shock at realizing that one! But he said he would try to be the go-between with NZATS for me. Time will tell.

Yesterday, I learned from a different NP that the chances of becoming an anaesthetic Nurse Practitioner here are slim, at least in the foreseeable future. NP's have only been in New Zealand since the year 2000, and there are only 52 NPs in the whole country! (yep, that sentence deserves an exclamation point) The biggest fight they've had has been with the Anaesthetic doctors. In obtaining prescriptive authority for their NPs, the only way to move forward with negotiations has been to exclude anaesthetic medications from the prescriptive authority lists. So far, the NPs have allowed that because they didn't want to fight that battle, they wanted to move on with negotiations, and no one had been interested in becoming an anaesthetic NP here anyhow. If I were to follow that route, I would be the first, and so I would have to fight that battle.

NP's here work independently. There are Clinical Nurse Specialists too, but these work under the auspices of a physician. It sounds to me like a NP in the U.S. is kind of like a hybrid between a Kiwi CNS and a NP, we have a little of both qualities. Both NPs I spoke with know American NPs, and we all agree that this is probably the difference.

To be an NP, I would need a master's degree. The one I obtained in the U.S. would count. Then I would have to write a detailed scope of practice and present it to the Nursing Council. This scope of practice is a definition of what I would do as an anaesthetic NP, how my role would be different than an MD anesthetist, what I could provide to the community, etc.

Once the Nursing Council approves this, then I would have to sit before a panel of 4-5 professionals, and allow them to grill me for a few hours. It sounds like what a resident MD in the U.S. has to do to get board certified. If I get approval after all that, then I can be a NP. If the Nursing Council approves my being an NP, then the College of Anaesthetists can't stop it.

Ok, if I'm able to become a NP here, I then have to find a job.

The problem is then finding the job. I would have to convince a DHB (District Health Board, which are the general hospitals for the National Health System, i.e., not private hospitals) that they need me. It would be a new concept in a new field, so I would have to do a lot of teaching and convincing. It would be helpful to find a sympathetic physician anesthetist who could push with me. The NPs of course would push with me. But the reality is that the NP licensure I obtained from the Nursing Council wouldn't do me much good if I can't find a hospital to hire me and to pay my wages.

There are a few things which make this even possible. First, there is a new CEO for the Nursing council. The last one was an 'idiot', so they say, who had been out of clinical practice for years and had put up all sorts of roadblocks for NPs. The NPs said there are about 300 nurses in NZ who have passed the qualifications in one way or the other, but have been unable to finish their NP because of these roadblocks. But the new CEO is supposed to be more informed of current nursing issues.

Second, there is a shortage of anasesthsia providers in the country. They don't pay their doctors well. Many doctors who train here leave to get better pay in another country. They end up importing docs from all over, and so use many locums. That seems silly to me, but that's the system. I mean, if you don't have enough staff because they're paid so low, pay them more so they'll not move away. Anyhow, an argument in my favor for a DHB is that they need my help, especially if I'm willing to go to a smaller hospital, which I am.

Third, there is a new Minister of Health, whose political agenda is to decrease wait time for surgeries. Surgical wait time is the time from when a surgery is determined to be needed to the time it is actually done. Sometimes, in Nationalized health care systems all over the world, this wait can be months.

I thought you might also want to know about the salaries. Annual pay for both an average experienced RN in NZ and for an experienced anaesthesia tech is about NZ $50,000. Shift and weekend differential can swell the pay a bit, sometimes up to NZ $60-70,000 per year. That's a decent living here, so I'm told, because the cost of living is lower than in the United States. A CNS makes about NZ $72,000 Max. A NP makes NZ $85 to 103,000. One NP told me that many Kiwis live on NZ $20,000 a year, but she said she couldn't see how. Since the current NZ $ to US $ exchange rate is about 0.6, I would make about US $60,000 annually if I were to obtain my NP license here in NZ.

So, there you have it.

Elize"

The North of the North

After I dropped Kent off at the airport, I drove north and thought about the discussions we had while he was in New Zealand. Kent had said, "I can see that you want to live here. It fits your nature. You are independent and self sufficient, but in a way that is kind to people. So often in the States, being independent and self sufficient has a different meaning, almost aggressive."

I had agreed, "It is more narcissistic. Independence means taking care of yourself only." I added, "Here, it feels more gentle. America feels more aggressive. America feels harder."

Kent and I had also talked about how to make the move to New Zealand work for us, for our relationship. Kent thought it would be fun to go to New Zealand for a change, rather than to the States. Occasionally we could meet halfway, like on one of the Pacific islands, to make the most of our time together. And over time, if I found I liked living in New Zealand and could have a good standard of living, he said he was willing to move to New Zealand too.

So I had headed north toward Cape Reinga. On the way, I spent a couple of hours at Ngawha Springs. These were small hot spring pools, open to the public. The owner of a hostel where I had stayed said that Ngawha Springs was a great stop on the way north. The pools were nothing fancy; they were simple lined pools, each with varying degrees of heat. Only a handful of soakers were there that day, and I, definitely, was the only non-Kiwi.

A couple of the soakers asked me where I was from, and I, in turn, asked where they were from. One couple was from Invercargill, and I said how much I had wanted to go there but didn't quite make it. Another was from Waitangi, by the beautiful Bay of Islands. We talked about the Treaty of Waitangi, and I told her I had visited Waitangi and the Treaty grounds. These friendly interactions were brief, and afterwards, they generally left me alone, to soak at my leisure.

After I left Ngawha Springs, I drove to the very north of the north, to Cape Reinga, as I had promised myself. Cape Reinga was a windswept projection of land, accessed by a gravel road under heavy construction. On the tip of the Cape's point, looking north with the lighthouse at my back, I knew that in front of me was only ocean, with only a few bits of island, for hundreds and hundreds and hundreds of miles.

Maoris believe Cape Reinga is a special place. They believe that the Cape is the point where the spirits of the dead enter the underworld. Also, since the meeting of the Tasman sea and the Pacific ocean is so turbulent here, the Maoris believe Cape Reinga is where male and female meet.

Just south of Cape Reinga, in the village of Ahipara, I found a self-catered apartment right on 90 Mile Beach. One of the owners happened to be from the United States. They had moved to Ahipara to open their small hotel about 10 years prior.

They invited me up to their private space for drinks one evening. They cautioned me that Ahipara had a lot of closed minded people, yet the three of us agreed we still liked the place. The beaches were wide, flat, long, and beautiful. And with Ahipara's position being so far north in New Zealand, it was warm, which was familiar to where I grew up.

They taught me that you made friends in New Zealand based more on your hobbies than on your work. They also both thought I could easily fit in to New Zealand's society.

"Why?" I asked.

Their answer, "You have a needed skill. You have the disposition. You've already cut lots of ties with material possessions since you have neither a car nor a house. And you're well traveled."

Near Ahipara, in the town of Kaitaia, was a small hospital. Before driving south, I decided to go to the hospital to inquire about available nursing positions. The HR employee I needed to speak with was not there, so I left my resume. I would follow up with phone calls and emails once I got back to the States.

Then I drove south along the north island's west coast. I took a long hike in the magnificent Kauri forest on my way to that night's accommodation in Bayly's Beach. I had stayed there when I first went to New Zealand. I had spent a couple of nights in a little Kiwi "bach" in the owner's backyard. I had good memories of the place, and wanted to see it again.

I arrived after dark, just as the light was leaving the sky. A big storm blew in during the night, hitting the windows and roof with wind and rain. In the morning, listening to a light rain on the roof, I realized that one of the things I liked best about New Zealand was its remoteness. It felt like a secret treasure, away from all the craziness in the world.

Bayly's Beach was such a great little spot in the world. Towering sand dunes faced the Tasman Sea, with "treasures" of new coal veined in it. Crashing blue waves roared onto a wide sandy beach. Cute little beach cottages, nothing posh or ostentatious, hugged the narrow road to the beach and clustered against the sand dunes.

I realized that when I was in Bayly's beach, I liked Bayly's Beach the best. When I was in Ahipara, I liked it the best. I also liked Motueka and Nelson and Kauri and Whitianga when I was in those places. I wanted to be there! My soul felt a connection to New Zealand; I wanted to be a part of it.

I am Responsible

I couldn't though. I couldn't give up my career and my income without having a better idea of what I was giving it up for. My responsibility streak was too huge.

I knew everyone has personality traits which are both good and bad, a unity of opposites, of yin and yang. One example was my ability to persevere. Some called that ability stubbornness, others called it bull-headedness. But the ability to persevere could also mean the ability to be goal oriented, focused, directed. My ability to persevere had helped me my entire life. It helped me to accomplish goals I had set for myself.

My responsibility streak was another of those good, bad qualities. I was born into poverty, into a dysfunctional household. My being responsible had helped me to climb out of that life into which I was born and make something of myself. But it also made it so that it was difficult for me to be impulsive. I couldn't just jump from one country to another, on a whim. I needed to have a better idea of what my life would be like, cost of living versus income, housing, etc.

Another concern I had was my parents. I knew I had my own life to live and I wanted to live it, but I loved my parents. The time I lost with them, I could not get back. I knew they were aging, and I didn't feel like I could live on the other side of the world quite yet. It would have been a long way for me to go to them.

My being so responsible was forcing me to do what was right rather than what my soul was telling me to do. It was an emotionally difficult decision I had to make. I thought of the book "Bridges of Madison County", which focused on the struggle between commitment and duty versus doing what you want to be content in your life.

I came to some decisions. I realized I didn't want to do what it would take to be an anaesthetic Nurse Practitioner there, or to even be an anaesthetic technician. The fight, the struggle to make it happen, my being a maverick again, none of that would make me happy. I thought that the only answer was to try to do some temporary jobs in New Zealand. Go and work there as a regular nurse for periods of time, two to three months at a time, and still continue my locum tenen CRNA work in the U.S. Perhaps the hospital in Kauri would be interested in working with me on that. I wanted to work in New Zealand, be there, live there as much as I could, until I learned what my life would be like there. I decided to start the application process for my New Zealand nursing licensure as soon as I returned to the States.

Time Travel

So I returned to the United States. I always had fun calculating actual travel time on those long trips. I would start when I walked out the door to go to the airport, and finish when I walked in the door at my destination.

So I left my hotel in Mantakana at 10:00 am, more or less, and headed to Auckland's International airport. I dropped off my rental car and got through Business Class check in and security pretty quickly. Then I went up to the First Class lounge, arriving there about 2:00 pm. Since I was traveling Business Class, with my upgraded ticket obtained "free" using Frequent Flyer points, I was able to have free access to the lounge. So that made four hours I had been traveling so far.

I waited in the First class lounge, which happened to be called the Koru lounge, for two and a half hours, for a 4:30 pm take off. While flying, we saw the quick sunset seen while flying east. We landed in the Cook Islands to refuel, at 8:30 pm Auckland time.

The island we landed on was a tiny drop of an island in the Pacific, with a tiny drop of an airport. It was 10:38 pm local time when we passengers shuffled into the waiting area. There were hardly any lights on in the island. A man played a guitar and sang loudly to greet the arriving sleepy guests.

The plane had left Auckland Sunday afternoon, but when we arrived at the Cook Islands, it was Saturday night. We have passed the International Date line, and like a science fiction movie, we traveled back in time. The waiting room consisted of a handful of small retail shops, restaurants and bars, plus an outdoor sitting area with little benches and tropical foliage. The locals were stocky and dark skinned. I looked around a bit, bought a small souvenir bag, and then sat outside. The air felt like the sea. The air was balmy, with a light late night breeze. I did so love that feel, that smell.

So that made four hours in the air, plus one and a half hours in the Cook islands for our layover. I moved my watch to local time. We took off at midnight, local time. So add the time with the refueling stop in the Cook Islands, and I had been traveling nine and a half hours.

On to Los Angeles, California, the flight from the Cook Islands took about nine hours. I missed the sunrise as I slept. My luggage was first off, with the priority tags given to me because of my high Frequent Flyer status. There was no queue at customs, so I made it through quickly, within 15 minutes, and so had time to sit outside a while. Amazingly for L.A., the air was cool and fresh, very nice. They must have just had a rain to clear the skies.

I went back inside and then through the domestic TSA security check point. TSA was so unfriendly, so unlike the cordial security in so many other countries. As they often did, they reminded me of the Kremlin guards, when I went there in the early 1990's: serious, commanding, half bored. They had absolute control over us, and they acted like it. The trouble with that behavior, I believed, was that it made those who were innocent feel nervous, so that those who were doing something illegal could not be singled out as easily.

Anyway, I was able to go into the VIP lounge, which was a treat, especially after my long flight. I had hit a wall about 30 minutes prior, and was utterly, completely tired. And I was grieving, grieving for having to leave New Zealand behind. America seemed so loud, so fast, so hard in comparison.

So, while waiting in the VIP lounge, I looked at my watch, which was on Cook Island time. Eleven hours had passed since we left the Cook islands. I moved my watch forward three hours to L.A. time, which was 2:00 pm. My flight was due to leave L.A. in two and a half hours, at 4:30. So by the time I would leave L.A., I would have been traveling 23 hours.

The flight between L.A. and Alabama, with a layover in Phoenix, was a fuzzy blur. My addled jet lagged mind was in slow motion. I did remember seeing the sunset somewhere over the desert. And about an hour before we landed, we flew around some massive storm clouds, with gorgeous cloud to cloud lightning. I don't often get to see that from a plane. The lightning was continuous, popping between the clouds, lighting up the darkness in high relief.

Arriving in Alabama, I checked my watch, which was on L.A. time. I moved the clock forward to local time, and I calculated I had traveled another six hours. The plane landed at 10:00 pm. So since leaving my hotel in Mantakana, New Zealand, I had been traveling 29 hours.

After I picked up my luggage, I helped a bewildered German tourist find her hotel. She said she had been traveling 24 hours, and was having trouble orienting herself to the local maps. After I pointed her in the right direction, I got my rental car and made my way to my hotel for the night. I had indulgently booked a hotel for my arrival, rather than staying with family. I knew I would be too tired to be sociable with them. When I dragged my luggage in my hotel room and shut the door, travel time was over. So adding another three hours, and from door to door, I had been traveling 32 hours.

My Beginning

No story of me would be complete without my saying how I started my life, without sharing how my childhood subsequently affected how I chose the direction of my life. Nature versus Nurture: which has more hold on a person's personality, on how they face the world, on how they choose who they are and how they react? Of course, both influence what a person is or becomes. I believe it is impossible to know which influences more; both are integral to the whole person.

As I have mentioned, I was born into a dysfunctional household. I am the third child of children born one right after the other, to a couple who married in the late 1950's when they were teenagers. My mother bore three children by the age of 21. Yes, my family had a roof over our heads, however humble it was. We were fed. We had a yard with a swing set and a dog. We went to summer camp, were given birthday parties, took piano lessons, and attended ballet classes. We attended school every day. As an adult, I think we were upper lower class, lower middle class, somewhere in there. Our parents loved us in their own way, of that I am sure.

But my parents started fighting early on, and the bruising started when I was still in diapers. Tension filled the house. My sister and I had nocturia until we reached puberty, I have often thought due to the stress. My father's take on our bed wetting was that we were doing it intentionally. So to add insult to injury, his solution was to spank us soundly a few times with his belt, and then to rub our faces in our urine soaked bed. Then we were made to sleep on the floor for a week.

He'd roar, "If you can't keep from wetting your bed, then you don't deserve to sleep on a good mattress!"

I grin now because going to sleep on the floor was actually a relief. When I slept on the mattress, I was too afraid I would wet it.

When I was 4, my mother's brother started molesting my sister and me. He would take us behind the neighbor's garage, and bully my brother into being the lookout so he wouldn't get caught. Best as I can recall, that went on for a couple of years before we finally got the nerve to break our silence and tell our mother. My mother told my dad, who told my mother's and my uncle's dad, who told his son that only perverts molest little girls. My uncle was in his late teens, so his father told him to date girls his own age, which he did, who all strangely happened to be very petite. The woman he married was almost half his height, which to this day makes me wonder what pedophilic tendencies he still carries.

And in case you're wondering, dear reader, he did and has gotten away with it. We tried to bring out the truth in one way or the other over the years. But he has denied it, and his wife has said no way she can believe it. And for reasons I can scarcely fathom, family and lifelong friends have decided not to believe it either. They appear to not even have a shadow of a doubt, because they have shunned my family. They have literally turned their backs on us and hung up the phone in our ears, treating us like slandering liars. Sad, really. Only my uncle can make things right, and he's cowering in the corner like a little boy, hiding behind his wife's skirts.

I think of my uncle from time to time, wondering how he has learned to live with himself. My cynical guess is that he feels relief for dodging a bullet. He has never had to take responsibility for his actions, while we who have accused him have been vilified.

My uncle's pedophilia cause me to consider the differences between a moral person and an ethical person. Ethics include morals, but the principles of morality go beyond ethics to include action. I believe that an ethical person may know what is right, but doesn't necessarily do what's right; their actions do not always follow their beliefs. A moral person knows what is right and actually does what is right. A moral person will follow an ethical code. The character of Dr. Mallard on the TV show NCIS gives a good example of this idea: "The ethical man knows he shouldn't cheat on his wife, whereas the moral man actually wouldn't."

So I guess a person with pedophilic tendencies can still be considered moral if they leave children alone. I feel sure that my uncle knows what he did to us was wrong, otherwise he wouldn't be cowering in the corner. But he lacks a moral compass. Even if he has never again molested little girls, he would have apologized to us and attempted to make things right with us. But he has done nothing but deny.

I have worked through all this now, and consider myself very happy and fortunate that Kent and I have a loving, healthy sex life. And I can amazingly even joke about it, jesting that men have wanted me all my life. People who don't know me well think I am just teasing.

Sadly, both my siblings continued the dysfunctional family tradition, and I wasn't too far behind them. My brother started stealing cars. Both were having prepubescent sex, and years later, they told me the extent, which included prostitution. My 12 year old sister and 13 year old brother began taking any drug they could get a hold of: pot, pills, cocaine, eventually heroin. They drank what was in our parents' alcohol cabinet, watering down what was left in the bottle.

They realized that it was really funny to get their little sister stoned by blowing pot smoke in her face. It didn't take long before they were handing me the joint to smoke myself. And then it was just a hop and skip for me to start popping any pill they gave me. I would briefly ask what it was and what it would do... quaalude downers, black mollie uppers, LSD hallucinogens.... and then pop it in my mouth with a grin. I was 12. I shake my head now whenever a parent absolutely insists that their darling little 11 or 12 year old is innocent of sex or drugs. Okay, perhaps occasionally this is true. But I will bet my bottom dollar that more times than not, those parents just have their head in the sand.

I wryly grin, thinking of a poem by Philip Larkin:

"They fuck you up, your mum and dad.

They may not mean to, but they do.

They fill you with the faults they had

And add some extra, just for you.

But they were fucked up in their turn

By fools in old-style hats and coats,

Who half the time were soppy-stern

And half at one another's throats.

Man hands on misery to man.

It deepens like a coastal shelf.

Get out as early as you can,

And don't have kids yourself."

Often I have thought about my life, all that happened during my developing years, and I wonder why I turned out so differently from my two siblings. My siblings continued their downward spiral into their adult life. Neither graduated from high school, and both have since held mostly menial jobs. Both regrettably continue to struggle with their existence.

Insights I gained from reading a book called "Outliers" by Malcolm Gladwell gave me the reason for our differences. Malcolm's definition of an Outlier is one who has "been given opportunities, and who has had the strength and presence of mind to seize them." Outliers have been given a chance, an opportunity for improvement, and then they persevere in that opportunity. Malcolm states research has repeatedly shown that 10,000 hours persevering at a task is what makes someone proficient, is what makes them an expert- at anything.

So I was given my chance when I was barely past my 13th birthday. A new drug abuse program, designed specifically for teenagers, had started near my home two years prior. By that time, my brother was in Juvie Jail and my parents' violent marriage had just ended in divorce. My mother, on her own and desperate to get help for her children, decided to drag my sister and me to a meeting. The youngest a teen could attend the drug abuse program was age 13, so the timing was perfect for me. My sister only went to a handful of meetings before she rebelled and refused to go to any more. But I took to the program immediately and completely.

It's tenets were based on Alcoholics Anonymous' Twelve Steps. The Twelve Steps are a list of twelve guidelines on how to improve your life. Each step is simply written, but each step has the potential to be worked on for a lifetime. The first step begins with admitting you have a drug or alcohol problem. We learned that admitting a problem is 60% of the solution.

So when I started going to meetings, my admitting I had a drug problem and getting off drugs was easy. Now, as an adult, I look back at my 13 year old self and realize it was easy for me because I had been pliable; I was still so young. Also, since I had only been doing hard street drugs for about seven or eight months, the habit wasn't too engrained in me. Furthermore, truth be told, I simply liked the people there better than I liked the druggies my brother and sister hung around with.

I fully embraced all the program had to offer, and was working my twelve steps. It was popular at the time, and so a large group of teens active in the program went to my Junior High school. We all hung out together during and after school. I went to meetings after school and on the weekends. I easily received my 30 day and then my year's sobriety celebrations. When I was 15, I was asked to be a steering committee member, which involved guiding others during meetings.

I was becoming Gladwell's Outlier, getting in my 10,000 hours learning to have an emotionally healthy and productive life. I learned the importance of penetrating self-awareness. I developed an inability to lie to myself, which I still cherish to this day. I learned how to change the dysfunctional scripting I was taught growing up. I learned to cherish the qualities of integrity, and of a strong work ethic. I came to believe intensely in personal responsibility. I learned that actions and reactions are intertwined, so self-reflection became a part of my core being. The program literally saved my life.

Along the way, I realized that applying myself in school and getting good grades opened doors to opportunity. In Junior High school, I raced a Science classmate to see who could get the highest grade above 100; this involved not only acing tests, but also doing extra credit work. I graduated high school in the Honor Society, and obtained the Deans List during several semesters of my Baccalaureate program. And then when I attended University several years later to become a Nurse Anesthetist, I excelled in my Master's program and was asked to be the Master of Ceremonies for our graduation ceremony.

Some may look at my young life and think, oh, poor you. That's so sad all that happened to you when you were just a child. But I don't look at my life like that. I prefer Kent's interpretation of my life, because that is how I see myself: Ok, so bad things have happened to me, but everybody has bad things happen to them. What is important is not what has been done to me, or what I have experienced, but how I have overcome those events. I believe the measure of a person's character is that person's ability to take the high road when those around you choose otherwise. Kent said, and I agree, that my life events have only made me a more interesting person. And from these interesting events, I have molded my life into something worth living.

So now, all these years later, I give a good old fashioned hug to all those who started and continued the drug abuse program that saved my life. And while I'm at it, I want to give a good old fashioned hug to Malcolm Gladwell as well, for making the connection for me.

Villains muddy the truth

While writing this memoir, I had a revelation about my character. Growing up, I had difficulty determining the character of another person. Good or bad? Real or dishonest? I could not trust my intuition.

I had a friend who insisted that you could tell a lot about a person in the first five minutes after meeting them. I was a bit bewildered by that statement, and obviously I looked bewildered, because she went on to say, "Well, you can. By the way they speak, how they carry themselves, how they dress."

I did agree with her; you could tell a lot about a person within the first five minutes. Yet I thought to myself, all my life, I had seen the multiple dimensions of people. I knew a person's personality revealed itself over time. The good people of my childhood did not stay good, and the villains of my childhood did not stay evil. They vacillated and varied, from kind and doting, to mean, cruel and manipulative. They muddied the water and caused me not to trust my own intuitions and impressions. I knew that the person they showed the world was not always the person they were in private.

But since traveling around the world on my own or with Kent, insisting on the honesty which I had always craved, I had learned that I could trust my intuition. I still liked my ability to see the multiple dimensions of people. I knew people were not just one thing. A person was not just one label, but was also a lover, a friend, a manipulator, a mother, a father, a pedophile, a murderer, a politician, a, well, whatever they wanted to be or could be. Also, I realized that I could trust my intuition, that what I felt about a person was what I felt. Simply.

Starting a New Contract

I came back to the States to start another locum job, this time in the upper north east. I had set up the contract before going to New Zealand, and had tweaked the details via email while I was abroad. It was a medium sized hospital and community, with a big city within easy driving distance from the job. That was my favorite kind of work locale: a medium sized hospital or community, with a little country space around it, but close enough to a big city for an easy commute when I wanted other activities.

I followed a fairly predictable course when starting a new contract. On the first day, I was just trying to make it through and to be a sponge, learning as much as possible. I paid attention. I made notes. I learned people's names and their roles. I got a feel for their personalities. I learned the routine. I focused on doing good anesthesia so my new co-workers would get a good feeling for me and trust my skills.

On day two, I was already familiar with the routine. On day two, I memorized details. I quizzed myself on names I learned on day one, and learned the names of new faces. I even took pictures of my new co-workers with my smart phone and put that in my phone's contact list. Taking pictures of new co-workers was a funny way to "break the ice" and open a conversation. Again, I focused on doing good anesthesia so people would trust me.

On the third day, I started to feel a part of the team. People were beginning to know me and to call me by my name. I started to learn details of their personalities. I learned who was the good resource person, and who had the level head. I learned who would not be helpful, or who depended on others to help them do their job. I learned who was open and friendly, and who was quiet and withdrawn. I was beginning to see who I felt connected with emotionally, who was of a like mind to me, who was a potential future friend. By the end of the first week, I had learned the rhythm of the job so that I could function fairly autonomously.

Frequent Traveler Points

I liked that new contract. Working there was a core group of older experienced CRNAs and anesthesiologists who took things in stride, helped and supported each other, and came together as a cohesive team during emergencies. If one CRNA was assigned to a busy operating room, then the CRNA with the lighter assignment gave long breaks to the busier CRNA, so they would not be stuck in a room while another CRNA sat out all day. In staff meetings, we got things done and problems solved in a light, good-hearted way. Staff meetings were actually fun, which made me laugh just to admit. I mean, whoever heard of a fun staff meeting?

My recruiter had me settled into a Residence Inn. These were extended stay facilities, a Marriott brand, and were pretty much the same throughout the country. Their decorations were so similar, you often saw the same pictures on the hotel room walls in Arizona that you saw in New York. Each room had a kitchenette with a two burner stove, a large refrigerator, and cooking and eating utensils. There was a couch and a chair to watch television, a desk, wi fi, and a queen size bed, all for the comfort of the business traveler. Sometimes, I was housed in a Staybridge Suites, an IHG brand, or a Homewood Suites, which was a Hilton brand. I felt sure which hotel they reserved for me depended on which offered the best corporate rates.

My favorite thing about staying in those extended stay hotels was collecting frequent traveler points. My best story was when I stayed for seven months at a Homewood Suites while working in Nevada. I collected enough points over those seven months to get six free nights on the executive floor at a posh Conrad hotel in downtown Tokyo, Japan. Being on the executive floor gave me access to their elegant executive lounge. In the lounge, a chef cooked individually ordered omelets in the morning, and prepared drinks and snacks in the evening.

The Conrad Tokyo hotel was a skyscraper hotel, with business offices below the hotel. The hotel lobby was on the 28th floor of the building, and the hotel rose above to the 37th floor. Staff lined the lobby, bowing in greeting to anyone exiting the elevators, and they moved toward you to inquire of your every need. The gym had a two story window view over Tokyo's Central Business District, remarkable during the daytime, but astounding after dark. Their pool was one level down from the gym, with three stories of glass windows overlooking Tokyo's posh Ginza shopping district. I loved to float in the pool in the evening, marveling at the skyline. Staying there was a beautiful and fun experience. And it was all free.

The English Competency Exam

I still continued to do what was needed to obtain my New Zealand nursing license. One requirement was to take an English Competency exam, called the International English Language Testing System, or IELTS. I thought it was pretty funny that I was required to do the test, but hey, just because I came from the United States did not mean that I knew English ! I got it !

The test was hard, very hard. Most of the test takers were from China or Taiwan, but a few were darker skinned, looking and acting a lot like tough Mexicans. I have had several Mexican friends in my life, so I tried to strike up a conversation with them, but they kept to themselves.

During the test, I wondered how the others were coping, since the test was hard for me. There was a lot of heavy moans and deep sighs during the test, with a definite palpable feeling of stress in the room. The test was not only to verify that you could speak and understand English, but that you could also decipher, argue, analyze, and calculate in English. You had to not only master the English language, you had to have a brain too.

The questions became harder as the test progressed. A couple, I know, I just flat missed. For instance, on the listening section, you were only given the chance to listen to the recording once. So I found it best to listen to the recording and read the questions at the same time. Then I had to fill in the blanks on what was discussed, using the exact words that were said in the recording. The last few sentences of the recording were spoken very quickly, about the technical aspects of something. I was doing a decent job keeping up when the recording came to a section of more rapid speech. So an answer went by me before I even knew it was a question.

On another section, the recording rapidly recited a ten digit international phone number and I had to get every number in order. And many times in the reading section, I had to infer answers. For instance, the technical reading section was about the aviation industry, the development of the FAA, and the like. They presented complicated questions where I had to deduce the answer from different parts of the passage. And on another section, I had to complete sentences based on what I had read. I had to match the beginning part of a sentence to the ending of a sentence. The problem I had there was that a couple of different ending sentences could be feasibly matched with a couple of different beginning sentences. That was the trickiest part for me.

A month later, I got my results. I needed to obtain a seven or higher band score to be eligible to obtain my New Zealand Nursing registry, and I made an 8.5 out of 9. They marked me down on my writing, I think probably because they could not read it. I laughed at that because I had never had good handwriting. Cursive writing classes in elementary school were the only times in my life that I had ever made a D or an F grade. And being in the health care industry for years, writing the volumes of documentation that was required of me, my handwriting had gone from bad to worse.

Like a Tidal Wave

On the horizon was the looming Great Recession, like a tidal wave poised to crest and crash. At that time, it had been rearing it's ugly head for about a year. The stock market was going into free fall. Anesthesia groups were tightening their belts, using less locums, and making do with the staff they already had. Retiring CRNAs were deciding not to retire. Part-time staff were going full-time. The Great Recession decisively changed many people's lives, mine included.

About the same time, Obama was presenting his Affordable Care Act, or A.C.A., later to be known as Obamacare. The A.C.A. was making hospitals in general, and anesthesia groups, anesthesiologists, and CRNAs specifically, twitchy. Once the A.C.A. went into effect, health care professionals did not know how things would change. They did not know how the medical system would shift. There was an air of uncertainty.

So for me, it was becoming harder and harder to find locum work. As I have said, I scheduled my work contracts around my trips abroad, and schedule my trips abroad around my work contracts. I was finding that work leads would start, and then the job would fizzle away as the anesthesia department found someone closer, cheaper. Or I would be offered a contract with an unspecified shift, varying between mornings and nights in just one week. Other jobs only had needs for a couple of days a week, or for just a week here or there. Not knowing whether I would be able to get enough work was becoming more of a worry. I was okay with having some time not working, but I was in the prime of my career and I did not want to be sitting on my duff too much.

I wrote this email to a CRNA friend, which pretty much summed things up:

"It looks like the locum market is drying up. Last summer, I was the last locum to work at that hospital. The job this last winter, they said they should be fully staffed by the summer. This job, they've just hired seven new graduate CRNAs and have offered me their last full time position.

Kicking and screaming, I may have to take it. I do like this hospital, the other CRNAs, and the operating room staff. The hire-on package they've offered me is pretty good. I could wait, hold out, continue as a locum, yes. But it feels more unsteady, this life, and who knows how Obama's changes are going to affect me. And if I hold out, then the good hire-on packages may not be as good, or they may even be gone. If a hospital is fully staffed, they don't have to offer bonuses to attract new employees.

Also, I could say no to the current job offer, and look for a full time position elsewhere. But I'd lose this opportunity, and I wouldn't know the staff and situation at other hospitals like I know it here. And I've worked in this state more than in any other state, so I'm familiar with the terrain.

The problem is I don't know the future. So from what I've heard and seen over the last year, going full time on a job, at least for a couple of years, seems best. I've talked with my family and they're supportive, as is Kent.

I've been averaging 38 weeks worked per year as a locum, and I'll have to work two or three more months a year. And I'll only get five weeks off a year. So Kent said he is willing to come my way more often and to travel abroad less. Hopefully after I accrue enough vacation time, I'll be able to get back into the traveling mode a bit and I will be able to travel to Canada to see Kent.

I think the transition is going to be very difficult for me at times, no doubt there will be lots of shed tears. And lots of changes. It has been years since I've had to pay household bills and such. As funny as it sounds, I have no clue how much things cost. Also, I have to get a car and a place to live, and all that is involved with making that happen, including insurance, cable, utilities, internet, washer and dryer, etc etc etc."

Broken Koru

A friend came to visit me for a week, unfortunately during the week that everything was coming to a head. I had to decide that week whether to stay a locum or to settle down into a job. I did not want to tell my friend about my decision until I knew for sure what I was going to do. Yes, I had talked with my friend at length about it, getting her opinion, but the final decision had to be mine and Kent's alone.

With my friend around, it was difficult to talk things over with Kent. We would catch each other in fifteen minute snippets of time, such as when I was coming home from work, so I could get his opinion. I had spoken with the chief CRNA a couple of times to understand the details. I wasn't sleeping well, thinking about all I needed to learn and do.

Plus, to make a difficult situation worse, the neighbor's car alarm kept going off in the middle of the night, keeping me awake. The owner of the car, I found out, was an elderly woman who kept accidentally pushing the alarm button. It was impossible to get a good night's rest. Also, I wanted to do things with my friend after work, tour the area, go out to dinner, so I did not have the chance to catch up on my sleep by taking an afternoon nap.

On Friday, the end of that week, I decided to accept their offer. I told the Chief CRNA that I would take the full time position.

Another thing that happened during that important week concerned my greenstone Koru. I had taken the Koru, which the Maori artist Peter had placed around my neck, to a jeweler to get it set in a pendant. The Koru was so important to me, and was so delicate and fragile, that I wanted to protect it. But on that same day, that same Friday that I had said I would accept the full time position, the jeweler called to inform me that he had accidentally broken the Koru while he was setting it. It was all very symbolic, my broken Koru and my broken dreams.

Kent reminded me that when we first met, I had told him that I had a sense of responsibility as big as Alaska. So now, again, I chose to be responsible. Rather, I forced myself to follow the voice of my strong sense of responsibility. But forcing myself made me think I was not making the right choice. That if I had to make myself do something that so much of my heart and soul was saying not to do, then I shouldn't do it. That struggle, that fork in the road of my life, was so difficult to decide. In the end, I chose responsibility because I couldn't just give up everything I had and everything I knew to dive like a bungee jumper into a canyon. I just didn't know enough about life in New Zealand to make the leap.

So after work that Friday, I came home dragging and cried like a baby to my friend. It was hard, oh so hard, giving up my dreams, of giving up my traveling lifestyle. It was hard thinking of the changes which Kent and I would have to go through. It hit me that I was transitioning from "the world is my oyster" to this being my home, making me feel that my world was closing in on me, restraining me, limiting me, confining me, controlling me. Hard, hard, heavy feelings made me wail. I cried and cried while telling my friend what I was doing, so that my face was red and puffy, snot was flowing out of my nose, and my tears were blinding me. I was crying so hard that I couldn't breathe. I would get my crying under control long enough to catch my breath, hiccoughing, blowing my nose and taking a deep breath, hoping that the tears were finished. But it wouldn't last long; I would just start wailing again, howling with the pain in my chest.

My friend just sat on her side of the couch, smiling gently, as I howled, "I don't want to! I don't want to!"

She said things like, "You can't have your cake and eat it too," and, "All good things come to an end," which only made me cry more. I had always recognized deeply how lucky I was to be able to have the lifestyle I had, to travel and to work like I had. I was fortunate to have a job which allowed me my peripatetic life. I was always grateful, every day.

Thankfully my friend did not feel sorry for me. She just watched me, letting me cry it out. She did not pat my shoulder and say, "Poor you". I told her why I was having to settle, and she understood and agreed.

All my other friends had similar things to say, all saying variations of the same line all-good-things-come-to-an-end. One friend, a friend whom I had met on my first locum job and with whom I had kept in contact with, was looking to settle down as well. She went so far as to say that the best time to find a job had been during the previous six to twelve months. Now, she said, the openings were fewer and the hire on packages the hospitals offered were not as lucrative. In her search for a settled job, some hospitals had not even called her back. She told me that if I had a good offer, I should push it.

She teased with me, "What happened to the good old days when a warm body was good enough?"

A recruiter who had recently retired from the business but who was still a friend sent me this email:

"From a former recruiter's standpoint, the job market for locum tenen anesthesia is drying up BIG TIME. No matter what our managers would tell us, we all know the truth.

The three big things about taking a permanent job are going to be: 1) you will have less vacation time, 2) you will now be exposed to possible political battles within the hospital system, and 3) you will be living in one place. If the offer is good, the people are reasonable, you like the area, and you're willing to forego your time off, I say go for it! Nothing is ever permanent, so in a few years, if you decide to hit the road again, great! But for now, you may be scarce on locum tenen work if you decide to continue on.

I told several CRNAs last year that the work was drying up, especially if they were picky about where they went, and that a permanent job may be their best option for now. You have my vote on the perm job. Hope that helps! Haha. "

Everything seemed to be pointing in the same direction. If I wanted to keep doing anesthesia, if I wanted to keep earning the money which anesthesia brought me, then I had to get off the locum train, settle down, and buy a house and a car.

I knew that I could still choose my dreams. A voice in my head kept screaming, "It's not too late! It's not too late!" I could still, even then, turn away and say, what the hell, and go to New Zealand. But I couldn't. Anesthesia gave me a roof over my head, food in my belly, clothes on my back. Anesthesia allowed me to go to New Zealand, it gave me the funds to do so. It gave me the ability to travel, to have the independence to do as I pleased.

I knew I couldn't depend on my family for financial help, should I need it. They were still struggling to make their own ends meet let alone have any extra for me. I knew I could ask Kent for help if I needed to, but I didn't want to do that. So staying in the States, continuing my anesthesia career, gave me the best choice for a secure future. As much as I wanted to travel and to continue my itinerant lifestyle, I could not give up my work.

But, funny as it was for me to say, I had really thought I was supposed to be in New Zealand. I was not one to believe in things like that, so it was strange for me to say, but I honestly thought I was meant to be there. Before I forced myself to settle down, before I forced myself to listen to the voice that drove me to be responsible, everything had been clicking into place. Even now, all these years later, I am left with a strong feeling of having missed something important.

But I did not have a crystal ball to know if I was making the right decision. I wished I did. And the truth was that going to New Zealand was an unknown too. I might get down there as a nurse and hate it. I might hate living in the culture. And I would have given up my career in anesthesia to be there. But I did, I fully admit, want the opportunity to see for myself.

I still wanted to be on the New Zealand nursing registry, so I sent in my nursing application. It would be a beacon of light for me, a hope that one day I would be there. The settled contract I accepted in the United States was for three years. In three years, I would still be less than age 55, which was the maximum allowable age to be a New Zealand resident. A lot could happen in three years. Kent kept telling me that he would remind me of my dreams. I just knew, from my experience settling down before, that once you established roots, it was hard to uproot again. So I could only hope and dream that I would get there one day. I did not want to be 70 or 80 years old, asking myself, "What the fuck?!"

So I took a deep breath, I moved on, and I counted the things I was grateful for. I had so many good things in my life. Kent and I were still together, connected as friends and lovers. We had our good health. I would have a lucrative job doing the anesthesia which I loved. I liked many of my new co-workers, and I was making friends. I had fun hobbies, such as kayaking, hiking, gardening, yoga, and QiGong, which I could pursue to keep me busy outside of work. I was okay.

To remember all I had hoped for and experienced, I took the fragments of my greenstone Koru to a professional picture framer. They were able to piece together my tiny jade puzzle and secure it in a frame. I look at my framed Koru often; so much of my personal history, so many emotions, represented in something so small.

Decisions made, the world turned, and life went in another direction. Koru, the symbol of new beginnings, the constant of new beginnings, the circle of things in life.

PART TWO

TIME OF TRANSITION

Haiku in the Sun

Before my contract officially started, while I still had time off, Kent and I met for a short holiday at one of our favorite beaches in the Caribbean.

I loved the rhythm of the Caribbean. The rhythm was heard in the click of the wind in the palms, in the tweet tweet of the tiny birds with a yellow breast, in the flush of the red hummingbird as it zoomed by, in the meow of the cats wandering around the hotel complex. The rhythm was felt in the cool of the mornings and the nights, and in the heat of the day. Time was measured by the tilt of the sun, confirmed by when the sun umbrellas were put up and when they were taken down. We slept when we felt like it. We drank when we were thirsty. We ate when we were hungry. We felt the sleepy numbness of the evening wine. I loved the rhythm, the song that was the Caribbean.

Trying to capture the essence of the moment while dozing on the beach, I wrote Japanese haiku in my head.

These haiku I write

Three lines in five seven five

verbal sudoku

Squinting at the bright Caribbean sea, I wrote

Liquid turquoise glass

sun sparkled diamonds, I love

tropical waters

Watching the tourists and locals play, I wrote

Caribbean sun

warming the tourist bodies

from white to copper

and

Bread brings angel fish

to tickle the toes of the

dark skinned girl. She laughs.

And in the heat of the day

A gift from the sea,

the cool breeze mellows the heat

of the midday sun

While on holiday, I took some time to search for houses on the internet. Quite a bit of farmland surrounded the little town where I was settling. It was very rural. Even though my online search was taking me away from the beach, I was happy for the time to leisurely look.

I also emailed car dealerships about buying a car. All my trips to Europe were influencing me towards a Smart car. Smart cars were everywhere in the cities of Europe. I liked its small size and its fuel efficiency. But Obama's Cash for Clunkers program was making it difficult for me to find an available fuel efficient car. All the 2009 models had been bought up. I had checked all the dealerships in the state, plus in the neighboring states. Nothing yet.

Smart Cars and Paradise

When I got back home, I did find a Smart car. A dealership sales agent which I had previously contacted called me when one of his contracts fell through, and I snatched it up, paying cash for it. Thankfully it was a color I really liked, called "lime pop". I liked the name of the color almost as much as I liked the color.

I also started looking at houses with a real estate agent. A lot of them were in terrible condition. The recession had been going on long enough that home maintenance had suffered. Homeowners did not have the funds to properly maintain their homes. Also, because many homeowners had to leave to find employment, many homes were empty, had been empty for a while, so that the air in the houses had a stuffy, musty smell.

We looked at probably 50 houses. But after about a month of looking, I found a house on a little hill with a view over a river. It was a small house, about 1200 square feet, but was perfect for me, and for Kent when he came. I emailed a long-time girlfriend about it. I loved her reply, "Sounds like paradise ! Not too shabby to buy paradise for your first mortgage."

I so wished Kent could be there. I wanted so badly for him to share that time with me, the feeling was almost palpable. I almost felt anxious and angry that he couldn't be with me. It was simply such a huge step in my life, I wanted him to be a part of it.

Do the Hard Thing

By working extra before and after my time off, I was able to get off a 4 days in a row from work to fly south to Alabama, to go to my storeroom to get it ready for the movers. I sat on my dresser, almost paralyzed, but thankful for the time. Thankful for the time to just sit and think and get past it.

With my settling down, with so much to do in only a couple of months, I had been continually driven to action. So much was still left to do before I could feel settled, it felt like a mountain looming. Sitting on the dresser, I had the quiet moment that I needed. I had my moment to thankfully be not as driven as I had been.

I was glad for the bottle of water I had at my elbow, left over from the flight. I was so thirsty because I drank too much whiskey the night before. I loved whiskey, served simple and "neat", straight out of the bottle, with a "thank you, sir". I loved feeling the warmth of it in my mouth. But I was sad to say I had lost my ability to drink whiskey. I had to be careful with it. I had become a lightweight and even a couple of shots of whiskey put me under the table, snoring heavily.

Anyhow, that day, I had bought a bottle of wine; I knew I would do better and feel better drinking that than drinking the whiskey. In the storeroom, I turned on some favorite music on my portable CD player. So much change, I knew fear was a part of it. I knew it was. So much was unknown, fear was to be expected. I am only human.

I looked at all my stuff piled in the storeroom, the stuff of my life. I wondered what would be important now. I had not looked at some of it for over ten years. I was such a sentimental fool, holding on to things which had no monetary value because of the sentimental value they held. I knew the small size of my new house was going to force me to throw things away, give things away. It was a good thing.

I knew to do like I had always done when confronted with mountains: take one step at a time. I told myself not to panic looking up at the mountain, but to look down at what was under my next step, to look at my feet under me and take just one step. That was all. I would cry if I had to, and rest a while if I could find the time.

I remembered the mantra I wrote and tacked on my refrigerator door when walking the treacherous mountain of my divorce: "Do the hard thing. Face it. Look at it. Feel it. Get on with it. Get through it. The only way around it is through it."

I knew through experience that fear, when focused on, grew. The only way to get past fear was through action. Do something, anything, to not focus on the fear. Fear, fear of the unknown, should never stop you.

The reality was that I did not know the future. I did not know how things would turn out. Encouraging myself, I spoke out loud to my quiet storeroom, "Do this now, because you have to but also because you know you want a house and to unpack. Take one step, Elize, just one. Move, Elize. All is okay. I am okay."

I took a deep breath. I told myself that I would do the things which made me feel better. I would go that afternoon to exercise at the gym until I sweated, and that night, I would take a hot bubble bath. I knew I would feel better because of it. I would start each day and end each day with positive words to myself. Nothing was worth all the angst. Nothing.

"Now get up, Elize," I told myself. "Move."

And then I got up, grinning at myself. I AM okay. I AM strong.

Newton's First Law

Settling down was a lot of work.

That is worth saying again. Settling down was a lot of work, especially if you were the only one doing the work, and had a full time job while you were doing it. I felt like I was a squirrel running around, gathering and storing nuts, getting myself ready for the winter.

And although I desperately wished I was not that way, I had always brought my troubles to bed with me. The emotional things which happened during the day went to bed with me at night, tucking under the covers next to me, cozying up against my pillow.

So now, I was having sleepless nights, nights of high anxiety. Up and down, in bed, out of bed, watch television, drink herbal tea, drink half a glass of wine, take a Tylenol, take a hot shower. Every time I would start to fade off to sleep, I would wake up with a start, with an adrenalin rush, with my chest aching, my stomach sore, and my feet sweaty. All traces of sleep and relaxation would be gone.

I kept seeing the mountain. I kept seeing and listing all the long line of things I had to do to settle there. So much was unknown, as well. At one time in the night, I was coaching myself to relax, telling myself to just breathe. Unsuccessfully coaching myself. And I started to laugh out loud to the dark, quiet room. Easier said than done.

And I realized I wasn't having fun. I realized everything could be fun, should be fun really. The excitement of looking and finding a house, moving and unpacking. The joy of finding surprising and fun things to do in the area.

But it wasn't. I knew it wasn't fun because I was afraid of making a mistake. I was afraid of spending my hard earned money on a house that cost too much money to fix. I was afraid of doing something that I could not back out of. I was afraid of spending money on one thing, and then another problem would come up which caused me to have to tear down what I just paid to have done.

I wanted so so much to have fun with the move. I wanted to laugh and to play and to live my life. But most immediately, I wanted to sleep. I needed to sleep. I needed a long couple of uninterrupted night's sleep. My health was not going to take the stress I was putting it under. I liked myself so much better when I was rested.

On good days, when I did get the rest I needed, I realized, I knew, that what I was feeling was the stress of the change. And I knew the stress was finite. I knew I would get through it.

On bad days, I felt like I was going nuts, absolutely totally off my ever-lovin' rocker. I kept losing my ability to speak. I had picked up a stutter. I had never done that before. I knew the stress was overwhelming the synapses of my brain, and there was no room left for speech.

Humans, such creatures of habit, habits that get ingrained into their psyche. I surprised myself when I realized that even the habit of travel, the habit of change, that habit was ingrained in me. It was proving difficult to stop.

Since I had decided to quit being a locum, I had been literally hearing screeching brakes in my head. The screeching to a stop of my peripatetic life. Since buying my car and finding a house, I heard the wheels turning in my head again, gaining momentum, turning faster. Perpendicular to where I used to be. Turning, facing, changing into a different direction.

Newton's First Law could not have stated it any better: "Every body perseveres in its state of rest or of uniform motion in a right line unless it is compelled to change that state by forces impressed upon it". I was persevering as a traveler, as a locum tenen, heading toward working in New Zealand. Then the Great Recession compelled me to change. So then I started heading off into a new direction, full speed. Already, my traveling lifestyle felt far away, like a happy magical dream to be recalled in vignettes.

Japanese Lanterns

I had booked a flight months before, before I even started being a locum at that job, for a two week trip to see Kent in Canada. Although I was then a full time employee with no accrued vacation time, I hired on with the agreement that I could still have the time off without pay. Some of my new coworkers were not happy about it, and were definitely not shy giving me a hard time.

One night, Kent and I went to a quaint village close by his house. The village was celebrating their 100th anniversary, and had advertised that they would be having a barbecue and fireworks. The fireworks were supposed to start at 7:30, so we went early to eat. When we first arrived, there were only about twenty people milling about. But within the following fifteen minutes, the numbers swelled to about 150. Lots of kids were screaming and playing and having fun. The street and the green space were full.

The garden space next to the street, which was only about 20 feet from where we were standing, became the fireworks launching ground. They started by launching three Japanese lanterns, which I had never seen before. The Japanese lanterns were basically small hot air balloons, made of a flame proof material. At the bottom was a small incendiary, a flame, which was lit. The heat of the incendiary filled the balloon with warm air, and within about 30 seconds, the balloon would gently float up and away. Japanese lanterns can only be launched on calm, windless nights. That night was just such a night, and with the full moon and clear skies, it was magical.

The townspeople watched the Japanese lanterns in silence until their flame was barely a speck, a speck which fluttered and turned to darkness. Then the village started the fireworks. Most of the fireworks did not travel very high, but since they were lit in rapid succession and with a lot of sound, it was a great, fun display.

Afterwards, on the way back to Kent's house, we drove through the open countryside, enjoying the full moon and bright stars.

While I was in Canada, my favorite walking boots wore out. I put them into the shoe recycle bin at the local cobbler shop. I had walked in those shoes all over the world so that the sole became thin and my feet would get wet in rainy weather. I tried to get them repaired in America, but the cobbler in America told me the same thing that the cobbler in Canada told me: that the sole was of a man-made material, all in one piece, that could not be fixed. They were perfect short boots, coming up to just below my ankle, with Nubuck leather uppers. I could go from the city to the country, the style was good for many occasions. And they fit my foot like a glove. I knew I would miss them. It represented yet another coincidence of my life moving away from traveling. My favorite traveling shoes, gone with my traveling lifestyle.

I am a New Zealand Nurse

When I returned to the States, I opened my accumulated mail. I was delighted, yes, delighted was the word, as I clapped my hands and gave a squeal in proud glee, to open a big envelope from the New Zealand Nursing council. Enclosed was an embossed, official Nursing Registry, with a nice letter from the council congratulating me on successfully obtaining my registry. I went to my computer to email Tim and Ron in Kauri. Before I even sat down, I knew what I would say, "I have my registry, but I can't come now."

Noticeably missing in the mail, however, was the letter I had asked my new chief CRNA to write for me, a letter to the New Zealand Nursing council confirming my work history. Thankfully the Nursing council did not require it! He had not even sent word about it via email while I was in Canada. Just silence, and all the while, I thought that his letter was waiting for me back in the States. If he had not wanted to write the letter, it would have been much better all around if he had just told me that. Then I could have asked someone else.

I was finding that that sort of behavior was a trend with people in that particular part of the world. If they did not want to address an issue, they just ignored it. Other examples were unanswered emails I sent to the Head of Human Resources at the hospital, to the Anesthesia secretary, and to a contractor who was going to give me a bid on some work with the new house. Not a word, just silence. In my book, that was rude. But there, it seemed to be the norm.

The Honeymoon is Over

I began to realize I was getting past the honeymoon phase at work. People were starting to move beyond their "chocolate side". Germans used the term chocolate side when they meant good first impressions. A person showed their best self when first meeting someone, their wonderful, sweet behavior. But I had been at that hospital long enough that people were starting to show their true self.

Maybe also it was that the winter season was getting to everyone, making people tense and aggressive. The weather had been cold, dreary and snowy. It had been so cold and the snow so dry, that the wind blew the snow off the roofs like it was dust, sending it swirling. It was mid-December, the days were short and the nights were long, and perhaps people were feeling the holiday stress. But I'd been there long enough that they didn't feel compelled to hide their stress from me.

A couple of things happened one day. One, there was a delay obtaining a laboratory result on a patient, and I asked the anesthesiologist I was working with whether he wanted to wait for the result before going back to surgery. He mumbled something that I did not hear as he walked away.

After a while, I went to ask the preoperative nurse if the the results were back, and the anesthesiologist walked up as I was asking her. I asked him again if he wanted us to wait for the laboratory result. He looked at me sternly and pointedly said, "What did I tell you last time you asked me that?"

I said, "You were walking away from me when you replied, so I didn't hear what you said. But I would be happy to hear your answer if you would repeat it."

He didn't say anything, just got a faraway, deer-in-the-headlights look. One of my CRNA coworkers standing nearby heard us and angrily looked at the anesthesiologist, shaking his head. I was glad to see that someone else thought it was just as rude as I did.

Another thing that happened was that I was doing the anesthesia for a friend of one of the operating room nurses. That nurse came in the operating room while the surgery was in progress and asked how her friend was doing. There are federal laws which protect a patient's privacy, called the Health Insurance Portability and Accountability Acts, or HIPAA. I gently reminded this nurse of the laws, and apologized for not being able to share any personal information about the patient, admitting to her that I knew she was her friend.

The nurse became harsh and said, "I didn't say any names", which didn't really make any sense to me. Even if she didn't call the patient on the operating room table by name, she obviously knew who was there.

I replied that the patent's husband had told me that he would love to talk with her out in the waiting room. I added that the patient, her husband, and I had spoken about this nurse before surgery. We had even talked about some beautiful home repair work that the patient's husband had done for the nurse and her husband. But apologizing again, I repeated that the patient had not given me permission to share any information with the nurse.

The nurse then said tartly, "You know everything about me."

I replied, "No, not really". At this point, I just wanted her to go away.

Little incidents, really. But the sum total made a discordant note to the day.

The Global Recession

I had emailed Tim and Ron, and my other contacts in New Zealand to tell them about obtaining my New Zealand Nursing Registry. The owners of a Bed and Breakfast Kent and I had stayed in, one of whom was a nurse, replied, "We hope all is well and we look forward to meeting up with you when you eventually get to New Zealand. Things are tight here too, with not many nursing jobs available, and lots of retired women are returning to nursing because of the economy."

Ron, my Anaesthetic Technician friend in Kauri, said he was "staying put" because of the economy. Before the recession, he had been entertaining thoughts about moving to a different job. He also said the hospital had scaled back on their nursing staff, and had cut three full time nursing positions in the operating theatre.

So I saw again that I made the right decision to stay in the United States, and to continue my work as a CRNA. I wondered, and was doubtful, that a job would have been available for me in New Zealand. And the locum market in the United States remained tight. So, reluctantly, I had made a good choice. I could still go to New Zealand some day. I had my lifetime Nursing Registry there.

I was warming to a new idea of having a home in America and a home in New Zealand. I liked the idea of being a snow bird between the northern and the southern hemispheres. Hopefully I could work toward that new goal. The world would turn, doors would open and close, and time would tell.

Clearing out the Storeroom

I flew to Alabama to meet the moving company at my storeroom, to load up all my stuff and move it to my new home. The plane was pretty empty, so I had three seats to myself, which was very nice. I laid down and took a nap.

The movers arrived at the storeroom on time and had it all loaded five hours later. That was the first time in my life that I had not moved my own stuff, and I had to say it was sure nice. My mother helped me, taking pictures of things as they were being loaded. In between, all of us talked and laughed and basically had a good time watching the men happily do all the work.

The storeroom manager had told me to just leave any trash, or anything I did not want, in the storeroom and they would clean it up and get rid of it. One of the things I left was an antique iron standing floor fan. I loved that fan, the motor was still in excellent condition, and I had always intended to restore it. But try as I might, I had never been able to find someone who would take on the task. So in the end, I decided not to take it. Freight charges with moving companies were based on weight, and the fan was so heavy that no way I could even lift it. I had to roll it to move it.

It was weird not having the storeroom anymore. It did not really hit me until I was leaving my mother's house to go to the charity shop, to drop off things I did not want. The last nine years, I would have turned right to go to the storeroom, but I realized that turning right had no more meaning for me. It was a weird moment.

Items I dropped off included a microwave, an old coffee table, my age-yellowed BSN nursing student apron, an old camp stool, and a brand new plant stand which was not my taste anymore. And I gave them my wedding dress, still preserved in the box from the dry cleaners. It felt really good, and quite symbolic, to DUMP that ! I also took a taxidermic duck which had belonged to my grandfather. I pointed out the duck to six grey haired male volunteers at the charity shop that day. They were still looking at it as my mother and I drove away, giggling.

Firsts

I like "Firsts". That is, I like doing something for the first time. So I kept a running list of Firsts, to be able to remember them.

So here was my list of Firsts when I was settling down from my locum life. First time changing the garage access code on my own house. First time looking outdoors through my own windows, with a house attached. First time living outside Alabama, not being able to call myself an Alabaman. First time calling myself a Northerner. First time having a catered housewarming party. First time that not one person stayed to help clean up after a party.

Because my life was so hectic, the housewarming party was a stretch to get arranged and planned, but I so wanted to do it, to celebrate my settling down with my new friends, neighbors, and coworkers. The party started at seven p.m., and by ten p.m., the house was emptying.

After saying goodbye to the last guest, I turned from the front door to find an utter mess. Even though my furniture had not even arrived from Alabama in time for the party, the place was like a trash heap, with bottles everywhere, trash on the floor, liquids and food scraps on the countertops.

It took three hours for me to clean it up. I would start in one spot, and get distracted with another pile of stuff in another spot. All the crap, everywhere, was daunting. I finally started making progress after I focused on one spot at a time. As I was cleaning up, I had a glass of wine. And then I had one more, just the two. By the time I was finished at 1 a.m., I was so exhausted and tipsy that I started to cry. I started crying so hard, I had to hold onto the bathroom sink to keep myself from crumbling to the floor. I was screaming in my head, "What am I doing!?!"

For the last couple of days, I knew I had been grieving again. I knew I was experiencing a loss, a loss of my hopes and my dreams. From all my education, I intellectually knew that resolution of any grief and loss followed no set course. I knew the reality, that I had chosen not to go to a country that I honestly knew little about, where I wondered if I could even find a job. But knowing that didn't stop the grieving, experiencing the loss. I knew I was looking at what I was losing, not at what I was gaining. And it felt so big, what I was losing.

At the time, the main thing that I was losing, the big thing that I was missing, was time off. Time off to reset my mind and my heart. Time off to sleep in and to wake naturally, without an obnoxious alarm. Time off to nurture my right brain and to discover balance in my soul. Time off to get away from the politics and the frustrations of work. Time off to lie in Kent's arms, just being, without pressure to do other things.

All the changes in my life really just happened over six months. It was a fast change over those six months ! Six months prior, I had been going posthaste in one direction, then, suddenly, I was going in an entirely different direction. I was going to grieve, it was only natural. The grief was going to explode out from me from time to time, because everything happened so suddenly. And I had been so busy reacting, taking care of all my lists and my lists of lists, that I had not had time to properly grieve.

The life I was making for myself was good. The job was okay. I liked my coworkers, for the most part. I was getting a good wage. I was loving my little house, and driving my Smart car was totally awesome. It was all good.

So that night, after I cleaned up from the party, was another First. I slept in my own home for the First time. I slept on the floor of the living room, on an air mattress borrowed from a coworker. Although I slept in front of the gas fireplace, with the flame turned on high, I was cold all night. I woke achey and exhausted. Then I looked out my window and saw someone hiking in the distance, bundled against the cold, and I smiled.

I realized I was over the tip of the mountain. There were still a lot of things I needed to do, but I felt like I had gone over to the downslope of the mountain. I was not looking UP at the mountain anymore. I first felt that when I came back from Alabama after the movers loaded up my things. Car bought, check. House bought, check. Movers had my stuff loaded and the storeroom was empty, check.

A couple of days later, I went to a home improvement store to buy needed things for the house. I bought a strong dolly to haul stuff, antifreeze for the car, a wet-boot mat, a broom, and a shovel. Then I aimlessly walked around the store with my cart.

I kept wondering, "What do you need for a house?"

It was so surrealistic and strange, I laughed out loud. It had been so many years since I had to think of house maintenance, I had forgotten the details.

The movers finally arrived with my belongings, and set everything up in my house. The driver, the only crew member who traveled with my belongings all the way from Alabama, complimented my new home, saying, "You have a nice house. I would love to live here. I can see myself here."

So their departure led to another First. First time sleeping in my own bed, in my own home.

The next evening, I found myself sitting by the window overlooking the river, watching the full moon slowly set. There was a haze in the sky, thin enough not to obscure the moon's brightness. It was a Wolf moon, mid-winter, with the proverbial wolves howling outside, me safe and warm inside my little Teepee. I do like a room with a view. And I had one.

No Topic is Off Limits

The milieu of the operating room had always been a close one. Those working in the surgical unit, especially in the smaller units, worked together a lot. Some complained they saw their coworkers more than they saw their spouse. We saw each other during our best and our worst. We learned each other's strengths and weaknesses. It was like one big crazy dysfunctional family.

Operating rooms could be loud and offensive. Many attempts had been made to curb that behavior, to keep a more professional and quiet atmosphere, but with only limited and temporary success. I have to say that it was all up to the surgeon. An operating room was noisy and obnoxious, and the music was loud, if that was how the surgeon wanted it. Or at least, if that was what the surgeon was okay with.

Music was played in almost every operating room I had worked. Some surgeons liked classical music. Others liked opera, belting out in tenor or bass along with their chosen operatic tunes. Some surgeons liked hard core heavy metal, some liked techno, other liked rap filled with vile, sexist lyrics. I had worked with surgeons who liked their music cranked up so loud that you can barely hear your own thoughts, let alone the safety alarms for the patient's vital signs. If that was what a surgeon wanted, that was what was played. If an employee complained, then that person was assigned to work in another operating room, or was talked about and called names.

I had also worked with a few surgeons who liked their operating room as quiet as a pin. Even discussions about patient care had to be spoken in a soft whisper, and kept as brief as possible.

But I would say the majority of surgeons did not really care how loudly people talked or how loud or soft the music was. They were able to focus so intently on the work at hand that nothing interfered. All surgeons, but these particularly, seemed to work best when they worked with a scrub tech who knew their preferences and techniques, who knew which instruments to hand them with barely a word from the surgeon. The surgeon just put out their open hand and viola!, the instrument was in it. It was like magic. But magic it was not; it was the skill and attentiveness of the scrub tech.

No topic was off limit for discussion in an operating room. The strongest opinions, the most vulgar or sexual stories, the craziest tales, the foulest language, were all heard during a typical day in the operating room. The only topic which seemed to be taboo was about the patient's body habitus. Generally, most people who worked in the OR attempted to refrain from discussions of how a patient's body appeared; it was like a nationwide mutual understanding.

One example of strong opinion given in the operating room was when a scrub tech told his thoughts about the then current devastating earthquake in Haiti. He preambled by admitting that what he was about to say could sound "harsh", but what he said next was not my definition of harsh. What he said was cruel. He said that all the Haitians should just die because they were all so poor, and because AIDS was everywhere. He had spoken like an American who had never had to do without. An American who knew that even if they were hungry, that they would not be hungry later, that food was always available.

That night, Kent and I talked about what the scrub tech had said. Kent said he was currently reading a book that brought up a related point. The book was about the air raids that the British carried out on German cities in World War II. The air raids are now largely believed to have had little effect on the outcome of the war, and may have even prolonged the war. The related topic in the book was that among the British public at the time, those who least supported the air raids on Germany were those who had suffered air raids by Germany. Contrasting to this were those Brits who had never been bombed themselves; they tended to be in support of bombing German cities. The ones who were most in favor of the bombings were the ones with the least knowledge.

In other words, support for heinous actions tends to increase as direct experience decreases.

The Commodity is People

Another day in the operating room, I listened as a surgeon and his senior resident talked quietly together. They had their heads together, focused over their work. Their voices were low, almost a mumble, and they talked together as if no one else was present.

This type of intimate exchange was common. Head to head, the surgical team shared breath and sweat. Conversations were whispered so that the whisperers forgot others even existed in the room. They forgot that others had ears too. And if by chance someone made a comment on their conversation, they turned toward the sound of the voice, slowly focusing on the face, slowly remembering their existence. And then they would turn away, back to their intimacy.

The surgeon whispered, "Have you heard about the company Justin's Joints, JJ's, yet?"

The resident nodded his head yes.

The surgeon continued, "The hospital here wants me to exclusively use their implants now. The hospital CFO said that JJ's has the best product for the best cost, and so they're saying that their products are the only ones which they will supply. But I'm here to tell you, JJ's is not the best. They have problems with fails and with a loose fit. I prefer Bob's Bones, have had better luck with them. And industry ratings give Bob's Bones a much higher success rating. But Bob's Bones is more expensive than JJ's products."

The senior resident quietly listened as the surgeon continued. "So all the orthopedic surgeons got together and went to Bob's Bones to see if they could offer a better price on their products, so to be competitive with JJ's. And, Bob's Bones agreed to go down on their prices, to take less of a profit so that they could stay with the hospital. The surgeons presented the new pricing scheme to the hospital's CFO, but the CFO still wouldn't take it. Come to find out, the CFO is neighbors with the JJ's product representative. They go play golf together, and their wives watch each other's kids."

As I listened, I thought of something which I had sensed for a while: that the healthcare industry is not so much about patient care anymore. It is a big business, and people are the commodity. Corporate healthcare is all about the money. And about who is in control.

From Minimalism to Choice of Bowls

Kent came to visit my new house for the first time. He only had a week off from work, but we made the most of the time we had. We decided to focus on having quality time, even if we had to cut back on the quantity time.

During that week, I really saw the contrast between my new life and my former traveling life. Kent was totally of my former life, but was transitioning to my new life. Kent was like a set of favorite flannel pajamas: easy to be with, cozy, comfortable. I did not want to lose that in my rush to create something new.

Another contrast I felt was a source of pride in my new home, a strange, look-what-I-have sort of feel. I am not a prideful person, so feeling pride in what I possessed was a new feeling for me. But a caution rang in my head. My home was a temporary dwelling. It was a finite object. I knew I should not put too much emotion into it, because the next storm could blow it away.

I told Kent about the stuff I had kept in storage all those years, that so much of it was useless or outdated, in poor condition, or no longer my style. I kept so much when I divorced because I had felt vulnerable, and I wanted to have enough for a good start when I did buy a house. So I had what I needed. I just had a lot of extra stuff which I kept calling junk.

I had to admit to myself that the luxuries of my newly settled life were fun, yes, and were nice. For the first time in years, I had a large choice of bowls, rather than just the couple of small bowls at the extended stay facility. I had crystal stemware for my wine, and so many drinking glasses that I could use a glass once and put it in the dishwasher. I had lots of silverware, and an amazingly comfortable bed every night. I had an attached garage which kept me safe and out of the weather. And I had a great gas stove. And I had an oven! And sharp knives! I rarely had an oven while traveling, and knives were usually very dull.

I also had a choice of cooking pans, and even, mind you, lids to match with the pans. And I had a blender, so I could finally make smoothies again. I had a great television, discarded by the previous owners but which was perfect for me. And I had wireless internet which actually worked great every single time. I had choices, and it boggled my mind.

I knew it was good for me to do without during all my traveling years. While a locum, I lived by the ideas put forward by The Minimalists, Joshua Millburn & Ryan Nicodemus, who challenge their followers to ask the question: How might your life be better if you owned fewer material possessions? So I had enjoyed my minimalist, simple lifestyle as I used measuring spoons to eat, drank wine from paper cups, made do with what I had at hand, with what I could pack in my suitcases without going over the weight limit. It was fulfilling, rewarding, satisfying. It suited my impression of myself, of not taking myself so seriously. All that I had when I settled down felt like a luxury, although for many Americans, these things were common, everyday. The luxury was nice, I did admit that. But I clearly saw the contrast.

Having all the luxuries did make me wonder if I would be able to do without in the future, if I would be able to function in a future which might have less, should I have to. I wondered if the luxuries would make me soft. I wondered if I could live with minimalism again, should I have to. But I knew I was being silly. I would be able to function with less if I had to. I had done it before, even enjoyed it, and I could do it again.

The Change of Seasons

After work one day, I walked to the parking lot with a couple of CRNAs and smelled the first whiff of spring after the long hard winter. It was a musty, warm, invigorating smell.

Having grown up in Alabama, I realized that I could more strongly feel the changes in the seasons in the north. I could feel it in my bones. The darkness, the hardness of winter gave way to softness, mustiness, bright sunshine, and translucent green leaves. The contrast with how I felt in the different seasons was greater there.

I realized a funny thing about the change of seasons in the north. In the summer, when it was hot and sunny, it was hard to imagine that the world could ever be cold, dark, harsh. Then as the winter wore on, it was hard to ever imagine this part of the world was hot enough to wear sandals and a sundress, or to run barefoot. It was hard to imagine that the world was sun filled and bright.

Ghosts

It took me about three months to unpack the last of my boxes. In the unpacking, I had learned, again, that I could not escape my past. I opened a box and there it was, staring me in the face: A painting a childhood friend created, a family heirloom, a stone egg made from Carrera marble, a Navajo rug, old newspapers. The past, it was always there.

The ghosts, they moved into my new house. I found, and watched, a video given to me by an American friend whom I had met in Spain. I, and many other international English speakers, had gone to a place called English Town in northern Spain. We were ensconced with Spaniards, thus giving them the opportunity to immerse themselves in the English language. For the ten days we were there, we would have one on one conversations, play board games, have group events, and put on plays. It was really just a whole lot of fun! The video my friend had sent me was of one of the plays in which he played the leading role. I watched him on the video, living, breathing, laughing. Since then, my friend had died from esophageal cancer.

And I found pictures of my grandparents and great-grandparents, uncles and aunts, and of a stepbrother and his wife, all dead. My home, it was becoming a mixture of old history and new history. But it was all me. I choose that life. I choose what I put into my home. I was a tapestry, woven with the warp and weft of many colors and with many textures. It was all good.

I was making peace.

I had felt as if I was leaving behind a life which I loved, not only my traveling life, but who I was during that time. I thought that my traveling life, and the me I had discovered while traveling, were intermingled, that losing one meant losing the other. Yet the reality was that I still was who I had been while I was traveling. Just because I settled down did not mean I had to compromise who I was. I wouldn't do it. I gave up too much to find me. I had learned so much while traveling and I did not need to reinvent myself. Those memories, that life, was still a part of me. All my life, woven into my own personal tapestry.

I also understood the value of having people in my life with whom I had things in common, who made me feel good about me, with whom I could feel comfortable and safe with. I did not want to force friendships with people who were not like me, making me feel out of sorts, like a square peg in a round hole, like I did not belong. I knew that not being able to relax and be myself, that that sort of existence could kill my soul. I did not want it.

The novel thought I had at that moment was that I did not have to feel pressured to be anyone's friend, or even to make friends at all if I didn't want to. It made my shoulders relax just to think that. I had so many ways to meet people, and all I had explored was getting to know people at work. I still had neighbors to meet. And I could take night classes and meet people there. I still had the friends with whom I had known for years. Making friends took time. Nothing was fast, and that was okay. There was no hurry. And I did like being by myself. In fact, I needed my alone time too.

I was coming to acceptance. I could feel it. Even if I had continued being a locum, my life would have changed because that locum life did not exist anymore. There were very few jobs to be had to continue that life. So it was good that I was able to settle down where I wanted to be. If I had continued, I may have been forced to settle in a place that was not advantageous to me.

I, Woman

In the predawn of one morning, I went out on my deck. The icy dew crunched under my house slippers. I wrapped my house coat tightly.

The view compelled me to go out. The air was still. Frosty fog had wrapped the world in white, and a Super Moon shone through the haze, setting low and orange on the horizon. The air was crisp, clean, fresh. A lone morning bird chirped in a nearby tree, reminding me of the camp outs of my youth.

"I like here," I said out loud, and then smiled at the morning.

My yoga instructor had been speaking about the Super Moon, about how the tides were affected. About how humans, being "water babies", were also affected. About how emotions were drawn to the surface by the moon's pull. True or not, I did not know, but I liked the sound of it.

So, using only the words in the magnetic poetry kit I had on the front of my refrigerator, I created the following poem in the moon's honor:

I, woman, sing beneath the sweet light of an enormous moon,

chanting from my breast the beauty of living.

It whispers a gorgeous symphony,

A languid language of love.

I sleep.

I dream.

Later that night, I went out on the deck again. A light wind blowing softly, gently rustling the trees. Frogs were croaking down by the river. Everything was quiet.

I thought, "This, this, this makes it all worth it. This is why I am here."

I saw a plane jetting through the Big Dipper. Beautiful.

I had been having a feeling inside me, a feeling which had been growing. I felt relief. I realized with amazement that this was the first time in my life where I had felt truly comfortable in the house where I was living. For the first time in my life, I felt safe from the dysfunction of my family. I could, I was, charting my own course, good or bad.

And the Sun Rises

I went to spend the weekend with a long time friend who lived on a lake. I knew my friend liked to sleep in late, but I liked to get up early while the lake was still quiet and take her kayak out. The weather for the weekend was supposed to be windless and pristine. So I gave my friend a heads up that I planned to go kayaking early the next morning.

The next morning, the noise in my head quieted, and I realized I was awake. Going from asleep to awake in a quiet room was a weird sensation. I would realize my brain was humming as it came awake, almost like I could hear my blood flowing. My mind recognized and told me that I was awake. I stretched, I turned, not wanting to be awake. I parted my eyes ever so slightly and saw that the bedroom had the gray light of predawn.

"Wake up," I told myself. "Wake up. If you get up now, you can be out in the middle of the lake at sunrise." Sunrise was my favorite time to be on a lake, when the lake was flat as glass and empty of boats. So I sat up in bed, suddenly and completely.

I jumped out of bed, rubbing the dust from my eyes. I turned the coffee pot on as I headed to the window. Looking out, I wanted to be sure the weatherman was correct. I wanted to be sure the lake was calm. It was, and that energized me. I started pulling on clothes. I grabbed my kayaking gloves, which were really just old bicycle gloves. I would occasionally do sprints, as I called them, when I paddled hard and fast across a lake. Sprinting was fun and good exercise, but if I didn't use the gloves, blisters formed between my thumb and first finger. I ran to the garage to get the kayak paddle and the life vest.

After making a half sandwich of almond butter and homemade jam, I poured a cup of coffee in a lidded to-go cup and put my smartphone in a waterproof bag. I walked fast to the water. The day had turned yellow, so I knew I probably had about ten minutes before the sun rose. I eased the kayak into the water, slid it over the sand, and felt the surface tension lift the bow. I tossed the life vest over my shoulders and cinched one buckle in front. The whistle dangled from the front of the jacket, for those just-in-cases. I climbed in the cockpit, settling on the seat. I still felt sleepy. Eight minutes prior, I was in bed. I smiled at that thought.

I had the lake to myself, with not even a fisherman in sight. I started paddling, dipping deeply into the water, picking up speed. My aim was the big center of the lake, so I could have the water around me as the sun rose. I kept looking toward the east, hoping to beat the sunrise, paddling fast, feeling my body wake up. It felt good to move. I was almost to the center of the lake when I realized the sun was about to come above the horizon. So I dug in my paddle to stop the kayak, and gently turned the bow southeast. I wanted to be facing the sun, I wanted the warmth full in my face.

I waited for the waves to settle, for the surface around me to be calm again. I raised the coffee cup to my lips and took a sip, and I waited. I knew how to wait. Tiny insects walked across the water's surface, skittering away. Fish plopped. Canada geese flew so close overhead that I could hear the rhythmic breath of the wind in their wings. A dog barked once, twice, in the distance. And the sun rose.

The Year of Exhaustion

A year after settling down, I had a week off to go visit Kent. It was only a week, but I had not been to Canada for ten months. At one time in my life, I was at Kent's house more than anywhere else.

It had been a crazy year, too crazy. Thinking back, I thought of that year as the year of frantic madness, of sheer exhaustion. More than anything that last year, I missed time off. All the years I did locum work, I averaged working 35-39 weeks a year. I was then working 47 weeks a year, plus overtime, holidays, and weekends.

I used to say that you could never say you did not have time to do this or that, because you actually had all the time that existed. But I had learned during my year of exhaustion that that was not true. My time did not belong to me anymore. My time belonged to my job and to my house. My time was so constricted that I always knew what I had to do, I never had any time to just be spontaneous.

I fully missed being spontaneous, being able to do what I felt like at the moment, having a whole day, or days, stretched out before me. I missed being able to do nothing more with my time than try to figure out what it was I wanted to do. I missed being able to go, on the spur of the moment, wherever I wanted, do whatever I pleased. I never had the opportunity anymore to just sit and explore the possibilities of my mind, based on my whims and desires. I missed time off to reset my head, to find my center, to get my bearings.

I missed time off to catch up on my sleep. My head was fuzzy with lack of sleep. When I didn't have enough sleep, I knew I became more focused on completing a task, on reacting, rather than on the feeling, the intuition, the what was right. And sleeplessness made me forget to have fun. I used to wake up in the middle of the night to the sound of my own laughter, from one fun dream or another. I had not woke up laughing for longer than I could recall. When I did not get enough sleep, I could not dream my fun dreams. I became more pedantic and unhappy. I lost my internal balance.

As E. Joseph Cossman, an American entrepreneur, put it so well: "The best bridge between despair and hope is a good night's sleep."

The last years of traveling, when I had the opportunity to explore what I wanted, to sit and just be, were so healing, so very healing. It taught me more about me, what I want, who I am, what I feel. And Kent was a big part of that by his nature of allowing me to state my desires and to do them, without criticism or negativity. It had always been give and take with us, which was so totally opposite of all the other men in my life.

Now, I was so busy, I felt like I barely had time to even talk with Kent. I felt at times like I did not even have time for our relationship, as little demand on my time as it took. And that made me sad, and it was dangerous, because I did not want to live my life without Kent.

I had learned a couple of important things about myself during my year of exhaustion. First, I learned that when I saw something at my home which needed to be fixed, I felt compelled to fix it. It gnawed at me until I fixed it. I knew I was going to have to not feel so compelled to get up and do projects.

Before my year of exhaustion, I used to believe, still did to a large degree, that if someone took on the responsibility of a home, then they should take care of that home. But my criticism of people who did not take care of their home was softer. I was not so harsh. It took me eight months of living in my new little house until I was able to get all the boxes out of my living room, and new furniture bought and set up. I had thought it would take me only four or five months to get the living room completed. So I understood more clearly how things could just not get done. How time, weeks, and months could pass and that thing you had been meaning, been wanting, to do, remained unfinished.

That year, I had also learned a new appreciation for homeowners, especially homeowners with kids and a family. I was clueless how they did it. I had a new found respect for parents, especially for single parents, who had to juggle children, a home, and a job. How did they manage it all? I was stumped, and I was humbled.

I realized I was going to have to carve out time to just relax. But I also needed time to get back to the gym to work out, and to take more yoga classes to find my center.

When the economy forced me to settle down, I knew I was going to have to give up a lot. The one thing I did not realize I was going to miss so much was time.

Practice Contentment

"Up dog, down dog, stretch, tilt your hips, hold hold hold," my yoga instructor guided us through his routine.

"Breeeeathe," he instructed. "Focus on the here and the now. Calm your mind. Feel your breaths, in and out, in your nose, out your mouth. Breeeeathe".

As we moved into the different positions, he continued, "Yoga is the mastery of mindfulness. Of living in the here and the now. Of focusing your attention on your breathing, on the movement of your body, rather than on the brooding over the past, full of regrets or missed opportunities, or on the endless worrying about the future. Only during mindfulness will the true measure of yourself be made clear."

My mind flicked to my missed opportunities, to New Zealand, but I quickly returned to the moment, to my breath, and I smiled. If I were in New Zealand, I wouldn't be with that great yoga instructor. I really liked him.

He continued, "Now let's do the eagle pose. Right arm over left, bring your hands around to face palms together. And, yes, I see some of you already in position. Tuck that ankle around the other ankle. Now bend at the knees, hold it, and breeeathe. Yoga is the practice of staying strong in your body, but also staying strong in your mind."

He continued, "So many people think that contentment is something which you luck upon. Or which lucks upon you, like when the weather is nice. But contentment doesn't work like that. Contentment is something that you have to look for and strive for. You have to insist upon it, and you have to fight for it. And once you have achieved some measure of contentment, you should then fight to hold on to it, because if you don't, it will leak away. If you are depressed or full of anxiety, this becomes a habit, a tendency which happens over and over again.

So practice. Practice contentment."

On the way home from class, my mind drifted back over the years to my marriage. I had always known that in a relationship, it took two to make it good, but it also took two to make it bad. I knew all along that I had a part in my long, sad marriage, and I was still learning the full meaning of that.

And I thought of my friend who was miserable in his life and in his marriage, so miserable that he became an alcoholic, depressed and barely functioning. Eventually, he put a bullet in his head. As I thought of him, I knew that a part of fighting for your own contentment meant surrounding yourself with people who supported your contentment. As I thought of my marriage and my friend, I knew that those around you could make you want to kill yourself.

During my divorce, and during the time afterward when I was trying to make sense of it all, I had decided that if I was going to go through all the pain and emotional torture of the divorce, then I was going to damn well make sure that my life was better in the future. I was not going to practice those behaviors which made me unhappy. My marriage and my friend had taught me well.

I had always known too well the passage of time. I felt it in my bones, in my soul. I had always known we only lived this one life on earth. We were just carbon creatures, made from complex combinations of molecules; ashes to ashes, dust to dust. Since we only had this one life, we had to make the best of it. The first time I realized this, the first time I knew it, I was the tender age of 13. Knowing that I only had the one life was amazingly liberating. It liberated me to cherish each moment, each breath of contentment as best as I could.

I thought of a quote by Stephen Hawking, "I'm not afraid of death, but I'm in no hurry to die. I have so much I want to do first."

The Ache to Travel

Before I became a traveler, I would look up at a plane passing over head and want to be on that plane. I could imagine a person sitting in the plane, looking down on me as I looked up at them. I could envision that person turning away from the window to sip tea, to listen to the other passengers talking softly, or to listen to the relaxing hum of the jet engines. And then I imagined their thinking of the destination ahead. I could imagine it, and I ached for it.

But I had not felt that ache for a long time. During my traveling years, when I would look up at a plane, I would think of those passengers and I could see myself there. I did not ache to be there because I knew that in a month, or in a week, I would be up there, looking down.

So I was in the operating room working with a student one day. The student was doing a great job, and the patient was stable. I turned toward the door to look beyond the door, out the window across the corridor to the clear blue skies beyond. Two jets were leaving contrails behind them, and for the first time in a long time, I wanted to be on that plane. It wasn't a strong feeling, certainly not the ache which used to overwhelm me. But I wanted to go where that plane was going. I could see myself sipping water and slowly eating the pretzels as I had done so often before, looking down on the small world, relaxing into the forward movement of the plane.

Then I caught my reflection in the operating room door window. I noticed that the operating room window vertical blinds were in front my reflection, like bars on a prison. My breath caught in my throat. I had to assure myself that I was not trapped, that I could travel again, that I would travel again. But the symbolism stayed with me, was still in my thoughts a week later.

The Sheer Effort of My Will

When I did the anesthesia for a really sick patient, I felt like I made them live by the sheer effort of my will. I fought for their life. They kept wanting to die, and I would think, not on my shift, not on my watch. I won't let you die. It took it out of me, that fight. Sometimes I felt physically exhausted, almost sick, the next day.

One day, I worked a crazy busy shift with a thoracic surgeon who had posted six surgeries to do that day, three of which were for critically ill Intensive Care Unit patients. About three a.m. that night, I woke, startled, with a dream. In the dream was an elephant with two trunks. The elephant was being forced into a narrow gorge. It was being forced to push against the sides of the gorge with its two trunks, knocking down parts of the gorge walls. He had to push his trunks sideways, one trunk on each side. The elephant could barely fit in the gorge himself, so pushing against the gorge walls at that very close range was torturous work.

Pound, pound, pound the elephant would hit against both sides of the gorge simultaneously. Somehow, the elephant was made so that all its energy went into its trunks, to pound against the walls. It did not even have energy left to stand, and its eyes were rolling up in its head with exhaustion. But pound, pound, pound it went.

Occasionally it would knock down part of the gorge wall, and then the elephant would be forced forward to the next section of the gorge. I kept saying, in my dream, poor elephant, poor elephant. It was dying, this elephant, with the task.

I woke up thinking of the long line of people I had cared for, that I had willed back to health. I felt like the elephant was me, and I was constantly being forced to knock down impossible walls.

Quiet Fierceness

I was amazed to realize I liked winters in the north. I liked how the world closed in and quieted down.

During the summer, the air was so fresh, the days were so long, and the temperatures were so moderate, that everyone was pulled to be outside. Summers in the north had become my idea of paradise.

In the winter, people went indoors, the world closed in and quieted. Everyone hibernated in the winter a bit. I understood why people wanted to close in. I was drawn to it too.

Winter was also a time of contrasts. Winter was quiet fierceness. Quiet, blue-skied, frigid days followed fierce storms. The weather was cold and the clothes were hot. I bundled up in layers to go outside, but inside temperatures were so warm, I became hot and peeled off the layers. When shoveling snow, no matter how frigid the weather, I got hot. When hiking in the crunchy snow, I got hot.

As the winter moved on, though, I got the winter blahs. My joints became achey, and I felt older. I had constant undercurrents of feeling sick, like with a mild cold. I got a sore throat, a headache, malaise, an earache. I woke in the mornings with my fingers hurting when I first flexed them. It was the constant effort of struggling against all the aches which got to me and gave me the blahs.

Added to this was the sameness of the scenery. The world became monochromatic, with shades of black and white and grey. I struggled against the cold and the dark and the ice. I worried about, and kept a sharp lookout for, deer crossing the road in front of me. The effort of it all, against the constant background of feeling ill, gave me the blahs.

The cold dark winter made me want to eat more too. I found I craved heavier meals, with more fat content. I had always heard how people in the north put on weight in the winter months and I never really understood it before.

Since I settled, eating and drinking was something I looked forward to. I used to be very thin, and such a clotheshorse, so in fashion. While I was traveling and did not have a house or a car, I had expendable cash to buy and enjoy nice clothes. Instead of buying a cheesy souvenir, I would buy what that country made well: a leather jacket from Australia, underwear from France, slacks from Switzerland, a wool sweater from New Zealand.

After settling, I did not have anywhere to wear the nice clothes. I did not dress up anymore, and my clothes were going out of fashion hanging in the closet. Loose work clothes, and bulky winter sweaters and coats, had become my mainstay. Since I was no longer out in the world, I did not feel so committed to staying thin. So my gaining weight gave me the blahs.

I did what I could to overcome it. I went back at the gym, getting vigorous, sweaty workouts, which helped. Getting to the gym in the first place was a mental effort because when I first started to exercise, I ached. But I felt so much better afterwards that I continued. I continued to go to the gym, I kept moving, because I could. Because I could move. Being a nurse, I knew too many people who did not have that option. They did not move because they could not.

And I was trying to stay busy and connected with people.

I remembered that in the last two to three years of my locum life, I was feeling the routine of my traveling lifestyle. And because of that, I was amazed to feel a hint of boredom. How could I feel boredom, I asked myself, when everything was change? But I knew the answer: because even change could become routine. Start a new job, finish a job, go on vacation, play the role of the tourist, start a new job, finish the job, and so on. But the boredom never lasted long.

I knew that change would always exist, and because of that, change could also be comforting. I always appreciated how fortunate I was to lead that life, to travel so much, to live so simply without a house or a car.

I was starting to feel the routine of my settled life. How many times had I traveled down that road to my house? My little house had become my house, with it's familiar sights and smells of me.

On the country road I took to work in the dark of the morning, I noticed that a branch had fallen out of the trees. In the headlights, it looked just like a man running full out, left leg kicked up high, right leg pounding the pavement, arms swinging. I got a laugh out of it every morning. Running stick man, I called it.

The Primitive Voice

I came home from work late one evening, and just stood in the driveway, looking at the beauty of winter. I saw the piles of white snow, the snow on branches, and I quietly felt inside me.... spring. It was early March and had been a sunny but very cold day, only 16 degrees. As hard as I tried to listen, I heard no birdsong. There was nothing to indicate spring.

I stood in the driveway for about 15 minutes, breathing in the beauty, asking myself why I thought it was spring. I asked myself what was different, different than a month ago, a week ago, even a day ago. There was nothing, nothing that I could see or hear or feel externally.

I came to the conclusion that it was a still soft voice inside me, a primitive voice telling me it was so.

The next day, I heard the voice louder. Spring! Suddenly, I could smell a mustiness in the air, an earthy smell. And, for the first time since December, the forecast for the following week was a whole week of temperatures above freezing. Rain, instead of snowfall, was even in the forecast for the first time that year.

I planned to listen to that primitive voice more clearly next time.

I Withdraw

I got testy about something at work, which taught me an important lesson about myself.

All the scheduled cases were finishing around dinner time. Only a couple of surgeries were scheduled for much later in the evening. We had five CRNA staff, including myself, who were not scheduled to get off for three more hours. But always, when the surgery schedule finished early, someone was willing to go home early without pay.

Normally, in situations like that, we had a fair way of deciding who was able to go home early. We started by asking for volunteers. If there were more than one, which there usually were, then we looked at who was off early before, or who had a lot of overtime, or we drew straws, or other such democratically fair ways like that. We didn't just let the first person who volunteered to go home go without checking with everyone else.

The Chief CRNA's policy did not require that those with overtime go home early should the schedule become light. His thinking was that the CRNAs would not volunteer to stay to help with surgical add-ons, thus getting overtime pay, if they knew they might lose that pay by going home early another day.

That particular day, one of the CRNAs volunteered himself to go home without checking with the other CRNAs. He simply left. When the remaining CRNAs found out and angrily asked the lead CRNA about it, she said she did not know any other way we had for deciding who went home first. That surprised me, because she had been working at the hospital for a couple of years, albeit generally in the off-site Gastrointestinal center.

The next morning, both CRNAs were in the anesthesia office getting morning report with the rest of the staff. After report, the lead asked the early leaver what had happened, explaining how the other CRNAs had been upset because no one else had been given the opportunity to go home early. The one who went home said, "We never send people home any other way than volunteering to go home."

Now THAT pissed me off, because I felt the lead CRNA might think I lied about it. I told them that when I was around and if I had anything to say about it, then everyone would equitably get the chance to go home.

I was so annoyed that I brought it up with several other CRNAs during the day. They agreed we did not just send home the first person who asked to go home. Later, a close friend of the CRNA who went home early admitted to me that the early leaver knew the unwritten rules, but had been tired and just wanted to go home.

With that explanation, my angry emotions deescalated. We all had days when we were tired, and just have had enough. I understood.

I was learning about myself, and was amazed to realize, that when I felt ill, stressed, exhausted, upset, angry, or yes, annoyed, I withdrew. I suspected that was leftover from my childhood. When my parents argued and fought, it was safer for me to withdraw, quiet and meek, out of the way, under the radar. I had struggled against withdrawing all my life, knowing I was happier with people in my life. So I realized it was a good thing that I was able to be angry from time to time so I that I could practice staying engaged. I liked that I could be okay with being angry. I liked that I could be angry about what happened and I could still have a relationship with those people.

Well, Bless Your Heart

Politeness is a huge part of who I am.

Growing up in a southern home, politeness was ingrained into my southern DNA with harsh looks, stern reprimands, and the sting of the belt.

"Mind your manners, young lady!"

"Cross your legs, Elize! If you sit there with your knees apart, you don't look like a lady. Sit up straight! Your hands in your lap too."

"What do you say? What's the magic word?" I responded with a "Please", adding the necessary, expected smile, the sweetest I could muster.

I would say, "Yes". "Yes what, Elize?" My scripted reply, "Yes, ma'm."

Whatever was happening inside a southerner's home, we were expected to maintain classical genteel manners outside the home. As I grew to adulthood, I embraced courtesy as a part of my personal beliefs.

Common courtesy was a way of life in the heat; perhaps it had to be. I even wondered if the southern tendency toward a gracious, obliging nature developed because of the heat. If the cultural norm was not civility, then the oppressive heat would make you vicious.

A joke exemplified that:

Two women who just met were talking. One lady was an arrogant woman married to a wealthy man. The second was an elderly woman from the South. The women started talking about their children, and the arrogant woman started by saying, "When my first child was born, my husband built a beautiful mansion for me."

The lady from the South commented, "Well, how nice for you."

The first woman continued, "When my second child was born, my husband bought me a beautiful Mercedes Benz."

The lady from the South said, "Why, isn't that special."

The first woman continued boasting while holding up a diamond encrusted bracelet, "Then, when my third child was born, my husband bought me this exquisite diamond bracelet."

The Southern lady commented, "Goodness me, well bless your heart."

The first woman then asked her companion, "What did your husband buy for you when you had your first child?"

"My husband sent me to charm school," declared the Southern lady.

"Charm school?" the first woman cried, "What on earth for?"

The Southern woman responded, "So I could learn to say 'bless your heart' instead of 'fuck off'."

My inclination toward politeness was further solidified during my many trips abroad. So often, the cultural norm in other countries, especially in crowded countries, was to be courteous. In addition, Kent and I viewed ourselves as guests in the other country, as if we were guests in their home. So, my scripted southern politeness was only strengthened by my traveling lifestyle. My frequent trips abroad validated my natural inclinations so that upon returning to the States after being away a while, I would literally wince at the loudness, harshness, and blatant rudeness so common here.

Also, growing up, I never developed a sharp tongue. I am one of those lucky human beings who learn well from other people's mistakes. While everyone screamed around me when I was a kid, I learned that the better way to get what I needed (needed, mind you, not merely wanted) was to speak calmly and softly, to make my words soothing. My dysfunctional upbringing taught me to mollify the way I said things.

The Silver Lining

Kent and I went to Porto, Portugal for a week. He flew from Canada and I flew from the U.S. and we met in Madrid, Spain. On my route, I had a layover in Charlotte, North Carolina, which extended because my plane was late arriving. Mechanical problems were the culprit, so they said.

It was a strength that I could see the silver lining of difficult situations, such as that layover. I realized that, amazingly, on that exact date ten years prior, I had been in that same airport traveling to my first locum tenen contract. Then, I had been fresh off a divorce and happy to have survived it, so I had bought myself a bourbon to congratulate myself for getting through it. I decided to use the current delayed layover to celebrate the memory.

My favorite alcohol was bourbon, drunk neat, straight out of the bottle. I loved the warm burn of it, its heady taste, as it went down my throat. But I drank too much of it the last couple of years of my marriage, and during the first bit of time after my divorce. Since then, I had gotten myself off hard liquor. So my giving myself permission to have a shot of bourbon was a treat.

I sat in the exact same bar and in the exact same chair which had been present ten years prior. I noticed the bar's grand piano had been moved to the other side. I chose the same bourbon as I did then, Maker's Mark, to celebrate my having survived then and to my living now.

I remembered the first time I sat there, the bartender asked me if I wanted to make it a double. And when I had told her, "yes", a couple of guys on the other side of the bar had whistled. I remembered glaring them to silence. They left me alone after that.

A funny memory. I raised my bourbon to those memories. "I salute you."

Shocked to Silence

My former locum recruiter had warned me. She had cautioned that when a locum settled down to a full time position, they would get more mixed up in hospital politics, whether they wanted to or not. One of the beauties of my time as a temporary contract employee had been that I could keep myself more separate from work dramas.

Since settling in one place, I began to struggle with the games and the hangups of the coworkers I had to be around. Work had become like standing on shifting sand. I was always unsure of my footing.

But the silver lining was the thought that settling in one place had only shown me more clearly the type of person I did not want to be around. The kind of person I wanted to avoid were those who were critical, angry at life, controlling, manipulative, and sometimes even downright cruel. They could and did make my life miserable. So the only answer was to avoid them. They were sad people, and I could not change who they were.

The problem I was having was that I could not steer away from them. It just was not possible. I worked with them and I was working more than I was off. Their opinion of most everyone was negative. I realized that the better solution was to not take personally their opinions, to try to just laugh it off. Then I would put myself around someone who made me feel good. Sounded good in theory, at least.

But I just hated being around people like that! They stressed me out. They gave their negative opinions of everyone and everything so freely, usually out of the blue, that it shocked me. It shocked me speechless, so that I could not think quickly of a comeback. It was five minutes later that I thought of the retort. It was only later I thought of the witty reply.

Typical examples which shocked me to silence:

Someone angrily charging into the employee lounge shouting, "Fucking bitch! She's a moron!"

Or

Four CRNAs were discussing the strengths and weaknesses of their coworkers, which in my opinion was none of their business. One CRNA criticized another CRNA by saying, "He's a lazy ass son of a bitch and needs to be fired. I think Paul just can't handle the task."

Or

A pharmacist who suggested to one of the CRNAs that he should reconstitute a powdered drug a certain way, and the CRNA saying "ok" to the pharmacist's face. But when he came into the anesthesia office, he said, "It's none of his god-damned business. I'll do whatever the fuck I want!"

Or

A CRNA who talked about the nurses on the floor, "I just walked up to the floor as a group of nurses were anesthesia bashing. They were talking about how they never mind calling us in the middle of the night to do the most minor things, because we make the 'big bucks'. They're the nastiest group of fat asses anywhere."

One of the other CRNAs suggested, "Take them doughnuts. They like to eat at the trough. They'll be hugging your neck before you know it."

Or

"That obnoxious asshole just came up to the head of the bed, where I was working, and blocked my way to the patient without even a nod. I stuck a towel clip in his ass. That made him move."

Or...

well, ok, you get the idea.

When I was the idealistic teenager who decided to become a nurse, I never thought I would end up being around "caregivers" who were so cruel. I knew if I complained, my co-workers would say, "Put on your big girl panties. This is the real world."

I already knew what my answer would be. The answer rolled around in my head. I would say, "Really? And why does this real world have so many assholes in it?"

And really, I did wonder why it was that way. It did not have to be that way! They could be better people. They could continue to be the facade which they put on for the patient, the facade of the caring professional. Why did all that go away when the patient went under anesthesia?

It was so nice when I was a locum to not have to stay around people like that. When I found myself working with people like that, and I always did, I could effectively avoid them until the contract finished. But the locum life was no longer my life, and those people were around me all the time.

I did wonder how much of their negativity Paul, the chief CRNA, heard about, and thus influenced his opinion of all of us. Who wrote our annual evaluations? The chief CRNA may have given me my evaluation, but he did not write them. He never observed what I did, he was always in meetings, or had his nose to his computer in his office. He had no clue about my strengths and weaknesses. So who told him what to put on my evaluation? I asked him at my last evaluation, and he would not say. He avoided my questions. He avoided my eyes.

One of the nice things about being a locum was that I never had to have a written evaluation. If an anesthesia group did not like a particular locum, they cancelled their contract. But since again becoming an employee of a group, annual evaluations had again become a part of my life. So on my second annual evaluation at the hospital, Paul gave me 3's and 4's, with a range of 1-5 and and five being the top score. He said that I was a "solid performer", and my only "needs improvement" was that I should seek out higher acuity cases. That was a bunch of crap, and really annoyed me. He had no clue that the last few months, I had done so many complicated cases with the thoracic surgeon that he and I had become friends. The surgeon and I bantered and teased each other like old pals.

Thankfully, thankfully, I really liked the thoracic surgeon, otherwise my being with him so much, I would have gone crazy! I laughed at the thought of that. When I was a little girl and my dad left to go to work or on an errand, I would follow him to the door begging him to let me go with him. I would say, "Where you going daddy?!"

I remember it clearly. He always said, "I'm going crazy. You want to go?"

I would always resoundingly say, "Yes! I want to go crazy too!"

And I laughed, thinking of my class theme song when I was a student nurse anesthetist. The lyrics went something like, "We're never gonna survive unless we get a little crazy." Yep.

Powerful Penny

I was quickly learning that one of the CRNAs, Penny, had too much power. She had too much power because Paul gave it to her.

Over time, I had learned that Paul was weak. He hated confrontation, avoided it at all cost, and that was definitely not a good way to be when you were the boss of a group of strong-minded people. My belief was that he lacked the emotional maturity to be intuitive about the various personalities. Whenever there was an issue, instead of coming up with solutions, he put the problem back on the person who told him about the problem. He was permissive about bullies because he did not want to deal with them. He relied on people who coddled him, and was highly susceptible to the sycophants in the department.

So Penny made me nervous because she was Paul's favorite. I did not really care about that particularly, but she had a lot of power in the anesthesia department and did not see situations and people accurately.

Penny did a lot of work for Paul. Paul was not a good organizer and did not have proficient computer skills, and everyone knew, including Paul himself, he could not do his job on his own. So Paul relied on others to do a lot of the real work of a chief CRNA, while Paul was just the face who represented the CRNAs for hospital meetings and events. The more I saw their relationship, the more I believed it was Penny who completed the annual performance evaluations for the staff. Paul then just gave the evaluations that she wrote, which answered my question about that.

So what happened to show me that Penny did not see situations or people accurately? When I first started the job, she had befriended me and introduced me to Brianna. Later, she told me that Brianna was born as Brian, and had successfully transitioned to a woman. I kept that information to myself because I did not know if Brianna would be happy that her friend was telling others about her personal business.

Over time, Brianna and I became friends. I really liked Brianna; we had a lot of similarities in how we saw the world. One day, when Brianna and I went hiking, Brianna told me about her gender change. I admitted that I already knew, that Penny had told me, but I had been respecting her right to share with me whenever she felt comfortable doing so. Brianna then shocked me by saying that Penny had told her never to tell me about her transitioning, saying I would never understand. It was definitely a "What The Fuck?" moment. It was very strange, since Penny was the one who had told me about Brianna's history in the first place !

Even now, thinking back to that conversation, I am still stumped, shaking my head. If anyone didn't understand situations and people, Brianna and I both agreed, it was Penny.

Divergent Thinking

As for me, I am a divergent thinker.

In 1956, the psychologist J.P. Guilford studied thinking patterns, and coined the two terms convergent and divergent thinking. Both are descriptions of how a person cognitively approaches situations, problems, or scenarios.

A convergent thinker follows a set of defined steps to come up with a solution. Multiple choice tests, mathematical equations, and the standard intelligence tests all require convergent thinking. An essential trait of a convergent thinking is that it leads to a single best, unambiguous answer. Answers are either right or wrong.

Yes, I have qualities which are convergent. I would not have been able to complete my master's degree, and to have such a long career in critical care nursing, management, and anesthesia, if I did not have convergent abilities. But on a scale with convergent at one end, and divergent at the other end, I definitely lean toward the divergent end.

A divergent thinker sees lots of ways to interpret a question, never thinking of one simple solution, but of many possible solutions. We are characterized as being creative, adaptable nonconformists, and openness and curiosity are our hallmark traits. Importantly, divergent thinkers also have persistence. When I realized I was a divergent thinker, I had one of those aha moments. The way I approached life clicked into place.

As a divergent thinker learning something new, I have to look at it from all angles. I immerse myself in what I am learning. I look at the situation front to back, upside down and sideways, so that I really understand it. I imagine it is like holding something in my hand, turning it every which way to see it completely. And once I see it from all angles, I got it.

As I've mentioned before, I also see people from all angles. I like seeing the multiplicity of a person's character. I never learn about a person just by what they say, but also by what they do, how they react, their body language, their facial expressions. Seeing the world from so many angles is so much a part of me, it feels like an intuitive sense. I think of it as another sense in addition to the five senses of touch, sight, taste, smell, sound.

As sad as it is for me to say, though, my divergent thinking makes it sometimes difficult for me to "get" questions and jokes. I laugh at that now, remembering all the frustrating times when I just could not get the joke. If someone could see into my brain as they were asking me a question or telling me a joke, they would see all the solutions that my mind was coming up with. And it would explain why I was not responding with the reply or laughter they expected.

Interesting research completed by J.A. Horne in 1988 showed the effects of sleep deprivation on convergent vs. divergent thinking tasks. He found that convergent thinking tasks were more resilient to sleep deprivation. Convergent thinkers could tolerate a few nights of insomnia and still perform.

These same studies showed that divergent thinking decreased with just one night of sleep deprivation. My reading about Horne's studies was another aha moment for me. I noticed with myself, when I had not been getting enough sleep, I lost my intuitive ability ability to divergently see the multiplicity of situations.

Because I have persistence and adaptability, I tend to prevail in things that others would turn from. I believe these qualities are what made it possible for me to enjoy being a locum all those years, adjusting to the various anesthesia departments I worked in. It is also what has made it possible for Kent, since he is also a divergent thinker, and I to live in separate countries and still have a loving, monogamous relationship. My adaptability is also what made it possible for me to have great pleasure in traveling so much in the world, seeking to understand the various cultures and lifestyles in our world.

But my adaptability and persistence have a difficult side as well. Early in our relationship, Kent complimented me by saying that he admired my ability to see the positive of any town, no matter how run down the town looked. My adaptability helped me to see the silver lining. And a friend I have known the longest of all my friends recently told me that a recurrent theme in my life is that I do not like to quit just because things are bad. I have persistence. So because I have the ability to see the good at work, I tolerate the bad. Because I have persistence, I continue with the work. These qualities I have make it so that, over time, I tolerate too much. It is like dancing the limbo. When is the limbo bar too low, so that I fall?

Part Three

THE ONE YOU FEED

Kindness and Compassion

I did love doing anesthesia. Anesthesia was a rewarding job, and as odd as it is for me to say, it was fun too. Taking a seriously ill patient directly from the Intensive Care Unit (ICU), successfully guiding them through surgery, making a soft, gentle post anesthetic landing, then returning them directly to the ICU, always, always made me smile. I felt a sense of personal pride. I liked the sense of accomplishment of doing something difficult, and doing it well.

Most days in the operating room, I could find kindness and compassion. I listened over the surgical drapes to the surgeon as she taught a fourth year medical student, new to the operating room, how to suture. The fourth year medical student came to the operating room knowing basic skills, such as sterile technique, types of suture, how to sew the skin, etc. The surgeon calmly spoke a running monologue, encouraging the movements of the newbie's hands:

"Do more of a vertical rather than a horizontal suture. Turn your hand over. Choke up on the needle a bit. You should have about two thirds of the needle out. You can do an interrupted suture, if you want. Stand up straight, it'll help your back over the long run. Raise the bed if needed. Elize, will you please raise the table a bit (it's the anesthesia provider's job to adjust the bed position; they have the bed control). Use a small horizontal suture in that spot, if you think you can get one in there. I think you can. Good, perfect. Now you can tie. Nowwww good. That tie isn't my favorite, but it'll do. Never push down a knot with your finger. Poke it down with your pickups. See how this part is not extra tight, so you'll have to push it through? Come out over here. That should bury the knot better for you. All right, Steri strips, 4x4's, Opsite. Steris should be placed in line with the incision."

She continued, "No matter what you go into, which surgical field, you have to love it. You will do it every day. It's a big deal to complete your medical degree. And if you decide to specialize, it's a lot of work and a lot of years. Just love what you do. That's my advice. And whatever you choose to do, trust me, you're going to learn what better not to do than what to do by watching other physicians. And you'll know it when you work with them. There's always people like that. Just remember that some times, it's better to know what not to do than what to do."

On another day, I saw operating room staff comfort each other after the death of a trauma patient. They gave each other encouraging words. They hugged each other and gave tissues or cups of water to the ones who were crying.

Another day, another surgeon, and I watched him work. His forehead was wrinkled above his gold rimmed bifocals, mostly salt and a little pepper hair peeked around his surgical cap, brown eyes focused intently on his task. Fingers were bent and knuckles were knobby, his movements were strong and sure. Feeling my gaze, he glanced up at me, quizzical. I smiled at him and politely averted my eyes.

"Please tilt the bed toward me a bit," he asked.

"Sure," I said, and reached down for the bed control.

"Thank you," he said.

The high pitched beep, beep, beep of the pulse oximeter was the only sound in the room. As he finished each surgery, he gave the task of closing the skin to his First Assist. At the end of the day, after completing six surgeries, he looked at everyone in the room individually, looked each person in the eye, and thanked them for the nice day.

The Circulating Nurse gave him a big hug as he left the operating room after the last case, and I noticed a circle of sweat on the back of his scrub top. The Circulating Nurse told me earlier in the day that she had worked with the surgeon for 24 years.

After we took the patient to the recovery room, I found the anesthesiologists in the break room. I told them my room was done and asked if it was okay to leave for the day. I said, "That's the nicest doc. Really calm."

Everyone agreed. "Others should take an example from him," they laughed, and then they started to list the handful of really calm, really nice surgeons who could give pointers to the handful of not-so-calm, not-so-nice surgeons.

Another moment in time, another day. The patient had had a motor-vehicle accident, causing blunt force trauma to his abdomen, rupturing his spleen. The bleeding was massive, and the patient received several units of blood. The patient's very survival was on the knife edge during the surgery to repair the bleeding organs and to remove the spleen. Afterwards, the surgeon sat in front of the computer, writing post operative orders and making a surgical notation in the chart. To the quiet room, she said in a calm voice, having just noticed it, "We're not getting paid for this one." She said the patient had no insurance, and was not covered by any government medical plan. The quiet continued. What could we say?

Another day, this from a nurse. "I've done some missionary work in South America. People are so appreciative for anything you do. They walk for hours just to get to you. Or they come on a little scooter. And they go home on the same scooter, I don't know how they do it, right after surgery. Give them a little Tylenol and they're good. Mission work is really rewarding. It certainly gives you a different perspective on the world. I think everyone should go on a mission trip at least once. It hooks you. I feel like I get much more out of going than they get out of our being there."

She continued. "But when you go on those trips, you have to learn to make do with the supplies you have. One place I went to, they had no cautery, no way to seal the bleeding vessels, but they did have plenty of suture. So we tied all the bleeders off. That's a lot of tying, but we made it work. And thankfully we had plenty of suture. "

And one day, a nurse, his baritone voice filling the room, sang along with the classic rock music. We all worked steadily, the music adding to the rhythm of our work. Occasionally, we sang with him, smiling.

Enabled and Empowered

Although I loved doing anesthesia, it was everything else which was wearing on me. The politics and the games were so prevalent in the anesthesia department where I was fully employed. I would be happy if I could just do anesthesia. But it was a package deal; you could not have one without the other.

Paul, the Chief CRNA, had a policy in the anesthesia department that those CRNAs working the 16 hour or the 24 hour shifts were usually the lead CRNA, even during the day time when he was right there in his office. As the lead CRNA, their job was to equitably assign cases to their coworkers, make sure breaks were given, and send CRNAs home early if all the cases finished.

Also, Paul's policy was that those CRNAs working the longer shifts got a lighter assignment during the day. On the surface, that was a good idea. Those who worked into and through the night were able to rest during the day, so they could better function when up doing cases in the night.

When this policy was first instituted, the 16 and 24 hour shift CRNAs were grateful, knowing that their coworkers were doing the bulk of the case work in consideration of their doing the long shift. But as time passed, these 16 and 24 hour shift CRNAs began to expect to be given a lighter load, no matter how busy the operating room schedule was. No matter how busy their coworkers were, they were sitting in the break room, having coffee, watching television. As the policy continued, they began to think it was their right to sit around all day, doing nothing. They would bad mouth their coworkers if they had to do any work at all during the day, claiming this or that coworker was lazy, not doing their job.

Another problem with Paul's policy was that usually the nights were quiet. Often, the CRNA got to sleep in the call room most, if not all, of the night. So what developed was that CRNAs with a poor work ethic finagled their way into these longer shifts so that they did not have to work. On the surface, they looked like they are working hard because they were working long shifts. But these CRNAs essentially got paid for working from 7 am to 11 pm, or from 7 am to 7 am the next day, and did very little.

Through Paul's policies, he not only enabled these CRNAs to be lazy, but he also empowered them by putting them in charge. Since they were the lead CRNA, they made assignments and so could make the other CRNAs do all the work. They used their positional power to control their coworkers. Anyone who uses their positional power to lord over and control others is a bully. Paul had created the perfect recipe for abuse.

One of the CRNAs who often worked these 24 hour shifts was Roger, and Roger loved being in control over his coworkers. He saw himself as superior to others. There was a running joke that if anyone had a question about anesthesia, then they should go ask Roger, because he knew everything. Anesthesia is a humbling profession, so thinking you know everything is a dangerous way to think.

But I learned an interesting thing about Roger one day. One of the CRNAs told me that she was one of Roger's CRNA instructors when he was a student. We started laughing about how cocky he was, and she said that he was even like that as a student. She said a lot of his CRNA mentors did not like him, and butted heads with him. That revelation explained a lot that I really already had guessed. He thought he knew it all, so if a CRNA tried to teach him, he was not open to being taught.

Also, one of the anesthesiologists admitted to me that Roger and another CRNA, Edgar, did not know as much as they thought they did. I believed Roger was one of those people who had gotten as far as he had through intimidation, bullying, bravado, and knowing just enough not to be dangerous. Edgar probably too.

It was a funny thing about Roger. He felt so compelled to give everyone anesthesia advice, it drove me a little nuts. It was pretty crazy some of the advice he gave, with so much bravado. I remember one time in particular where he sat down at the table next to me and started by saying"I'm really disappointed in you." Then he continued by saying, "You should have done...." and "You didn't do...."

But I had quit listening after his first sentence. I was thinking, "How arrogant. Why would I care if you're disappointed in me?"

After his first sentence, I was listening to Shania Twain's in my head, singing, "You've got being right down to an art. You think you're a genius. You drive me up the wall. You're a regular original know it all. That don't impress me much."

Out loud, I said nothing. Out loud, I just laughed softly. Roger stopped speaking and he took on an openly quizzical expression, a very human look which I had never before seen on his particular face. I reckon he expected a much different response from me. But the look didn't last long. The look quickly morphed into a scowl. He then pushed his chair back, got up, and sat on the other side of the room.

Judge, Jury, and Executioner, All in One

An altercation one day not only exemplified Roger's need to be in control over his coworkers, but also his penchant for laziness. On that particular day, although it was by no means an isolated event, all the cases, except for one small case, finished about five p.m. There were six CRNAs scheduled to be on the clock until seven p.m, with only that one case to do. Three of the seven p.m. CRNAs, including myself, were in the break room having a snack, and one of the CRNAs suggested, "Why don't y'all go home? I went home early last week, so I'll stay and do that last case."

The other CRNA, a friend of mine, said we should ask Roger if we could go home, since he was working the 24 hour shift that day and thus the "boss".

To this I said, "He's funny about that. You know he is. He doesn't like to send people home because he's afraid he'll have to work."

He agreed, adding, "Roger can be vindictive if you even ask."

I wryly laughed, saying, "Yes, I've always thought of him as judge, jury, and executioner, all in one."

But my friend decided to talk to him anyway, and I offered to go with him to give my support. I said I needed to go to the locker room first and that I would meet him in Paul's office, where we knew that he and Edgar were hanging out. Edgar was working the 16 hour shift that day. While I was in the locker room, I saw that all the operating room staff were going home because there was nothing for them to do.

When I got to Paul's office, my friend was in the process of asking Roger if they could go home. He was telling Roger the obvious, that there were six CRNAs getting paid for the one case. Roger just looked at him with a deadpan expression, saying nothing.

The CRNA who had volunteered to do the one case was there as well. She told Roger, "I'll stay to do the case so that three CRNAs can go home. There's no reason to have us all here." She then left the office, saying she was going to set up for the case. My friend asked again if the extra CRNAs could go home, explaining again that the hospital was paying for six CRNAs to be on the clock for just the one case.

Roger commented about the CRNA who had volunteered to stay to do the one case, adding sarcastically, "That was big of her".

I said, "Yes, it was, but she thought it was fair because she got to go home early last week."

My friend asked for a third time about going home, adding that if he could get off early, he would be able to get home before the forecast storm rolled in. Roger still wouldn't agree.

It was then about 5:30, and one of the physicians came into Paul's office to visit with the CRNAs there. My friend gave up asking and left the office. I listened to the physician a minute, then just grabbed my things and left. I liked that physician, so I touched her shoulder as I passed by on the way out.

She asked, "Are you going home?", to which I said yes.

I am usually a rule follower, but I just snapped that day watching Roger humble my friend. Roger liked to be in power over others so much that withholding his approval was just his being a bully. Everyone agreed that three CRNAs should go home, and the only thing missing was Roger's approval. That would have still left three CRNAs there to do the one case, so the chances of Edgar and Roger having to actually work would have been slim. But Roger obviously didn't want to even take that slim chance.

The next time I saw my friend, I asked him why he thought Roger wouldn't let him go home. Being the nice guy that he was, he looked sheepish and said, "Because he'd have to get up and do something".

If He'd Just Asked

Another day, with Roger again working the 24 hour shift and thus in charge, I was scheduled to get off at 9 pm. At 8:30 pm, I went to the operating room where the 16 hour CRNA was working, to see if he wanted a break before I went home. He said he was fine, that he'd been out most of the day and the current case had just started, so he didn't need a break.

While I was there, Roger came in and asked me why I was still there. Not wanting to escalate the situation, I just shrugged my shoulders. But I was thinking, because you didn't tell me I could go home, and I didn't want to ask and risk your vindictiveness. So I said, "I guess I'll go home then."

Roger then angrily accused, "Why did you get Edna out late? She was pissed."

I said, "I didn't get Edna out late."

He said, "I saw you in the recovery room at 5 minutes after 5 p.m."

I clarified that Edna's shift ended at 5:15 p.m. He just shrugged his shoulders and left.

Thinking about his accusation later, I realized where I had been around 5 p.m. I was in the recovery room because I was checking on a patient. I had seen Roger pass through with an obvious bag of take-out food in his hand. I found out later that, against departmental policy and while on the clock, he had driven to a local restaurant to get his dinner. As he passed through, I remembered looking at the wall clock and saw it was 4:55 p.m. I remembered thinking I should get Edna out of to go home, knowing she would be mad if she couldn't get out early.

But on the way to get Edna out, I saw another CRNA and told him I had just signed his patient out of the recovery room. En route, I saw another CRNA who asked me to witness a narcotic wastage. I got into the operating room where Edna was working at 5:12 pm; I remembered looking at the wall clock as I opened the operating room door. She didn't seem mad at all.

If Roger had just asked, rather than accused, our conversation would have gone much better. And I would have told him all that.

Helping Paul

The day that Paul gave my third evaluation, he admitted to me that he hoped people weren't resentful. He said, "I know that I have three CRNAs who I often keep out of the operating rooms, helping me in the office. But I need the help. I can't do this job by myself."

The big problem, the crazy result, was that when those three CRNAs were on the schedule, they were still counted in staffing for the day. Yet they rarely did any actual anesthesia. They were in the office, helping Paul.

So I came to an amazing realization. I realized those three CRNAs who helped Paul in the office didn't do much actual anesthesia work. Add to that were the two CRNAs who worked the 16 and 24 hour shifts who also did not do much productive work. So that left the rest of the staff to do the bulk of the anesthesia cases. No wonder I was tired so much.

Letter to the CFO

I started to feel like I was working in a hostile environment. I did not function well in hostile environments. I decompensated. I withdrew. I just never knew when someone was going to come out of the blue and attack me. I even started to think about selling my house, moving away.

But I did not want to sell my house. I did not want to move. As I tried to decide on ways to to make my work life better, I decided to write a letter to the Chief Financial Officer (CFO), new in his position. For me to write the following letter was a big deal, an indication of my desperation. In the end, I never sent it; I felt it would only be used as a tool for retaliation against me. But writing it helped me feel better.

"Please excuse this letter being unsigned. I will explain there are valid reasons for this. However, I want to point out to you a situation which exists within the anesthesia department that should cause you concern.

Recently you assessed the department as being 98% productive. However, this does not take into account the work rate of individual members of the department. Presently, work is scheduled in such a way that a significant number of those working 24 hour shifts are allocated the lightest actual work load. This commonly results in CRNAs being paid for being present for 24 hours, but actually working on many occasions no more than one hour out of the 24. The 98% productivity rating was gained despite the activities of these 24 hr shifters, not because of them.

Under recent changes to scheduling and payment, some of these CRNAs will see an increase in their pay as some of the 24 hours become marked as "over-time". I feel there is a clear financial implication to this in addition to an increased burden on the rest of the department.

While I feel the financial implications of this situation are significant, there are also very serious implications on morale and working conditions in the department. Those who are on 24 hr shift receive considerable "down-time" - anything up to 23 hrs of the 24. Much of this time has been spent launching personal attacks on other members of the department, including manipulating CRNAs daily schedules, and spreading disinformation about members of the department to the Head CRNA. The Head CRNA has been made frequently aware of this situation but has admitted his own weakness in dealing with these issues. The result has been a small group of highly unproductive workers using their working time to create a climate of fear and disruption within the department, able to maintain their low productivity through their hold over the Head CRNA, and using their free time to manipulate the caseload of others.

While this letter has been sent anonymously, it should be easy to check the validity of the claims I make by, for example, checking the case load and productivity percentile of each individual CRNA. Also talking confidentially to a wide range of members of the department."

16 Cases

One day, I went home brain dead. I was so exhausted.

I had 16 cases that day. My assignment was by far the busiest room. One other room was busy too, but two CRNAs were assigned to that room, so each CRNA did half the work that I did.

Roger was again the 24 and Clarence was the 16 this time. Roger documented that all the CRNAs were to give their own breaks in the morning because he thought everyone had enough time. He even marked that I had a break because my room started at 8 am.

Later, one of the CRNAs expressed surprise about Roger's doing that, rolling his eyes, saying, "What? Because your room was so busy, you should have been given a break. Clarence and Roger, those guys were sitting around all morning. They had time."

About 10:30, the next case did not need anesthesia assistance, so I took a quick snack break. It was rushed and I practically inhaled my food; the operating room staff were waiting for me to go back when I was done. At 2:30, as I was passing by the anesthesia office with yet another patient, I saw that a couple of the CRNAs were preparing to go home early. They were scheduled to get off at 3:15. I asked one of them to give me a break before they left, and one did. Mind you, Roger, since he was the 24, was supposed to verify that CRNAs working had been given adequate breaks.

Later, I told another CRNA about my lack of breaks during the day, to which he said, "I don't know what happened. I thought all the breaks were done. It's not like we were busy today."

I told him, "I know there were a lot of CRNAs out today, doing nothing. I had noticed that as I was coming and going with all my patients."

I finally finished the 16 cases at 6:15 pm. Clarence was setting up the assignment board for the next day while Edgar and Roger watched, everyone laughing and joking. I went to the anesthesia office. About 15 minutes later, Edgar came into the office and said he was leaving for the day. Edgar said only one case was going, and a different CRNA was already in it. So I went to ask Roger if I could go home too. He just mutely looked at me. Since he didn't say no, I left.

As I was at the pharmacy window, turning in my narcotic box, I heard Clarence tell Roger, "Elize is leaving", my impression was to stop me. Thankfully, he didn't.

I Thank the Defenders

I began to notice a new thing happening. In addition to Roger's control issues, Edgar had developed his own ways to bully his coworkers. I was sad to realize that he had found a new game to target me specifically, to make my own life miserable.

I began to realize that the assignment sheet would indicate I had time to take my own break, or that I had already been given a break, even when I had been in an operating room all day, working. Watching the trend for a while, I noticed it only happened when Edgar was working. The result was that no available CRNA came to check on me to see if I had a chance to go to the bathroom or to grab a bite to eat. As soon as I realized what was happening, I figured I would just bypass the assignment sheet altogether, and start calling out for my own breaks.

One day, a CRNA friend of mine was functioning as the lead CRNA. Long after I should have been offered a break and my bladder was about to burst, I called my friend to ask if someone was available to get me out. He said he was available and came into my operating room. He expressed surprise that I had not been out yet, saying that the assignment sheet indicated that I had been able to get my own break. He said that once, he had even started to get up to check on everyone, but that Edgar had told him to sit down, to not worry about it, that everyone was taken care of.

My friend said, "I'm sorry for not checking on you personally. "

I told him, "Edgar has gotten in the bad habit of marking me that I'd been given a break."

Thankfully for me, my friend expressed shock and outrage. He said he would put a stop to it, and he somehow did. It sure felt good for someone to have my back.

So, now I take this moment to personally thank all the defenders in the world who stand up for those who have difficulty standing up for themselves. The social scientist and psychologist Ty Tashiro, in his book "Awkward", clarifies the risk a person makes when they act as the defender. Tashiro states the defender pays a high social cost, significantly increasing their chance of being bullied themselves. Tashiro defines this risk as "social capital", and because of this, defenders will typically only intervene to help a limited number of times. So, I gratefully acknowledge the social cost defenders absorb.

Bullies Isolate Their Targets

Edgar began to use another weapon to target me. His new weapon was more vague than his other game of marking my breaks done, yet it happened often enough, regularly enough, that I could not help but notice it. His tactic was actually one of the common weapons in the arsenal of a bully: marginalize and isolate the target from others, effectively removing their support system.

Bullies have a talent for being selectively charismatic, and Edgar could be very charismatic. Edgar used his selective charisma to win my friends over to his side. Or at least I got the impression my friends had become good friends with Edgar. Either way, the end result was the same; I felt marginalized and isolated.

What he did was when he saw me talking with a friend, having a light moment, the next thing I knew, I saw him with that same friend, publicly and loudly joking with them. It was as if he was making them think he was the greatest guy. Then if I ever mentioned to my friend the grief I was experiencing at Edgar's hand, that person defended him.

For example, I told a new friend, a new CRNA in the department, how little Edgar actually worked, that he had a strong lazy streak.

She told me, "Oh, Edgar's okay. I don't judge people like that."

As is my unfortunately usual way, I was speechless. She had dismissed my concerns so easily, writing me off as judgmental. But I thought later, "If you had to work with him as long as I have, and have picked up his slack as much as I have, you'd think the same as I do."

I wonder, now, if she has finally learned my lessons.

Why am I a Target?

What occupied my thoughts during the day, and in the wee hours of the night when I could not sleep, was "Why am I a target?" I had never considered myself a victim, and I didn't then. But I knew I had become a target. I also knew that if I was going to find a solution, I had to clarify the problem exactly. So I searched for reasons.

Because of my self-reflective nature, I asked myself what my part was in the problem. I knew that in any relationship, each person contributed who they were and how they reacted to different situations. So what was it in my personality which made it so people felt they could treat me badly? I knew myself well enough to quickly make a mental list.

The anesthesia group had several cliques, and I had never liked cliques. I never liked the rules of cliques. I never liked gossiping and talking badly about those outside the clique. I did not like excluding people who were not in the clique. I had always enjoyed having different people in my life, with different personalities. I thought, and still do, that having friends with a wide variety of lifestyles and viewpoints made me a better person. So my not being in a clique put me on the "outside", on my own, vulnerable to bullies.

Interestingly, as a side note, according to Katherine Crowley, co-author of Working With You is Killing Me, "We find that office cliques tend to form most in corporate environments with weak management. They are like office gangs that emerge to fill the void of leadership." So Paul's being a weak manager was what contributed to the development of so many cliques.

Going my own way, marching to the beat of my own drummer, had always been my nature. All my life, I wanted to think my own thoughts, do my own thing, walk my own path. I believe my desire for individuality was what made me successful traveling for so many years both in the United States with my work and also around the world. I presented myself to the world and to my work as a single person. But, at times, my individuality isolated me. So I tolerated isolation at the job because it was familiar.

Also, I thought that my actions would speak for me. I believed that actions spoke louder than words. I was a hard worker, so I thought people would see my strong work ethic, even if the bully was telling everyone I was lazy. But I have since fully realized that people do not always see what is right in front of them. They have to be told. And if all they are told is the bully's version, they often do not look further.

Another part I played in my being the target was that I tended to pull away from cruel game players rather than calling them out. I just did not like to speak sharply, and it was simply not in my nature to be spiteful or revengeful. It was difficult for me to give a quick retort in the face of rudeness or cruelty, made worse when I was not sleeping well.

Furthermore, I did not like being around people who could not see nor care that they had wronged another person. I did not know if that person would do wrong again.

But also, as weird as it is for me to say, I thought Edgar targeted me because he was jealous of my friendship with Sal. Sal was a hard worker and one of the few 24 hour shift CRNAs who actually did cases the whole 24 hours. I admired him for that, so he and I were friends. But Sal and Edgar were big buddies too. They even did things together outside of work.

But I noticed that when Sal talked with me, Edgar blatantly turned his back to us. Other times, he flat out interrupted our conversation, and sadly, Sal almost every time stopped mid-sentence to talk with Edgar, suddenly and completely ignoring me. I had complained to Sal about it several times, but he continued.

I believed Edgar wanted me in a room, working. He wanted me out of the way so that I would not have the chance to talk to Sal or to any other of his "audience". Trying to understand the nuances of my life then, I came to realize that Edgar needed an audience like he needed air. So he did what he could to get rid of me, to isolate me. Anyhow, it just all felt weird.

I Didn't Believe Their Myth

One day, my assigned surgeon had completed his case quicker than scheduled, so I had a little bit of down time before starting my next case. I went into the anesthesia office and three CRNAs were already there, talking about the anesthesia department. They were discussing about how toxic the department was, saying that Paul ran the department in name only. Everyone agreed that four CRNAs, Roger, Edgar, Penny, and Clarence, really ran the place according to their own whims and self interest.

"Edgar, when he's in charge, uses the position to bully his coworkers."

Although I guessed at his opinion because I already had my own ideas, I asked him to verify. "How do you see him doing that? What do you see that he does to bully people?"

He replied, "He gives bad assignments, makes you do all the cases. Or he keeps you uninformed or misinformed. Stuff like that."

"I also have problems with Edgar," another CRNA said. "When I'm the lead, he makes me feel like I'm doing everything wrong. Like I'm not doing a good job."

I was surprised, and told her so. "You two are always laughing and carrying on like you're big buddies."

She replied, "You have to laugh at the jokes of those who are power hungry so that you won't be the butt of their jokes."

I said, "That's pretty profound, but I disagree. It's the cheap way out. By laughing at their jokes, you only encourage them. By acting like they're your friend, you only enable their cruelty and bullying. I don't mean to be harsh, but by doing that, you become part of the problem."

She looked me straight in the eye as she admitted, "Yes, true, but it works for me. Roger and Edgar have so little real internal power and strength that they have to wield the iron fist when they can, and I don't want to be in front of that fist. You know that's why they like to be in charge."

Right then and there, although I didn't say anything out loud, I realized another reason why Roger and Edgar targeted me. I saw them for what they were, weak and vindictive, and I could not hide my feelings behind a joke or a smile. I couldn't fake it. I had never had a poker face; my feelings came out on my face. I did not believe the facade they put forward to the world. I did not believe their myth.

Two of the CRNAs said that they had talked to Paul about the problems, but nothing had changed.

One said, "The issue is that Paul hates problems. So if there is a problem, it has to be your fault, your responsibility. If you bring a problem to Paul, he tells you to go fix the problem yourself. You're not a team player if you don't. It's your fault and your problem. And then the person who did not do their job in the first place never gets confronted because Paul does not like confrontation."

Everyone agreed.

"I have a good example of that," said another CRNA. "Paul told me to calibrate all the hemocue monitors. When I went to do it, I noticed on the checkoff sheet that the monitors had not been checked for the preceding five days. When I told Paul, he told me to just check off those days as if they had been done. I asked him about confronting the people who were assigned to check the monitors but didn't do it, and he got annoyed with me. Then he told me to just leave it, to go check off the sheet."

She continued, "This department has been dysfunctional since I came here five years ago, and all I can do is just keep hoping it will get better. I've thought about leaving but for the 30% more I get for working here, I'll just shut my mouth and stay until I pay off my student loans."

Another CRNA, who had been quiet up to that point, said, "Half the people in this department are looking for other jobs. The abuse is so widespread that everyone is affected by it in one way or the other."

We all agreed that we had never worked in a place so unprofessional. I added that I had also never worked in a place with so many inconsistent decisions, that something which was okay for one person was not okay for another. One of the CRNAs pointed at me to emphasize and agree, while the other CRNAs shook their heads yes.

We then talked about the overtime which Paul allowed, even sanctioned in some cases. Two of the CRNAs said that Paul was supposed to cut back the overtime and said he should be fired because he allowed so much of it. We figured that Edgar, with all the overtime he did, made about $350,000 a year. One CRNA said she noticed that Clarence had been able to book 32 hours of overtime on his last paycheck, and we marveled at how his overtime was allowed while others were forced to decrease theirs.

Evil Prevails When Good Men do Nothing

When I was a teenager in the drug abuse program and forming my opinions about life, it was common knowledge that a bully was a weak person with low self-esteem. A bully put people down and pointed out their flaws so that they could feel better, more superior, about themselves. They needed to pick on others so that no one would notice their own flaws.

But some time in the last twenty years or so, the social idea of a bully had changed; they were no longer considered emotionally weak. A bully had become someone who was strong.

In the anesthesia department, the bullies were even rewarded for being a bully. They could go to work and do very little actual anesthesia. Because their work day was easy, they were able to work a lot of overtime. They spent a lot of time during their work day watching television or talking to whoever would listen. They then were paid a whole lot of money for basically doing nothing. And because they were getting away with it, the operating room staff began to think their behavior was accepted, even normal.

In frustration a few weeks later, I asked a group of CRNAs how to fix real problems in the department. I already pretty much knew the answer, but was hoping that the group had some new ideas. So I asked, "Really, how do you bring a legitimate concern forward? You guys know that, generally, if you bring a complaint or concern to Paul, he either ignores you, puts it back at you to fix yourself, or gives it to you to do that thing all the time. It is obvious Paul really doesn't want to supervise."

We all agreed that you quickly learned never to bring complaints or problems to Paul.

I continued, "But if you then go above Paul and tell his boss, everyone finds out and blasts your name all over the operating room. Or if in frustration you vent to coworkers, you get labeled a whiner and your problems become negated or ignored."

I added, "And you can't bring complaints to H.R. (Human Resources). First, they are difficult to even make contact with. And if you do make contact, they treat you like the problem is due to a fault of your own."

One of the CRNAs surprised me by saying she had gone to Human Resources about the problems in the department. The woman she spoke with expressed surprise that we had problems, and said, "Do the CRNAs know how much power they have?"

I asked, "What does that have to do with the price of rice in China? How much power we do or do not have doesn't change anything about the problems we're having."

The CRNA said, "She suggested that the CRNAs go together to Human Resources to discuss the problems. But I told her I didn't think that would work. I told her that the CRNAs would not even talk about problems in a meeting."

I agreed, "Yes, that will never happen. There's too much dissension between the CRNAs for them to get together to go to H.R. People get shouted down and retaliated against if they talk about problems in meetings. I've seen it before."

She said, "Then H.R. should go to each individual CRNA to talk to them."

I said, "That would be best. That would probably be the only way the CRNAs would talk. You should suggest that to the H.R. person you spoke with! "

She refused. "No. I've stuck my head out enough. The person I spoke with offered to get back with me but I didn't want that. I told her I would know if there was any improvement."

She added, "I told her how one of the CRNAs had gone to Paul's boss about an issue. But when Paul found out, he retaliated against that CRNA by giving her difficult assignments or by getting back at her in other ways."

I sighed, "So everyone just ends up putting up with the problems. It doesn't have to be like that. Things could be better."

I continued, "I think the problems in this department are so entrenched, so much a habit, that people don't realize that they are a part of the problem. They make all sorts of explanations for the problems rather than fixing them, saying stuff like 'That's just the way it is', or 'It's always been like that', or 'oh, that's just the way he (or she) is'."

I felt so alone. Yes, others saw the problems like I did. But they seemed content to just put up with the problems, rather than working together to fix them. Why didn't more defenders step forward to protect those who were bullied? Why did so many people cozy up with and enable Edgar and Roger rather than calling them out for their bullying behaviors? Why did everyone seem to so easily accept the dysfunction as normal?

I thought of a quote an elderly friend taught me: "Evil prevails when good men do nothing." The quote, by an 18th century statesman and philosopher named Edmund Burke, meant that when a good person saw something which they knew was wrong, but choose to do nothing about it, then that person was just as culpable as the person doing the wrong. Nothing would change if those who knew better just turned away.

So I asked the group again, "Really, how do you resolve a legitimate concern in this department?"

The CRNAs gave me a blank stare, no answer. One offered, "Most problems tend to eventually just go away."

Later, thinking about that conversation, I remembered the observation I had when I first started to work there. I remembered observing that if someone did not want to address an issue, they ignored it, hoping it would go away. Strange and sad that I was still seeing that.

But hoping a problem would just go away never solved anything. Sticking your head in the sand, refusing to see the approaching storm, did not stop the storm. Pretending that a problem did not exist might make you feel better, but it did not change things. As Henry Kissinger, former U.S. Secretary of State and National Security advisor, so eloquently stated, "Competing pressures tempt one to believe that an issue deferred is a problem avoided: more often, it is a crisis invited."

Bullying is like Water Torture

And so the months and the years passed, and the bullying continued. The bullying and cruelty at work was wearing me down, making me dread going to work. I had always loved doing anesthesia, had a passion for it, but I could feel that passion ebb away, being replaced by dread.

Bullying at work is analogous to domestic abuse. As with domestic abuse, the abuser inflicts pain when and where they choose. Their attacks are often frequent small attacks against the person's psyche, with occasional full frontal attacks, all meant to keep the victim off balance. A bully is adept at getting you where they want you, stressed and tense. And once they get you under stress, they twist the knife in your back.

Even though the pain of being bullied is not physical, the pain is real. Becky Chambers, in her book A Long Way to a Small Angry Planet, stated this well: "... If you have fractured a bone, and I've broken every bone in my body, does that make your fracture go away? Does it hurt any less, knowing that I am in more pain?.... Feelings are relative. And, at the root, they're all the same, even if they grow from different experiences and exist on different scales...."

Workplace bullying and domestic abuse are both like water torture. With water torture, the victim is tied down and a continuous stream of dripping water strikes the same spot on the forehead for a prolonged period of time. At first, nothing happens. But as the incessant drip continues, the water becomes like a bore, drilling a hole in their forehead. It drives the victim mad and causes them to do almost anything to make it stop.

Like water torture, bullying behavior is done repeatedly over a period of time. Bullies find a target, and then go after them again and again. The abuse is an insidious and persistent drip that not only alters the target's perception of the world, but also of themselves and of how relationships should work. No matter how emotionally strong a person may be, bullying slowly creeps into their mind and makes them question their every thought and step. It makes them question their own self worth. It is slow, gradual and destructive. And much as a gradual drip of water can, over time, become a stream, then become a river which can carve through rock to create a waterfall, the abuse can alter everything.

I was seeing that happen to me.

The Need for Control

As idealistic as it sounds, philanthropy was the reason I became a nurse. I simply wanted to help people. Well, and because I was good at chemistry, science, and physiology classes. But within a year of my being out of nursing school, I realized that many people, whether they consciously knew it or not, went into the medical field for the control. As a young nurse who's idealism was shattered by that new knowledge, I cried big tears.

Whether for beneficent intentions or not, the need for control is prevalent in the health care industry. Health care workers work to have control over diseases, over the drugs they give, over the bleeding artery. They have control over their their ill and weak patients. The work itself reinforces the need for control. The work is exacting, meticulous, and is literally the difference between life and death. But sometimes the need for control becomes distorted. And any inclination towards dysfunctional controlling behaviors gets modified, fed, grows.

This reminds me of The Tale of Two Wolves:

"A grandfather is talking with his grandson and he says, 'There are two wolves inside each of us which are always at war with each other. One of them is a good wolf which represents things like kindness, bravery and love. The other is a bad wolf, which represents things like greed, hatred, and fear.'

The grandson stops and thinks about it for a second, then he looks up at his grandfather and says, 'Grandfather, which one wins?'

The grandfather quietly replies, 'The one you feed.'"

When a health care worker devolves into manipulative, controlling bullying, other health care workers are vulnerable. This control can manifest as vertical bullying, where those so inclined have control over employees lower in the pecking order. One example is the way in which some nurses teach nursing students. They believe the only way to teach a student is by the "school of hard knocks". They are harsh, condescending, and degrading to the students, they say to toughen them up. This is so common that others have created the expression "eating their young" to describe it. Vertical bullying can go the other way too, when younger, more tech-savvy nurses condescendingly criticize veteran nurses who are slower to adapt to new technology.

Another example of vertical bullying is the long accepted doctor's "order". The truth is that no nurse can be ordered to do anything. A nurse does not have to follow a physician's order just because that physician told them to do it. If the nurse considers the order unsafe or inappropriate, they can and should refuse to follow through. I personally believe the term "physician's orders" is archaic and should just go away. Instead, physician's "recommendations" or "requests" more correctly describe reality.

The need for perfection makes the situation worse. Life and death is often on a razor's edge, and mistakes can kill. So workers tend to be self critical already. The trouble is that some internalize any weakness in themselves, and too often criticize the weaknesses in others.

Are you sick? You better be so sick that you have to go to the Emergency Room. I once knew a talented resident who became ill with a virus, but she pushed herself to continue working until she collapsed. She was admitted to the Intensive Care Unit and eventually died from multi system organ failure.

Have you been up all night working? You have to work during the day until someone is available to relieve you. If you complain because you feel your sleepiness makes you unsafe, then you are criticized for being weak.

Are you complaining about your work load? You are just lazy.

Is someone making sexual passes at you? You are told to not say anything, because if you do, your life will be made a living hell.

Is someone being cruel to you? You're whining. They're just joking, and you can't take a joke. Don't be so sensitive! Get a spine! Buck up! Grow some balls!

I believe this is why it is so difficult to define, clarify, and resolve bullying issues in the health care industry. Each incidence may be viewed as inconsequential. If a health care worker complains about a problem which is seen as inconsequential, it is that worker's attitude which needs adjusting, a problem they need to fix. But, similar to domestic abuse, if any complaint is seen as an attitude problem and not as a real issue, then that worker is unprotected against others who want to exploit them.

I saw over and over our departmental bullies' dysfunctional need for control. They needed it, not just wanted it. So when a coworker had a strong work ethic, when they were focused on doing a good job, the bully took advantage of them.

If someone threatened the bully's agenda, the bully made that person a target and forced them into a vicious circle. For example, if the target questioned the bully's laziness, the bully became more fiercely critical. The bully systematically beat the target down, criticized them for not doing enough, for taking too long breaks, for not being flexible enough with their schedule, for not being a team player, for not working enough overtime, etc etc.

Bullying the target kept them docile, off kilter. The target then had to expend considerable energy proving that what was being said about them was not true, that they really were team players, that they really were professionals. It was mentally and emotionally exhausting. The bullies were playing a ferocious, manipulative, dysfunctional game. And were winning.

Everyone Knows There's a Problem

I am going to say that the bully always wins. So if you want to win in this world, learn to be a bully.

Sounds harsh, eh?

A quote from Wikipedia confirms this though. It states "Bullying behaviors in the workplace also exist among colleagues. They can be either the 'target' or perpetrator. If workplace bullying happens among the co-workers, witnesses will take a side between target and perpetrator. Perpetrators always win, because witnesses do not want to be the next target. This way, it encourages perpetrators to continue this behavior."

So how do you distinguish isolated behaviors and work stress from bullying? Bullying is repetitive, like the water torture, and continues over a long time. The aggression usually increases, and the target lacks the power to successfully defend themselves.

Research has shown time and again that bullies are rampant in the health care industry. One of the pioneers in bullying research was a pediatrician named Henry K. Silver. In 1990, he gave questionnaires to medical students, and concluded that up to 80% of senior medical students had been bullied. And similar research done on nurses by Hutchinson and Hurley in 2013 found that 80% of nurses reported workplace bullying.

Dr. Pauline Chen was the first to enlighten the general public about the issue in 2012, through her New York Times article The Bullying Culture of Medical School. Dr. Chen stated, "...the striking similarity of experiences across a generation of students suggests problems not just with one institution, but with the culture of medical training itself." She defined how this abusive environment not only increased the student's morbidity but also significantly interfered with effective patient care.

An excellent synopsis by the editor of the March 2014 issue of the AMA Journal of Ethics titled To Bully and Be Bullied: Harassment and Mistreatment in Medical Education further defined and clarified the extent of bullying. The editor related studies performed in countries around the world which had found similar inability to resolve the problem. He quoted researchers Ogen and Elnicki, who state that the mistreatment was a "universally wrong tradition in medical culture".

Even the Joint Commission, the organization which accredits hospitals and other health care facilities, has recognized the extent of workplace bullying and how it can result in patient harm. In a 2008 Sentinel Alert, The Joint Commission noted that "intimidating and disruptive behaviors can foster medical errors and (lead) to preventable adverse outcomes."

They issued a standard on these behaviors, citing concerns about patient care: "Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments. Safety and quality of patient care is dependent on teamwork, communication, and a collaborative work environment. To assure quality and to promote a culture of safety, health care organizations must address the problem of behaviors that threaten the performance of the health care team."

But although this standard was adopted in 2008, I have yet to see improvement behind the closed doors of the operating room. Joint Commission auditors do not often enter the environment of the surgical suite. Surgeons and staff discourage them from doing so, stating concerns for surgical sterility and patient modesty. For the brief times when auditors are present, everyone is on their best behavior.

One of the major obstacles to resolving bullying is that targets tend to be silent about what has happened to them. The Joint Commission's 2008 Sentinel Alert recognized this by citing an Institute for Safe Medication Practices survey which found that 40 percent of health care workers have "kept quiet or remained passive during patient care events rather than question a known intimidator." And in the Emergency Nurses Association's 2011 Emergency Department Violence Study of 7,200 emergency nurses, they found similar results; the majority of respondents who said they were victims of physical or verbal abuse never filed a complaint. This silent culture unfortunately only serves to empower the bully and their abuse.

So combine bullied and bullying nurses and doctors in the close environment of the operating room, it is a tough place to work. I have heard these things said in various ways in operating rooms all over the United States:

"If you're going to work in the OR, you're gonna have to grow a pair. Because I'm going to say what I think"

or

"You have to let it roll off your back. Working in the OR is tough."

or

"You can't be sensitive. If you're too sensitive, then you don't belong here."

or

"So he yelled at you. Get over it."

or

"If you don't like it, if it pisses you off, then you can go work somewhere else"

or

After someone slapped a nurse's bottom and the nurse jumped away, scowling, the nurse was criticized, "You can't take a joke ! I was just joking !"

or

"Quit your crying. Never cry at work," as they turn their back and walk off.

I say it does not have to be that way! I cry bullshit! But it is that way, and that's a fact.

Bloodied and Bruised

So often, people give advice to victims by telling them to stand up, fight back, don't accept the abuse. They say, "You are a professional, you don't have to take that ! Tell them you don't like it ! Don't cower in the corner, not confronting these people. You don't have to accept what they're doing to you." They argue that you have to call them out right on the spot, because only public humiliation will make them back down. They insist that this is the only way to stop the abuse.

In theory, that sounds like great advice. And sometimes it actually works. Sometimes, the abuser will back down and stop their harassment. But too often, the abuser backs down only temporarily, and then returns for harsher rounds of abuse.

The problem with calling out an abuser is that too often, the abuser's actions are up for personal interpretation. This makes it difficult to get the abuser under control. They are adept at using manipulations which blur the lines between right and wrong. The bully abuses their positional power to control and dominate others, so that a target's complaints are ignored, or the target is told they are just too easily offended. The target is maligned or debased. Occasionally they actually even lose their job.

I had occasional discussions with a scrub tech about the hostile milieu in the operating room. With every discussion, she would say, "You just can't be too sensitive in the operating room. You have to let it all just roll off your back, like water off a duck's back."

I knew she meant well, and was just trying to give what she thought was good advice. But every time she told me that, every single time, an image would pop into my head of a woman lying on the floor, bloodied and bruised from a beating, as some well meaning person stood over her saying, "Get up! Don't be so sensitive!"

Gaslighting

I learned a new word at that job: gaslighting. Edgar, Clarence, and Roger were master gaslighters. But gaslighting was not limited to those three; gaslighting in the department had become rampant, like a spreading cancer.

Gaslighting is a form of psychological abuse in which information is twisted and false information is presented with the intent of making targets doubt their own perceptions. Dr George Simon, psychologist and author of In Sheep's Clothing: Understanding and Dealing with Manipulative People states gaslighting is when you know in your gut that you have a situation read right, but the gaslighter is trying to convince you that you have read it all wrong.

There is a scale of gaslighting, a range of behaviors and tactics which the gaslighter uses to manipulate others. On the milder side of the scale, the gaslighter will lie and exaggerate to make you doubt yourself. These accusations may be subtle, so that the target may just get the feeling that something is weird, or "off". On the other end of the scale, the gaslighter practices control, manipulation, and domination.

The gaslighter's arsenal utilizes several strategies: They feign a lack of understanding or refuse to listen. They repeatedly question a target's memory, despite the target having remembered things correctly. The gaslighter manipulates situations repeatedly to trick the victim into distrusting his or her own perceptions. A gaslighter redirects the conversation from the subject matter to questioning the victim's thoughts and controlling the conversation. They trivialize the victim's thoughts or needs as unimportant. The gaslighter pretends to admit that things have occurred, or they deny that promises which are important to the victim were ever made. They accuse the victim of lying or making things up. They may jeer the target for misinterpreting things. They pick up on the weaknesses of their targets, and often use the target's good nature against themselves.

Taken individually, these tactics may seem trivial. But the target finds they have to continually defend themselves against these accusations. The gaslighter can be so convincing that a target will start to question themselves. Over time, as the pattern continues, the target's sense of self worth is shaken and their sense of reality erodes.

So who is the typical target of a gaslighter? Dr. Simon states, "There are two traits that people - and we must say people as men are also vulnerable - who are prone to being gaslighted share. One is conscientiousness. People who have a conscience, people who generally do the right thing and are trusting, because they are trustworthy in nature. The other is agreeableness. You want to treat people well and get along. You don't want to unnecessarily rock the boat in your relationships."

According to an article written by Megha Mohan titled Cheating and Manipulation: Confessions of a gaslighter, a third quality that targets often share is that they are intelligent and successful. Intriguingly, this is a key factor in how receptive they are to being gaslighted.

In the article, an anonymous reformed gaslighter confesses, "From my experience it's not true that it is vulnerable or insecure women who are susceptible to gaslighting. These were successful women but that came with a perception of what they thought a 'successful' relationship should look like and they shared that. They gave me a blueprint to what they were looking for in a man."

He continued, "The women approached relationships like they did their careers, with high expectations and a checklist of qualities."

Unfortunately and sadly, the gaslighter's target is faced with the prevailing social belief that if they would just fight back against the abuse, then the problem would go away and everything would be fine. Therefore, the target feels they have to face the abuse in silence. They keep quiet about what is happening to them. Then, as the gaslighting continues, the target becomes depressed.

Under the Bus

Over the years watching my coworkers be bullied and gaslighted, and having the same done to me, I found myself becoming withdrawn and jumpy. I had stopped enjoying going to work. I would feel dread the night before I had to work. I felt like I was walking on eggs all the time; I never knew when an attack would come, when I would be thrown under the bus. One of my friends even called Edgar "The Bus Driver", since he had such a habit of blaming others in order to save himself or to gain some advantage.

I remember several instances of abuse in our department. One CRNA was targeted over a period of time by both Edgar and Roger, who changed the CRNA's assignment so that he always got the same obnoxious surgeon. Edgar and Roger always strongly denied doing anything, trying their best to look like they were innocent victims being blamed. But one day I caught them changing the CRNA's assignment, laughing about it like it was a big joke. And when the victimized CRNA complained about it, he was labeled a whiner, was laughed at and ignored.

Another instance was against a coworker who was given a special assignment by Paul to complete. Doing the assignment was keeping the CRNA out of the operating room, working on the project. But Edgar and Roger wouldn't have that. They wanted her working so that they didn't have to, so they spread vicious rumors discrediting the CRNA's work ethic.

Edgar was particularly extreme in gaslighting me one day. He was the lead CRNA, and as usual, was not giving any breaks. He was in a particularly obnoxious mood and so did not communicate to me the changes in my assignments. I would be set up and prepared for the next case which was scheduled to be in my room, only to find out from the circulating nurse the case had been changed to a different operating room. Circulators at our hospital were not in the habit of informing anesthesia about schedule changes because they were used to the CRNA in charge passing on that information.

Anyhow, late one morning, when I learned that the next case had been moved to another room, I found Edgar to ask him if I was still assigned to the case, or if another CRNA was doing it. As usual, several operating room staff were standing around Edgar, listening to his stories. He gave me an angry, hard look and, without answering my simple question, said, "I can't believe how lazy you are. The next thing I know, you'll be complaining that you work harder than anyone else. How old do you have to be before you start complaining that no one else is working but you?"

Everyone went quiet. You could have heard a pin drop. I was embarrassed and humiliated. And unfortunately, I was speechless. I scowled at him and went to set up for the case which had been moved. Five minutes later, I realized what I should have said, "So I've been working all day and you've done nothing, and you say I'm lazy?!" I finally finished my room at 2:50, not even having had time for a meal break all day.

Research by Dr. Miriam Hirschstein, Ph.D., a scientist with the Committee for Children, had discovered that a person may bully "because they believe they will get social mileage out of it." The committee also learned that 85 percent of bullying incidents involve bystanders. "Bullying," she says, "can help you be a very popular child."

Until I started to work in that surgical department, I had always been told how hard I worked. I knew I was not lazy, far from it. Through all the years of bullying and gaslighting while working there, I could still see me for me; my core strength, although battered, was still intact. But I was sensitive about false accusations. So I found myself struggling to overcome the false accusations by just working harder, feeling restless even when I had legitimate down time. I felt like I had to get up and do something, anything. I was beginning to feel like a pack mule.

They Threw Themselves off a Cliff

Another good example of the bullying and gaslighting in the department happened when I volunteered to become part of a group of coworkers who were tasked to devise a new way to cover the holiday shifts. I had given a lot of thought to an idea which would allow those CRNAs who wanted more control to have more control, and those who were happy to be flexible, could be flexible. But others in the group said they didn't like my idea. They said it was too cumbersome, and because of that, they refused to even read my whole proposal. I suggested that everyone work together to streamline it, but they had no interest in doing that.

I then realized that the real roadblock was that these CRNAs, who were friends outside of work, already had another idea. I imagined that while they were out together playing golf, they came up with their own plan. I realized that getting together as a group, so that the "group" would devise the new plan, was actually just their way to affirm and legitimize their own agenda.

Their idea, which they thought was the best way to proceed, was to assign and mandate the holiday schedule. I personally thought that was the best way to anger the most amount of staff, and told them so. Their reply, which was another example of gaslighting, was that everyone would then be pissed off equally, and if they didn't like it, they could go somewhere else.

Their method was that everyone could turn in their requests for holiday shifts they did not want to work, and then one CRNA would be responsible for assigning the shifts they did work. I warned them several times that the group of CRNAs who worked there would not go for someone telling them which holiday shift they had to work, no matter how careful and transparent the scheduler was. I told the group that I felt strongly that the person doing the assignments would become a target of ridicule and abuse.

I tried to warn them against it, but my warnings were ignored. The CRNA who elected herself to make the assignments began to respond to me like I was attacking her, like I was not having faith in her competence or sense of fairness. Then everyone in the group started to reject me, to turn their back to me, to even be cruel to me, telling me that I wasn't being supportive of the new holiday scheduler.

To see if Paul might intervene, I invited him out to lunch so I could tell him what was going on without our being interrupted. But nothing changed, so I gave up. I thought, if you want to throw yourself off a cliff, don't let me stop you. I just shook my head at that. It was crazy.

Sure enough, the scheduler was so harassed and bullied over the course of the next year that she gave up the job in tears, crying in Paul's office. I actually felt bad for her.

At the time, I felt that there was a philosophical shift in the department. I had liked that the past scheduler in the department tried to work around your personal life, to actually care about and respect the life you had outside of work. But with this plan, by their own admission, the staff would have had to work their life around the assigned shifts. I didn't like it.

Cognitive Dissonance

Another new term I learned while working at that job was cognitive dissonance. Basically, it is the filtering of information that conflicts with what you already believe about yourself, in an effort to ignore that information and reinforce your beliefs. Cognitive dissonance is the lies we tell ourselves to make us feel okay about our existence.

According to Psychology Today, cognitive dissonance occurs when your ideas, beliefs, or behaviors contradict each other. An example is the discomfort you feel when you consider yourself an honest person but you tell a lie. Or it is the unease you feel if you think yourself financially savvy, but have made poor stock investments.

I first learned about cognitive dissonance while watching Roger. He saw himself as a hard working family man, and even promoted himself on social media that way. He was like Richard Nixon decrying in 1973, "I am not a crook. I earned everything I've got." But his coworkers knew the truth. Roger worked a lot of hours, but he definitely did not work hard. What he told himself to justify his laziness was beyond my understanding.

I would not so much care about either Roger or Edgar and how they approached their lives if they did not have so much control over my life. But because Paul's policy was that the CRNAs working the longer shifts were in charge, they were able to make my life and my coworkers' lives miserable.

The funny thing about Edgar and Roger was that they loathed Paul. They would tell anyone who would listen how they thought he was "worthless" as a manager. But that stumped me. It was Paul who was the conductor of their gravy train.

Oozing Narcissism, Laziness and Myopia

Over time, the permissiveness of laziness started to permeate to other CRNAs. An oozing narcissism and myopia spread in the department. There had become a core group of CRNAs who thought that it was okay to sit around, doing nothing, whenever they had a chance. I felt increasingly frustrated with so many of my coworkers.

But the funny thing was, I truly believed that they thought they worked hard. That the failure in the system was someone else's, not theirs. They never thought of getting up to help someone outside their clique, never even considered it. And in the rare chance someone suggested they help fix a problem, it was back to "It's not my job! They aren't doing their job!"

I had worked places where the CRNAs helped each other. In fact, when I first started to work there, the CRNAs helped each other more. If someone was having a busy day, a CRNA with a lighter case load would help out. They would offer to do the next case, or to alternate doing cases, so the case load would be more even. Or if someone was assigned to do a long case, a CRNA with a lighter load would give longer breaks, or even several breaks, to that CRNA stuck in a room.

People seemed always aware of those who were having to work hard, and would help to even out the work schedule of all the CRNAs each day. Everyone helped everyone else. I really respected those CRNAs. The reason I came to work there full time was because I used to respect so many of the CRNAs. But the team approach which I so loved was gone.

The CRNAs had developed bad habits. Perhaps they decided that if you can't beat 'em, join 'em. But it just seemed like what they were mostly concerned with was what was good for themselves, not necessarily what was best for the department or for the team. They wanted what they wanted, when they wanted it. The CRNA with a lighter load might have given a 15 minute break to that CRNA who was busy, but loudly complained if the CRNA took 16 minutes for their break. Then they smugly felt like they had done their job and so felt justified to sit around for the next hour. Or if someone was struggling with a really sick patient, they may have talked about it in the break room, but they didn't get up to help.

So I began to realize that a big part of my discontent had become that I had stopped respecting so many of my coworkers. But I had flashes, memories, of working with CRNAs whom I respected. It was a whole different work place.

Face Your Fears

In the wee hours of one morning, I realized what I was feeling was fear. I was afraid to go to work.

I fortunately was given a powerful lesson about facing fears when I was a child. I used to be afraid of thunderstorms. I remembered clearly that when the skies started booming, I would run to the bathroom and hide between the toilet and the cabinet, bending down low, shrieking. According to my mother, a baby sitter had told me that thunder meant goblins were coming to eat me. So I remembered during one storm, my mother became tired of my crying, and gathered me in her arms to take me out to the porch. My brother was on one side of my mother, my sister on the other, and I in my mother's arms. Every time it thundered, she would tell me it was only God bowling. Kaboom ! She'd say, "There, that's God making a strike! God's just having a good ole time."

Finally, I quit crying and listened. Since then, I have loved a big thunderstorm. That day taught me a valuable adult lesson which I still carry into today. Face your fears, face them because they're never as big as they seem.

I am not stupid about facing fears, mind you. I did, and still do, have a strong survival instinct, so there has to be a good amount of safety involved for me to do something. After all, when my sister invited me to go fire walking with her, I said no.

Scared Stiff

There have been two times in my life when I was so scared I could not move. The first was the first time I went snow skiing. I was in my late teens, and I went with my boyfriend. I had grown up in the flat coastal plains of southern Alabama. The highest "mountain" of my youth was the overpass on the highway, and I had only seen an inch of mushy snow when I was 12. So everything about snow skiing was new to me.

I took bunny lessons with a group of kids. I learned to snowplow. I learned to fall over.

After the lessons, my boyfriend thought I should be able to manage going up the mountain and skiing down the easy runs. But the higher we went up the ski lift, the more nervous I became. At the first ridge, I thought, okay, we're getting off here. As I scooted myself forward in the seat to dismount, he pulled me back and pointed up to the top. At that point, I got mad. He hadn't told me that we were going to the highest peak !

So when we finally got off the ski lift, the expansive mountain vistas and quickly moving skiers spooked me. I was able to make it only a little way down from the top before I froze. I couldn't move, I was so scared. The wide open mass of the valley lay below me. People were whizzing past me on their skis, glancing at me, I'm sure wondering why I was in the middle of the ski run, not moving. My boyfriend alternated between yelling at me and coaxing me. Finally, I made it down, snow plowing all the way.

It took me about 10 years to get the chance to snow ski again. That time, I told myself, I was going to do things a little differently, so I hired a private ski instructor. I told him what had happened before, so he taught me how to ski properly. By the end of the lesson, I was even having fun, and went up the mountain for several runs during that trip.

Drowning

The second time I was so scared I could not move, I was in my mid 20's. I went to Colorado with a group of friends to do whitewater rafting. That year, the river had experienced excessive snow melt and so one part was particularly turbulent. We landed our boats before the rapids, got out, and climbed up onto the cliff overlooking the river so we could plan our route through the rapids. It was awesome up there, looking down on the white water, watching other boats fight their way around the boulders in the water. Our guide showed us three big boulders in the middle of the river, going down river, which pinpointed three steep drops in elevation. He warned us that we had to steer away from the boulders, otherwise our boat would go up on the boulder, flipping it over. I admit I was nervous.

Once we were back on the river, we paddled furiously to steer our way safely downriver, but we couldn't fight against the current. Try as we could to prevent it, we hit the first boulder. The current took our boat up its side and flipped our raft over, dumping everyone in the water.

I struggled to stay above water, flailing my arms to keep my head up, as I went down past the three steep elevation drops. I caught bright flashes of life rings being thrown in my direction, but I couldn't reach any of them. I thankfully remembered the safety lesson the guide had taught us, which was to keep my legs up in front, so that they could be used as springs to bounce off boulders. But every time I dropped over an elevation change, I went under water. I barely had time to get my head up and gasp a breath, before going down under the water again. I was inhaling water. I was drowning.

Finally, finally the river released me. I was able to clear the water from my face long enough to see a big rock ahead. I hurled my body toward it, thrashing against the current, lining myself up so the current would push me on top. Once on top, I crouched on my hands and knees, gasping and coughing. I couldn't move off the boulder on my own; someone had to get to me to lead me off.

It took me years to get the opportunity to do whitewater rafting again, but when I could, I took it and had a blast. I did not want to be afraid of a river. I wanted to get back up on that proverbial horse which threw me off.

In Front of the Camera

I was approached by a television crew asking me to be interviewed for a man-on-the-street opinion piece for the nightly news. I decided to do the interview because I wanted to assure myself I could be in front of a camera, speak well, and keep my wits about me. In the end, the news crew liked my interview so much that it became the whole news segment. Everyone who watched the news piece said that I looked relaxed and engaged, even funny.

A Healthy Respect for Heights

I used to be afraid of heights. Well, not exactly afraid, more like a healthy respect for heights. Since facing my fears was a part of my personality, I decided to fix the situation by jumping out of a plane. Twice. Tandem skydiving is THE best way to get rid of a fear of heights. It is only the first step which is difficult. It is all downhill from there ! And what a blast it was, a real rush. Both times, I landed laughing, wanting to go immediately back up.

Another time when I landed laughing was when I went tandem hang gliding in the Alps of southern Germany, in an area called the Alpspitze, near Garmisch. So I am not afraid of heights anymore. I know that if I can jump out of a plane or hang glide off a mountain, I can go up to that guardrail overlooking a canyon. And I do so love a view.

Fears are funny things. More times than not, when you face them square on, they're nothing.

The End Result is Waste

But how could I face those fears at work, when they were so prevalent, when I couldn't get away from them? I had worked there for years by that point, and things had only become worse with each passing year. The fear of rudeness, manipulation, and cruelty had made me develop symptoms of social anxiety. I had insomnia, tension, and stomach upset. I couldn't seem to keep my thoughts in order. I was fearful of making even the littlest mistake. I had started to stutter, which made me self-conscious and which lowered my self esteem.

I had lost my other sense, my intuitive sense. I had lost my center. I truly missed my quick-witted, spontaneous self. I felt like I had become a shell of my former self. I missed me.

I realized, and it amazed me, just how much the job was like my marriage. Petty annoyances and big frustrations were followed by moments of cruelty without remorse. Narcissism was abundant. I had an insidious feeling of a hopeless future.

But I did not experience enough of all the above to make me leave the job, and I knew that no good decision could come out of fear. So I continued to get up and to go to work. Moments, hours, days passed which were doable, some even filled with friendship, laughter, and good times. But those moments only served to be the salve, the balm, to make the abuse bearable.

So the years passed in that state of good, bad. Tension pulled me one way or the other. Bad outweighed the good, but there was enough good so that I was fooled into thinking I could manage. I knew I was strong. I knew I was adaptable. But the end result, the end result of it all, was waste.

I began to think that it was going to take something significant to change my trajectory. But I had no clue how significant that something would have to be before I moved on.

My Breaking Point

We all have a breaking point, and none of us know exactly when that breaking point will be. I found my breaking point after three separate nights within a month of bolting upright from a dead sleep with a feeling of anxious panic. The first time it happened, my heart racing, I told myself to calm down, relax. I assured myself I was okay. The second time, I was more concerned. I had a flash of a thought that I had given up my chance to live in New Zealand to put up with the shit there, but I knew there was no use crying over spilled milk. The third time, I said, "Enough is enough." It was time to get out. Whatever it took, whatever I had to give up to leave, I had to go.

So after that third time, my heart racing at 2 am after an exceptionally bad day, I sent an email to Kent. I had told Kent the evening before about the bad day, and Kent had told me how angry he was that my work situation was so bad. He had offered in the past for me to quit work and to come live with him, and so offered it again.

I replied via email, "Yes I'm angry too. And I feel so defenseless. Powerless. These are not good feelings for me, and I don't respond to them well. I woke with a start and have been unable to sleep since. I'm so tired I can barely think straight. I read my book and finished it. It was a good book and I'm glad I've had it to keep me occupied. I made celeriac remoulade for breakfast, which was fantastic. And I put on a big pot of vegan chili to cook.

Thank you for the offer to come stay with you. If I could retire now, quit all together, I would. In a heartbeat. It would be the perfect solution. But since I'm too young to quit, I must continue to work. And if I stay off a bulk of time without having a confirmed job at the other end, I'm afraid I'd lose my confidence in my work all together. My morale is so low I don't know if I can pick myself back up if I stopped. You know, it's the getting back up on that horse thing.

Unfortunately, Edgar is working again today. And he'll be there Monday too. All that I dreaded when I knew I was working this long stretch with him has been worse than I imagined. I feel like he has made it his personal goal to destroy me. I am strong and I will survive. But I have to make a change. I've been thinking too much about how depressed I am here. I just can't do it anymore. I don't have it in me. But oh how I wish I could catch up on real sleep so I can think clearer."

I am Their Pack Mule

For years, I had been feeling like a pack mule at work, marginalized and inconsequential. And the only time I was given any notice was if someone claimed I was not doing anything. I had felt that gossip about my not working was used as a prod, so that I felt I had to work harder to prove the gossip was not true. I was being used. I was being used for my work ethic.

Others at work were the pack mule too. It was not just me.

Being Scared is Never a Reason Not to do Anything

Over my life, it has helped me to sort out difficult emotions by writing them down. So I made a list of why I wanted to leave, to sort out facts from emotions:

1) Angst. Constant and continuous.

2) I realized that I no longer respected many of my coworkers.

3) I was happiest on busy days in the operating room, when everyone was working.

4) I was tired of swallowing the anger and the angst, becoming depressed to the point of clinical depression. I was tired of smiling when I felt angry, of being helpful and cheerful to people I didn't like nor respect.

5) The milieu was so different from my fundamental core values, so different from who I was in my heart. I felt like a square peg in a round hole.

6) I missed me. The problems had gone on too long. Years.

7) I was not sleeping all night. I would start to doze and then I would jerk awake with my heart racing. I tossed and turned. The third night that happened, I realized I couldn't live like that.

8) And then I had an epiphany. I realized that the reason why I didn't quit the job was because I thought quitting also meant selling my house. But I realized that I could separate the job from my house, that I could actually quit one without quitting the other. I realized that I didn't need to decide about what to do with the house right then, that I could keep it and decide at a later time whether I wanted to sell it or not. That realization made the decision much easier.

9) I also didn't know if I could find a locum job, or whether I could find enough work as a locum. But I realized, after yet another night of tossing and turning, I didn't care. I had to get out.

10) Then I realized that the reason why I wanted to retire early was because I hated my job. I thought I would probably work longer if I was in a job that I liked.

11) I had long ago lost hope that anything would ever be any different there.

12) I hated watching one coworker after another be systematically bullied.13) I didn't have any power to change things, nothing to help myself nor to help the others being bullied.

14) I wanted to work part time, be with Kent more, and I could do that as a locum.

15) As a locum, I could be more in control of my own life again.

16) As a locum, political workplace issues would not matter again.

I realized that being a locum again would be different. I was older. I expected and wanted different things. I didn't want to travel as much; I had a house which I wanted to visit and which needed upkeep, and I knew that would influence my contracts.

I realized I was scared to make the leap. I was afraid to go to work and I was afraid to quit. I was living in fear. But I don't live well in fear; the history of my life had made it so that I faced my fears, head on. So I had to make a change. I had to make a change before I could take one step forward into the day. The sleepless nights propelled me forward.

Being scared was never a reason not to do anything.

Stick Me With a Fork, I'm Done

And so I made the decision to jump off into the locum world again. I had a thought, true or not, that the hospital where I was working did not really want people like me, with my gentle, polite soul, no matter how hard I worked, no matter how well I took care of the patients. They wanted something else, something which was not me. I had hoped I could hold out until things got better on their own, as my CRNA coworker had once suggested things do. But six years of putting up with the dysfunction was enough. I kept thinking, "Stick me with a fork, I'm done."

I had been like that metaphorical frog in the pot of water. Throw a frog into a pot of boiling water and he will jump right out. But throw a frog into a pot of lukewarm water, slowly raise the heat, and he will stay in until he is literally boiled to death. It was time to get out, before the abuse figuratively boiled me to death.

Being a locum again was a big deal. After the idea of moving to New Zealand died, I thought my trajectory was there, at that full time job, in that part of America. I hoped and planned to retire at that job. But Like Newton's First law, the sleepless nights and the escalating work difficulties shot my trajectory in a new direction.

To confirm a locum contract, I needed references, so I gave a lot of thought to who I would ask. I needed a reference who would keep my confidence. I didn't want Paul to find out I was leaving until everything was set for the new job.

At least one reference had to be from an anesthesiologist, so I choose Dr. Voyageur. When I asked him, he was so nice. He told me how much he thought the world of me and said he would give me his best recommendation. He said he was sad to see me go. His kind words brought tears to my eyes.

Another reference was Mark, one of the CRNAs. Mark was a buddy, and was more matter-of-fact about my resignation.

I also asked the thoracic surgeon to be a reference for me, and he gladly agreed. Since we had been working together so much, I knew he was one surgeon who knew my skills well.

I gave everyone a song and dance story that I needed to be a locum so I could be nearer my elderly parents, which was actually partially true. I did not make it known that the main reason I was leaving was because I was so unhappy, and had been unhappy for years. I didn't make it known that I just couldn't stand the bullshit and the backstabbing anymore. I had long ago lost hope that anything would be better, and I knew saying something about it would only bring me grief.

I thought Mark actually knew my reason for leaving was because I was so unhappy, yet he didn't question me about my story. I didn't think Dr. Voyageur realized how unhappy I had been. I did wonder if he would be mad to learn that the reason I was leaving was because I hated the place, and the reasons why I hated the place. I suspected he would try to raise holy hell about it, and he didn't need to get into that; it would only bring frustrating grief to him.

Complicit

Most of my life, even since I was a child, I believed that if I asked forgiveness, if I said I was sorry, then that implied that I knew I had done something wrong and intended to not do that thing again. "I'm sorry" equated with "I won't do that again".

Which brings to mind a common belief that if you do not forgive someone, you are only hurting yourself. The mantra is to forgive and forget. But how do you forgive someone who doesn't think they did anything wrong? Or someone who knows they did something wrong, but refuses to admit it, take the blame for it, make it right? Or even someone who lacks the emotional intelligence to see that they did anything wrong?

My thinking is that if a person is not sorry, for whatever reason, they may do that thing again. First time, shame on you. Second time, shame on me. The forgive-and-forget mantra only works with someone who sees their actions for what they are, and is regretful. If they are not regretful and I forgive and forget, I am opening myself for them to do that thing to me again.

It would be like I am complicit in their wrong doing. I have accepted that they have done something wrong although they have done nothing to make that wrong right. It gives them license, it even gives them permission, to harm again.

This reminds me of the incident with nurse Alex Wubbels, which made international news in 2017. Alex had been aggressively and forcefully arrested by Detective Payne after refusing to allow him to draw blood on an unconscious patient, because the patient, being unconscious, was unable to give informed consent. It is a national law that a patient, before any procedure can be started on them, has to give consent for that procedure. If no consent is given, then doing a procedure can be considered assault and battery. Alex was just protecting the unconscious patient's rights.

After the detective's subsequent dismissal, his attorney was quoted as saying, "Had this incident not received that (type of attention), there's no way that this conduct, in my opinion, would have merited a termination."

I thought, What?!

Alex's attorney echoed my thoughts exactly. "I honestly struggle to understand how detective Payne doesn't think that his conduct warrants termination. I don't get it," she said. "If Detective Payne does not believe this is a fireable offense, then I'm glad Detective Payne will not be out on the street in uniform tomorrow."

It made me wonder how many other times Detective Payne had so aggressively responded to the word "no". If Detective Payne did not admit he had done anything wrong, nothing would stop him from doing the same thing again.

So how do I know that an abuser will not do harm again? If they are not sorry for what they did, if they feel no remorse, or if they do not even see that they did anything harmful, how can anyone know that person will not be abusive again? The answer is, you don't.

So how can someone deal with these people? What I do in my personal life is to just move away from them. I see the person and their actions for what they are, and avoid them. Just get away, move on. I feel that this is the only solution. I can't make that person be a better person, more than what they are.

As a good friend poetically told me, "Steer away from vexatious persons. You don't change poison ivy by rubbing it." Well said.

I like how Will Smith put it, ".... it is for damn sure your responsibility to figure out how to take that pain and trauma and how to overcome that and build a happy life for yourself.... As long as we're pointing the finger, and stuck in whose fault something is, we're jammed and trapped into victim mode. When you're in victim mode, you're stuck in suffering. The road to power is in taking responsibility. Your heart, your life, your happiness is your responsibility, and your responsibility alone."

So if I ever feel the very human urge for revenge, I've learned that the best kind of revenge is to live a successful, happy life.

Short Timer

I gave a month's notice, and during that time, I emotionally disconnected myself from the job so that so many things which irritated and annoyed me lost their power over me. My feelings no longer had any energy behind them. I just didn't care. All I felt was sleepy. I was apathetic.

I almost hated to admit it, but I was happy, perhaps even relieved, to see that although I had a serious case of short-timer's syndrome, and a serious case of the I-don't-cares, that I still saw my coworkers suffering and unhappy. That now that I could more objectively see the situation as an outsider looking in, that things were still as crazy and dysfunctional as they had been for years.

The bullies ignored me, which was really a total blessing. But they were keeping at it with our coworkers. One of my friends ranted to me in private for about 30 minutes at the end of one day, telling me all the problems in the department. Mostly I just listened and agreed, telling her, "That's exactly how I think about that."

And JoAnne, bless her heart, was a good friend and one of the then current major targets. Clarence had chewed her out in the middle of the operating room, saying she was lazy because JoAnne wanted to only work a minimal amount of overtime and did not want to work the long shifts. JoAnne worked hard when she was at work ! She just had a life outside of work with her fiancé, and with the new house they had recently purchased. I heard that Clarence was so cruel to her that JoAnne cried right there, in the operating room.

JoAnne and and I talked about it later. She wanted to quit working at that hospital too, but had only one hospital in mind for future employment. But that limited her because the hospital where she wanted to work did not then have any current openings.

A couple of weeks before I turned in my resignation, knowing how unhappy I had been for so long, JoAnne had exasperatingly asked me, "Why are you still here?".

I hadn't answered her at the time because everything was not set up for me to leave, so I just shrugged my shoulders. But after I resigned, I asked her, "Do you remember what we talked about a couple of weeks ago?"

She said, tears welling up in her eyes, "Yes, I thought of that immediately."

I said, "You're the only one I've told straight out the real reason why I am leaving. You are the only one who knows I am leaving because I hate this place. To everyone but you, I'm saying I'm leaving because I need to go help my parents, which is actually partly true."

I continued, "JoAnne, if words could change how things are here, then I would say those words. I truly would. But words won't change anything, and so that is the story I'm saying".

Another CRNA was being bullied along with JoAnne. Word was circulating that he also didn't like doing the long shifts and excessive overtime. And he didn't want to be the lead CRNA when Paul was absent; he just didn't like doing that job.

A couple of the other CRNAs talked to Paul about him. They were worried that he was going to be the next one to quit. They asked Paul to talk to the CRNA, telling Paul, "We can't afford to lose another person." Sadly, no one mentioned talking to Paul about JoAnne's unhappiness.

I asked, "What is Paul going to do about it? Is he going to give him a schedule which he's more comfortable with? Or is he going to make it so he doesn't have to be in charge?" I figured Paul wouldn't do anything, keeping to his normal habits.

It made me mad that since I had resigned, everyone had started saying, "We can't afford to lose another person". Why wasn't something said about losing CRNAs a long time ago? Why wasn't job satisfaction and retention an issue before I decided to leave? I suspected the real reason was because with my leaving, the volume of work I did would have to be done by someone else. They were afraid that they would have to get up and work.

I did wonder how many knew, or even suspected, how miserable I had been. I thought about it a while, and then I realized that it didn't matter anymore. The lack of self-awareness, if that was what it was, was quite amazing. So many people who thought the world should revolve around them, and were mad when it didn't.

I had one bright light during my last month of employment. I realized just how many friends I had made, friends who I was going to miss.

I received a text from one friend who said, "It's so sad for us to see you leaving."

I replied, "Yes, it is sad, isn't it? You'll be one I miss. You're a great guy."

Another friend, who was off on vacation, sent me this email: "It was a pleasure working with you and I'll miss you. You are a very dedicated CRNA, who cares about doing a good job and giving excellent patient care. This organization will miss you and needs more CRNAs like you. I wish you the best and please keep in touch, I will truly miss seeing you."

Clueless

I told Mike, one of Paul's new office helpers, that my first locum job was going to be at a Level One trauma hospital. He was pretty amazed that I was going to work at a Level One trauma hospital, and said, "If you get tired of taking care of trauma patients, you're always welcome to come back to this easy job here."

I just looked at him, making sure he wasn't teasing. He wasn't. Then I got my tongue back and thanked him for letting me know that I could come back. An easy job for him maybe !! He was able to often sit in Paul's office, helping him with his paperwork. Mike was one of the few in the department given a set work schedule, which made it possible for him to plan for personal events like doctor's appointments or family get-togethers months in advance. And when Mike wanted a day off, he got it without getting grief from anyone.

I wondered why Mike was clueless as to why his working life was so easy. I wondered if he believed that everyone had it as easy as he did. What I couldn't fathom was if he had figured out a way to have a cushy job, if he had figured out how to make things sweet for himself, and if he was so myopic that he couldn't see the same did not go for his coworkers, then how could the whole system work? It was like a narcissistic relationship. If all you thought about was yourself, how could the relationship last? The answer was that it couldn't. It was not sustaining.

I knew that part of the problem with Mike's narrow-mindedness was that he had never worked at any other hospital but the one. He worked at that same hospital as an ICU nurse, and then had returned once he finished anesthesia school. With few exceptions during his nursing and anesthesia training, he had nothing else for comparison. That environment was all he knew.

When I left at the end of that day, I happened to walk out to the parking lot with Mike. He was sighing, complaining because he had had to do a difficult case in the afternoon. He sighed like he was exhausted; he rarely did big cases. I thought to myself "welcome to my world" and "I don't want to hear about it". I did like Mike as a person, but he was part of the problem. Easy job, my ass!

The Screaming Quiets

I read through some old emails and it made me realize how I was when I first started to work there, before I felt beat down, when I still felt strong. There was a different cadence to my emails. It was just one more proof that it was time to leave.

In retrospect, I should have left long ago. Doesn't that often happen, staying too long in a bad situation, thinking that things will improve? I couldn't exactly see how my future would be, but I knew I didn't want that hospital or those people anymore. Once the emotional energy that I had struggled against for so long began to fade, I had a couple of moments when I asked myself, "Are you sure about leaving?" But I was sure. That place was toxic for me.

So walking out to the parking lot after working my last shift, I thought, "Yes, I am glad it is done." I felt good walking away, my shoulders were lighter, my step confident. I was amazed at how good I felt.

I was touched many times during my last month by all the people who wished me well and hugged me, much more than I thought there would be. People were even surprised that I was going, saying they were sad to see it happen. I found myself wishing they had given me such warm regard and, yes, help against the cruelty and bullying all the years I had been there. Anyway, it didn't matter anymore. It was what it was.

I decided to take off six weeks before starting my first locum tenen job, so I went to Canada to spend it with Kent. I slept a lot. I slept ten to twelve hours each night for the first five weeks. At first, I thought I was sleeping so much because I was just tired. But as the weeks progressed and the long nights of sleep continued, I realized I was coming down from all the years of stress. I could feel my thoughts calming. I could hear the screaming in my mind quiet.

So, the world turned, the fern leaf opened, a new day appeared, and I started another new beginning. Koru.

Part Four

THE FIGHT

I am Less Tolerant

My first job out, I realized I had changed in the six years since I had worked as a locum. At first, things were definitely better. I was so relieved to be away from all the angst.

But all the good feelings, passion, and internal strength I enjoyed about myself and my life as an anesthetist had mostly vanished with my being in that toxic environment for so long. What I was missing was an unbreakable confidence I had all my adult life, a confidence that I was okay. I no longer thought that no matter what life threw at me, I could survive it, live through it, surmount it. I was less tolerant of the cruelty, the games, the domination, the aggression, and the sexism which was so common in the health care industry, and which I had witnessed for over three decades as a nurse.

Years ago, when I was a locum the first time, I had a discussion with a friend and fellow locum CRNA about the toxic health care environment. She said, and I agreed, "In very few hospitals, too few, the toxicity is not allowed at all. In a handful of hospitals, it occurs but is not commonplace. But unfortunately, in the rare times it does occur, a blind eye is turned, as if what is happening is not really happening."

She continued, becoming agitated as she spoke. "But you and I both know that in the majority of hospitals, we have known many people, including ourselves, who have experienced or have witnessed such widespread sexism, misogyny, bullying, and harassment that I've lost hope that anything will ever change. If you stand up for yourself, you run the risk of being vilified or made an outcast. We've both known people who have even lost their job. And if you believe that administration has your back, or that there is an easy fix, you are either blind, a fool, or have been very lucky."

But I wanted to make my locum life happen. I needed to make it work. I so wanted to be content with my work again. So I tried. But my eyes still saw, and my ears still heard:

"God damn it, I'm tired of this fucking hemostat! This is the same one I got last week, and the ends don't meet, so that it can't be used for shit!" The surgeon then grabbed the ends of the hemostat and twisted them so that it came apart. Then he took the parts, bent them in half, and threw the mangled mess on the floor. "There, I won't be seeing this hemostat again."

The scrub tech just looked at him, a deadpan expression on her face. "You know that I could have sent that to be repaired. You didn't have to twist it into a ball like that."

The surgeon just looked back at her, impassive, then asked for another hemostat.

And this:

I was working with a student nurse anesthetist one day. She was bending over to check the urine output from the foley catheter when a man came in the room. I didn't know this man; I had just started working at that hospital. He stood behind the student, effectively pinning her underneath the surgical table and started to dry hump her, grinding his hips back and forth against her.

I was immediately angry. I forced myself between him and the student, backing him away, and looked him square in the face. I said, "Excuse me. What was that? What do you think you were doing?! Leave my student alone!"

The surgeon roared with laughter. The man looked me square in the face and chuckled indifferently, then left the room without saying a word.

When he was gone, I said, "Who was that?!"

One of the the nurses said, "You don't know who that is? He's one of the partners for the anesthesia group here." A partner is basically the owner of the anesthesia group. A partner is either a CRNA or anesthesiologists who contracts with the hospital to provide anesthesia services for that hospital.

She continued, "He always does shit like that. He's been getting away with it for as long as I've been working here. He's a real scumbag."

The scrub tech said, "I'm so glad you said something to him. Most people are afraid to say a word. He's made lots of CRNAs' lives a living hell. Be careful. He can terminate you."

The student gave me a hug and thanked me. She looked relieved. "He's done things like that before, and no one has stood up for me like you did. There's not much I can do as a student. I have no power to do anything. I'm told to just go along to get along. But many days, I go home crying."

And another day:

"I can't do surgery with the patient moving like this!" Looking up at me, eyes angry and challenging, he continued, "Are you going to stop it?!"

I looked at the monitors, and everything was calm and stable. I looked over the surgical drape and the only movement I saw was the movement of the patient's breaths.

He bellowed, "What are you looking at? Are you questioning what I'm saying?"

I looked at him and calmly replied, "I just wanted to see what you were seeing, so I could better know what to do about it."

"The patient is breathing too heavy. Do you actually expect me to do surgery like this? Do you?!"

I glanced up to see the Circulating Nurse, who was standing behind the surgeon, shrug her shoulders. I turned back to the machine and gave 50 mcg of Fentanyl, a narcotic which would depress the respirations. See if that helps, I thought.

Later, he mumbled down to the surgical field, "Get me a bigger needle".

"What?" asked the Circulator.

"God damn it, get me a fucking bigger needle! Get me what I want !" he boomed.

The circulator, who had been working in the O.R. for years and knew the surgeon well, boomed back, breaking the tension. "We're getting it for you! Your big and my big are different."

"Yes, that's obvious," he said, giving a smirk in her direction.

"So hold your horses," she said as she peeled back the sterile packaging.

Later, after the surgeon had left the room, the resident was closing the surgical wound. The resident said, "All day, he tells us how to be, how not to be, the patient is breathing too much, not breathing enough, we're not moving fast enough, turnover is too long. All day long."

I peeked over the blue surgical drape and said to the Junior Resident, who was assisting with the closure, "Sometimes people come in our lives to teach us how to be and sometimes they come into our lives to teach us how not to be."

The Resident, teasing, said, "Just what are you trying to say?"

I laughed, "I'm just making a general statement", and then turning to the Junior Resident, I asked him, "Are you learning how to be?"

He smiled, "Yes, I"m learning."

And this:

I had been at a new contract a couple of weeks, so I knew the routine. As I approached my first patient of the day in the preoperative waiting area, I noticed a man standing next to my patient's bed, talking with her. I went to the other side of the bed and stood quietly listening until I realized that the man was an anesthesiologist. When he finished his interview, I reached out my hand to shake his, and politely introduced myself. I said, "I started a couple of weeks ago, and I haven't had the chance to meet you yet."

He shook my hand, saying, "Welcome", but had a funny look on his face which I could not read.

After I did my own preoperative evaluation with the patient, I went through the adjacent room to go to the operating room. The anesthesiologist I had just met was putting in central intravenous lines on another patient, with an anesthesia technician assisting. He stopped, looked me in the face, then tore into me. He thundered at me, saying how he thought I had been unprofessional introducing myself in front of the patient, that I should have waited until he and I were alone. He screamed that he thought we should present ourselves as a cohesive team, and not as unknowns just meeting. I listened to him yell, my mouth agape, as a circle of bright red blood spread on the sterile drapes which covered the patient under his hands. Finally he glanced down, saw the spreading blood, and halted his tirade.

I left to check if the operating room staff were ready to start the surgery, and they said they were. I went to roll my patient back to the operating room and found her anxious and teary. She looked at me, took my hand, and said, "I don't care so much that you two didn't know each other but how he just treated you. I heard him yelling at you in the next room. I heard it all. That was awful."

I held her hand, apologizing for what she heard. I gave her an intravenous sedative called midazolam. I hoped the midazolam would relax her enough for her impending surgery, and I crossed my fingers that it's mild amnestic quality would help her forget what had happened. I stayed with her, holding her hand, until her eyes closed and her breathing relaxed.

When the anesthesiologist came to the operating room to start the anesthesia with me, he was stern but quiet. After the patient was asleep, I told him that the patient had heard his yelling at me, and that it had upset her. He made no comment and left immediately after I secured the endotracheal tube.

I went to see the patient the next day, to see if she was okay. I was concerned for her. She still remembered what had happened preoperatively and was still upset about it. But she was distracted about her discharge that morning, looking forward to it.

I spoke with the chief CRNA about what had happened, and asked him never to assign me with that anesthesiologist again. The chief CRNA said that he wouldn't be able to comply with my request. He said the anesthesiologist was the head of the anesthesia group and had been working there for years. He had always been rude and abrasive like he had been with me, but everyone just accepted him as he was.

We discussed the anesthesiologist's point of contention, that he thought I was being unprofessional by introducing myself to him in front of the patient. The chief CRNA said, and I could see the point, that it might show a lack of cohesion in the group. But I told him that for my whole career, I had introduced myself and others had introduced themselves to me in front of patients. I said it was commonplace, and no one ever thought anything about it until I came to this hospital. We finished the discussion agreeing that the anesthesiologist had gone overboard with his reaction, but that I should not expect an apology nor for anything to change.

So the weeks passed, and at the end of my last contract day, I was in the anesthesia workroom, saying goodbye to the CRNAs. The anesthesiologist came in the workroom and a couple of people told him it was my last day.

He said, "Wasn't there some issue with you when you first came? I can't remember what it was. But you turned out to be a good CRNA, and we'll welcome you back anytime."

The chief Nurse Anesthetist was in the workroom and put me on the floor, laughing, when he softly answered, "She said hello."

And this:

I was assigned to work with the same surgeon for three cases one day, and the anesthesia for each case was difficult. On the first patient, her anatomy was so unusual that no matter what we tried, we could not place the breathing tube. That was a big deal, and did not often happen. She woke up fine but we had to cancel the case; canceling a case also did not happen often. But before canceling, we had spent an hour and a half trying to place the tube, which put us behind on the schedule and made the surgeon irritable.

The second case of the day needed an arterial line, which is a tiny tube in an artery. The anesthesiologist I was working with that day tried to place the line in the preoperative area, but was unsuccessful. The attempt delayed us even more, which made the surgeon even more irritable. After the patient went under anesthesia, the anesthesiologist continued to try to place the arterial line, unsuccessfully. Thankfully when the surgeon tried, he got it on the first attempt. But that unfortunately then made the anesthesiologist irritable.

The circulating nurse then commented that it was a bad day. Jokingly, I told her that all bad days came in threes. That we were due for one more bad event.

So after the third case started, sure enough, something happened which never happened, and which is considered a major event: my anesthesia machine malfunctioned. The patient was asleep, the surgeon was about to cut the skin, and my machine which had been working fine all day would not work properly. I quickly called for help. Three people came in the room at once and thankfully were able to change the machine to a new one. But during the change out, I had to put the patient on a temporary vital signs monitor and manually breathe for the patient using a special breathing machine. It was a tense 20 minutes or so.

But the stress of that event combined with the other two events made the surgeon yell. He looked at me angrily and blamed me and "anesthesia" for delaying his day and for causing problems. I, in return, gave him a "go to hell" look, the best one I could muster over my face mask. We were doing all that we could! Asshole. But during all that happened, I suppressed my frustration and put a smile on my face. The anesthesiologist and the surgeon were going crazy enough!

Bottom line at the end of the day, though, was that all the patients did okay. Not one patient had a bad outcome. Couldn't the surgeon see that, and give us a break?! Nope.

But, a bad start to the day didn't mean a bad rest of the day. So the circulating nurse and I laughingly decided we had been in a vortex of bad vibes, and were done with it now. I teased her as I reminded her that I had known there was going to be three bad things. And thankfully, the rest of the day was good, no more problems. No more unusual events.

And then this, from another day:

"Okay everyone," I spoke loudly to get the attention of the operating room staff. I made sure everyone had stopped, and was looking at me, before I continued. "I want to put her to sleep on the bed. She's in too much pain to move her over to the table."

"Mrs. Rowe," speaking close to her face, her eyes, clear and blue and intelligent, fluttered open to look at me. "We're going to go to sleep right where you are." I held her hand as I spoke, her small bony fingers cool, her pale pink skin stretched thinly over her knuckles. "What I need you to do now is to breathe this oxygen. You don't have to do anything right now but breathe." She gave a barely perceptible nod.

Giving her a reassuring smile, I turned up the oxygen to 10 liters per minute and positioned the face mask over her mouth and nose. I asked the circulating nurse standing next to me to hold the mask over Mrs. Rowe's face while I readied everything else to start the anesthesia. I saw that the nurse held the mask perfectly, making the seal snug, keeping out any unoxygenated air.

Working quickly, I texted the anesthesiologist, Dr. Marly, to come to the OR. "Ready for sleep in 6". I connected the gastric tube coming out of her nose to suction, and briefly watched to verify the brown liquid was coming out of the tube into the canister. I then connected the blood pressure cuff tubing, and pushed the button on the monitor to start the automation. I listened to the zip of the cuff inflating as I placed the pulse oximeter on Mrs. Rowe's finger. Within a couple of seconds, the monitor had picked up her pulse and was beeping into the quiet of the room. 96% was the number, which increased to 99% as I watched. Good, I thought, she was becoming pre-oxygenated. I placed the sticky EKG electrodes on Mrs. Rowe's chest as Dr. Marly came in to the room.

"I've drawn up Etomidate for Mrs. Rowe. She's so sick. You ok with that?" I asked politely.

She shook her head yes, while looking with concern at Mrs. Rowe. That was only the second time I had met Dr. Marly, so I didn't know her style of working with Nurse Anesthetists. But the first time we had worked together, I had a good feeling about her and her skills, and she had even told me to call her by her first name of Randi. That always rated high with me, that a doctor was grounded enough in their own selves to not have to be called "Doctor".

"Mind if I put in the art line after she's asleep? I like doing them whenever I can get a chance, to keep my skills up," I asked.

"Sure. As soon as you get the endotracheal tube in, you can go around to put it in. I'll secure the tube," she said.

I glanced at the monitor to verify that the EKG was functional. Normal sinus rhythm, a couple of premature beats, rate low 90's. Nothing unexpected for a 94 year old; actually it is pretty good for a 94 year old. The higher rate was expected; pain and sickness made the heart rate go up. I pressed another button to run a paper EKG strip, for documentation of the baseline rhythm. I left it in the monitor to keep it from getting lost in the shuffle of going to sleep, called induction.

I looked at Randi and asked if she was ready. She looked up at the monitor to verify that everything was connected and functioning. I pointed out that about 200 ml of brown fluid had already come out of Mrs. Rowe's gastric tube, and we both bent to look at the canister located under the anesthesia machine.

A second circulating nurse handed me a Yankauer suction connected to a second suction canister, knowing I would need it if any gastric contents came up from the esophagus during induction. I thanked him and put it underneath Mrs. Rowe's pillow to quiet the hiss and to keep it within immediate reach. I saw the smile in his eyes, above his face mask, as he acknowledged my thanks.

Randi reached behind me for the syringes filled with induction drugs. I took the breathing tube on the cart to my right and placed it on Mrs. Rowe's chest, and grabbed the metal laryngoscope, placing it next to Mrs. Rowe's head. I looked around the room. The surgeon was whispering in the corner with his resident. The anesthesia tech whom I had just met was waiting at the edge of the room, standing next to the arterial line setup. He had already connected the IV fluids to the fluid warmer. We needed to do everything we could to keep Mrs. Rowe's body warm. The staff looked back at me.

My eyes rested on Mrs. Rowe's protuberant belly. It was round and firm. A flash in my mind was of Saint-Exupéry's description of the boa constructor after it swallowed an elephant. Everyone knew that it would be a tricky induction. The expectation was that Mrs. Rowe had a bowel obstruction, preventing anything above the obstruction to move through her bowels. That made Mrs. Rowe a high risk for aspiration, for getting those toxic liquids in her lungs, causing pneumonia and death. From the moment of unconsciousness, when her gag reflex would disappear, to the moment of actually placing the breathing tube, thus isolating her lungs, was a precarious time. We had to make that time as brief as possible.

I looked at the circulating nurse. "I have the mask now, thanks. Would you do the cricoid pressure?" Crcoid pressure would help to prevent any residual liquids from coming up from the stomach to the back of the mouth. It was not a 100% effective maneuver, but it helped. Randi looked at the nurse's fingers as she did the cricoid pressure, placing them on the front of the patient's neck. I knew she was verifying that the nurse was doing the maneuver correctly, which she was. Another glance at the monitor, saturation 100%, heart rate 92, blood pressure 102/64.

"Do you have some pressers ready?" Randi asked me.

As she asked, she looked and saw that the syringes filled with pressers were sitting on top of my anesthesia table. I already had Phenylephrine and Ephedrine drawn up and ready, with the stronger Vasopressin placed next to them. Randi opened the warm intravenous fluids to maximum, then started by administering a small dose of phenylephrine, then added the Etomidate and Succinylcholine, all in quick succession. We were doing a true Rapid Sequence Induction. A quick unresponsive touch of Mrs. Rowe's eyelash showed me she was asleep. I opened her mouth with my left hand and was relieved to see nothing but a dry, pale pink mouth.

"Clean and grade I view," I said out loud to Randi. Within 5 seconds, I placed the breathing tube and inflated the soft cuff at the tip of the tube. Randi listened to breath sounds with her stethoscope and the nurse asked if it was okay to release the cricoid pressure. I tapped her hand and said, "Thanks".

Thankfully the phenylephrine that Randi had given Mrs. Rowe before the other drugs helped keep her blood pressure from lowering too much as she fell asleep. I gave another small dose before moving around Mrs. Rowe's arm to put in the arterial line. Sometimes, a flash of blood was a bad thing: a wrist cut for suicide, the trauma of a vehicle accident, a mishap during sports. But sometimes, a flash of blood was a good thing, like when I could see the rhythmic movement of the heart pumping blood up the arterial catheter. Bingo, I thought to myself. I always get a little thrill when I saw those small rewards. I told Randi I would start a second IV line next. Seeing that the arterial line was secured and the vital signs were stable, Randi gave me a tap on the shoulder, asked if I needed anything else, and left the operating room.

The staff gently lifted Mrs. Rowe's sleeping body to the operating room table. The Foley catheter was placed, the abdomen prepped, the sterile drapes draped, antibiotics verified, time out done. The surgeon made his first cut, cleanly opening the skin. The resident cauterized the small bleeding vessels. Very little blood was lost.

Once the surgeon reached the intestines, Mrs. Rowe's blood pressure began to dip. 94/54, 90/ 45, 85/ 50. I continued to give doses of phenylephrine, and placed the second IV line with a larger size catheter. When I saw that those drugs were not keeping her blood pressure as high as I wanted it to be, I gave a dose of Vasopressin. That did the trick, at least temporarily.

Another nurse anesthetist then came in to offer me a bathroom break. Rule number one in anesthesia: never turn down a break when offered because you never knew when you would get another offer. Anesthesia providers are never to leave a patient unless someone was there to relieve them. I had heard stories of anesthesia providers, stuck in a long case in the middle of the night, having to use a urinal or a bedpan in the corner of the operating room while the circulating nurse held a blanket up for privacy. Since Mrs. Rowe was stable at the moment, I caught the CRNA up to speed on what had happened so far, and went out through the O.R. core door.

Nine minutes later, I was back. The CRNA said Mrs. Rowe's blood pressure had dipped again, and that he had given more pressers. He asked me if I was okay, I responded that I was, and he left the room.

Dose the Phenylephrine, check the blood pressure, dose the Phenylephrine again, ask the nurse how to call the pharmacy. I needed to start a Phenylephrine infusion. Called the pharmacy to order the infusion. Called the anesthesia tech to get an IV pump setup. Bend to check the color and volume of the urine output from the Foley catheter.

"Excuse me." Blood pressure 72/49. Give another dose of Vasopresson while waiting for the Phenylephrine infusion. "Hey, anesthesia! Excuse me."

I stopped and looked up, tilting down the sterile drape to see over. I was surprised to see that everyone in the surgical field had stopped and was looking at me.

"Are you talking to me?" I asked.

"How long has this surgery been going on?" the surgeon looked at me, eyes angry over his mask.

"What? How long has this surgery been going on?" I had to shift gears in my mind. I couldn't believe what he was asking me.

With a firm, angry voice, he repeated, "I asked you how long has this surgery been going on?"

I looked at my charting, wondering why he was asking me and not the circulating nurse, who would have been able to answer that question quicker than I could. "Twenty seven minutes," I calculated.

"So," he continued, "this surgery has been going for ONLY twenty seven minutes and you found that you HAD to take a break now! We'll be done shortly, and you could have taken a break then."

I looked at him, incredulous. "OK," was all I could get out of my mouth. After a few more moments of shooting darts at me with his eyes, he bent back over Mrs. Rowe's abdomen. The room was so quiet, the only sounds were the hiss of the suction machine and the beep of the monitor.

WHAT THE FUCK? ! My mind was reeling. First, how was I to know how much longer he was going to take with the surgery. Second, what did it matter if I took a short bathroom break? The CRNA who had relieved me for the break was quite capable of handling any issue. The CRNA had told me the other day that he had been doing anesthesia longer than I had, and that was a LONG time!

Glancing at the monitor, I saw Mrs. Rowe's blood pressure had gone down to 68/39. Fuck! That asshole surgeon had interrupted my train of thought to yell at me about leaving the room, and now our patient was trying to die. I could feel my mind shift gears to throw out the feeling of anger and annoyance at the surgeon. Focusing, staying vigilant, keeping calm, that had become a part of my DNA over the years of my doing anesthesia.

Thankfully the pharmacist came in at that moment to give me the bag of phenylephrine for infusion. I focused on getting that up and going, of setting the controls of the infusion pump, of giving phenylephrine doses until the infusion kicked in. I carried on. Check urine output, it was okay, color yellow, no blood. Reposition the wrist to be sure the arterial waveform was accurate, giving me the correct blood pressure readings. Draw blood from the arterial line to send to lab for analysis. Look at the estimated blood loss. Move on, carry on. Keep her alive.

Surgery finished. Mrs. Rowe was thankfully breathing well so that I felt comfortable removing the breathing tube. Phenylephrine infusion was still going, but at a low dose. Four of us moved Mrs. Rowe on the sliding board from the OR table to her bed. I connected the oxygen mask tubing to the portable oxygen tank, turned it on, and verified oxygen was coming out.

As we left the operating room, with one of my hands and my hips pushing the bed and my other hand reaching down around Mrs. Rowe's face to feel her breathing, we passed the surgeon. To his Resident, I heard him say, "She looks good".

I was still annoyed with him, so barely glanced up at his words. I knew he was only thinking that he was thankful that ninety-four year old Mrs. Rowe had survived the surgery, that she looked pink and was extubated and breathing well. But I said, "Thank you".

The asshole flinched ! I saw him flinch out of the corner of my eye. I knew that until that moment, he hadn't snapped to the fact that it was me, who he had yelled at an hour prior, who had made his patient LOOK GOOD. Me alone! Not the anesthesiologist seeing the next patient, getting them ready for surgery, nor the anesthesiologist sitting in the anesthesia office, looking at their smart phone. Asshole.

But the next time I saw that surgeon, he knew my name. The next time I saw him, he greeted me kindly and called me Elize. I guess that was his proud way of apologizing. And I, in return, greeted him kindly, calling him by name.

And so the anesthesia world turned.

I have P.T.S.D.

About a year after I became a locum tenen again, I had to go to a store across the street from the hospital where I used to work. I had not been back in that area since I walked out the door. In the intervening year, I have regained some of my inner strength and self awareness. I hadn't stuttered in months, and I thought those stuttering days were over.

But seeing the hospital again brought all the memories and all the anguish right back. I began to feel anxious and shaky inside. And when I talked with the salesman, I was surprised to find myself struggling not to stutter.

Driving home, I wondered if what I was feeling was post traumatic stress disorder, or P.T.S.D. Perhaps it was a mild case, I didn't know. But it shook my confidence that I had actually moved on from those turbulent times.

Life is Fragile

I had a dream. A dream which startled me awake, and made me sit up in bed, my heart pounding.

In the dream, two policemen were arguing. One was the police chief, a mild mannered, kind man. The other cop was pushing him toward his breaking point, pushing all his buttons, saying, "You don't care! You have never cared!" When the truth was that all the police chief did was care.

They were in the room where I was. The room had glass walls, typical of a police chief's office. When they first came into the office, I thought it was a simple heated conversation between two colleagues.

I thought I might be intruding into their privacy so I searched for a way out of the room, to give them their space. But I realized that the only way out was past them. I wanted to leave the office but I couldn't get out. So I just hunkered down in a corner, trying to be as unobtrusive as possible.

Suddenly I saw things clearly how they really were. The police chief was very angry. The other cop was intentionally and purposefully trying to push the police chief over his emotional edge. And the police chief was almost there. I magically saw his vital signs, his heart rate and blood pressure, all elevated. I could magically see his thoughts, that all he wanted was for the abuse to stop. That he even fantasized pulling out his gun to shoot the other cop.

Since I couldn't get out of the room, I was crunched in a corner between the filing cabinet and the wall. I was trying to make myself as small as possible. I had my fingers deep in my ears to try to block out their argument. They were taking no notice of me, but I magically knew everything. I saw that the other cop had a black heart, and was only pushing the police chief because he thought it was fun. His cruel, black heart liked having the power, the control, the dominance.

Later in the dream, the police chief was speaking calmly with an older woman, so I knew the chief had not yet reached his breaking point. But I knew he was close, and I could still visualize his fantasy of pulling out his gun. Even though I magically knew all they were thinking and feeling, I kept hoping in my head that they would be grown adults, that they would act rationally in the end.

I woke, wondering where the intensity in the dream came from. I woke, knowing how a rational, kind person could be pushed beyond their limits. I woke, thinking of my friend who had put a bullet into his head to put a period to a long, tragic marriage. I woke knowing the lesson, that life was fragile.

The Locum World is a Good Hiding Place

I started a new locum job at a busy, growing hospital in the midwest. The anesthesia department functioned with the Anesthesia Care Team model. A couple of months went by, and all was good. They liked me and I liked them. There was a good mix of surgery types, and the surgeons seemed to have decent skills. It was a good fit for me.

With the hospital's expansions the previous year, they had added five operating rooms, which was the reason why they needed my help. They would prefer to have their own CRNA staff, but were happy to utilize locum help until they could find permanent employees.

They were also utilizing locum anesthesiologists. A new locum anesthesiologist started, a Dr. Inetto. Immediately, all the CRNAs started to question her skills.

I had been doing locum work for long enough to know a truth, that there were two different kinds of locums. One kind was the professional who did locum work because they loved traveling and the itinerant lifestyle. They loved to have the flexibility of contract work, and they liked staying out of hospital politics. These were the reasons why I was a locum.

The other kind of locum were those like Dr. Inetto. Those locums had lost their skills for one reason or another, or had never had strong skills. So they couldn't find a group or a hospital who would hire them for a permanent position. Those locums learned the only way they could find gainful employment was to hide in the locum world.

How could an incompetent practitioner hide in the locum world? The usual scenario started with an anesthesia group needing help. They called one or more locum tenen recruiting companies to inform them of their need. The recruiting company had lists of providers, both CRNAs and anesthesiologists, who expressed an interest in doing locum work. So, the recruiting company matched the anesthesia provider with the anesthesia group, and were paid a fee for doing so.

The anesthesia group assumed the recruiter had fully screened the locum tenen employee before presenting them to their group. I felt sure the recruiter did the best they could, but they could only present what they knew. Often, former employers were reluctant to say anything negative about weak professionals for fear of legal repercussions.

As for the practitioner, it was, of course, in their personal interest for everyone to believe they were highly skilled. A lot was at stake, more than just a lucrative income: self pride, professional collegiality, etc. Way too often, they didn't even want to admit to themselves their lack of skills. They didn't want to reveal that they had only been supervising CRNAs and had not done an actual anesthetic on their own for years, relying on a CRNA to provide the skilled work. They did not want to say that they had not done this or that procedure, and were not knowledgeable about the nuances of its successful performance. They hadn't been caught yet, so they told themselves that they must not be doing too badly. They guarded their psyche with cognitive dissonance.

In every profession, there are people with strengths and weaknesses. Everyone has that thing they are better at and things they are worse at. It is human nature to even have bad days and good days. Some days, no matter what you do, how you work the problem, no matter how you hold your tongue or cross your fingers, you are unable to do that one thing you have done a thousand times with skill.

All my career, I had worked with physicians and nurses who had skills better or worse than mine. It was a continuum. With those stronger, I would jokingly admit, "I'm not proud. Good for you for being able to do that." With those weaker, I would pick up their slack.

Generally, those weaker practitioners needed what all human beings needed, for someone to be courteous to them, to not point out their inadequacies, to politely suggest alternative anesthetic techniques, and to accept their reasonable requests. Our being courteous to each other got us through the day. One way or the other, we took care of the patient, kept them safe, kept them alive.

Far Beyond Accepted Standards

But that new locum anesthesiologist, Dr. Inetto, was on the far end of the continuum. Her personality had the impossible mixture of bravado, aggression, and sycophancy to the other physicians. To keep the CRNAs off balance, she was argumentative, critical, and challenging towards them. I knew her intent was to keep the CRNAs so busy defending their own actions that they would not have the opportunity to look at her skills too closely. I'm sure she hoped they would not see her incompetence.

Dr. Inetto made suggestions for anesthetic techniques which the average anesthesia provider would know to be far beyond the accepted standards, and were even harmful in some cases, and then she expected her directives to be followed. Suggestions by the other anesthesiologists were either not followed or partly followed, which was quite frustrating for them. She plowed her way through the day with a dizzying mixture of sickly sweet cooing and harsh criticism.

Some of the surgeons began to refuse to work with her. The staff CRNAs started refusing to work with her. That was a big deal for a surgeon or a CRNA to refuse to work with an anesthesiologist, and was very rare. So the chief anesthesiologist, to give Dr. Inetto something to do, assigned her to work with the locum CRNAs. I knew the other locum CRNAs, of course, so we started venting to each other:

"I think the regular CRNAs don't like her so they pawn her off on us. She's been totally condescending today. And micromanaging. To the point of being cruel. I'm not going to be able to tolerate that shit day after day."

And

"I had to literally yell at her! It was the only thing to get her to stop being so mean!"

And

"She's a total idiot ! I can't stand the woman."

And

"She's a black cloud. She argues with me about everything and is condescending and critical about everything else. If you figure out how to manage things with her, let me know. I'm at a loss."

And

"Is she always rude like that? Why is she so rude?"

And

Coming in to the anesthesia office after doing a procedure with Dr. Inetto, one of the CRNAs told the group of CRNAs there, "I'll tell you what. If I'm ever here as a patient and I have to have a block placed, don't ever let Inetto touch me. Just don't! That was painful to watch!"

And

"This is the first case I've worked with her. Why does she have to be so critical of everything and everyone?! It's none of her business or her concern."

The Code

A week after Dr. Inetto started, she was assigned to work with me. We had four cases scheduled that day, and thankfully, the first couple of patients did okay.

The third case was a sick man who had a long standing problem with circulation to his legs. We did a general anesthesia for him so the surgeon could bypass a blood vessel on his left leg which had become clogged. During the surgery, I had to give medicines to keep his blood pressure at a normal level. Generally, though, he was more stable than I had originally thought he would be.

When the surgery was over, he was breathing adequately and his carbon dioxide readings were only slightly elevated, so I removed the breathing tube and placed a nasal cannula in preparation for transfer to the recovery room. But pausing to look at the patient, I asked the circulating nurse to wait. My gut was telling me that all was not right. He just wasn't responding to stimulation like I wanted him to. I watched him, called his name, tapped his shoulder, with no response.

As I watched, I noticed his respirations were becoming shallower, and his pulse oximeter reading had disappeared. I pulled out the mask on the anesthesia machine so I could ventilate and thus control the patient's breathing, until I could better assess the cause. At the same time, with my other hand, I was troubleshooting the pulse oximeter, trying to get it to give me a reading. I moved it to another finger, to the ear lobe, then to one nare, all without success. He did have carbon dioxide (CO2) readings, which indicated that he was still breathing and that his heart was still pumping, and his heart rhythm looked as it did during the surgery. I felt the carotid pulse, and it was present.

I was just about to call out for assistance when Dr. Inetto came in the room. She glanced up at the monitor, looking at the CO2 tracings. I told her the pulse oximeter reading had just disappeared.

She said, "This patient, he's a vasculopath. He has terrible circulation. It doesn't matter. We don't need the pulse oximeter."

She pushed the oxygen mask away and continued, "He looks okay, he is breathing.... see?" She pointed to the monitor, showing the CO2 tracing. "He's just sleepy." With this, she started to slap his face hard, yelling, "Wake up! Wake up! Your surgery is over!"

I was mad. I hate it when anesthesia providers slap their patients to wake them up, and I thought to myself, "If you slap my patient's face one more time, I'm going to slap yours."

Instead, I took a deep breath and calmly said, "Look, he's starting to get bradycardic. His heart rate has gone down to the 40's, and it had been in the 80's for most of the case. And I still don't like that we don't have a pulse oximeter."

I said I was going to give some Robinul to increase the heart rate. Without waiting for a response, I drew up the Robinul and gave it intravenously. I checked the blood pressure, and there was still a decent pressure, although lower than it had been.

I moved the ventilation mask toward the patient's face to ventilate again, but Dr. Inetto pushed my hand away, arguing with me, "You don't need that. See? He's breathing. He just needs to wake up." She slapped the patient's face again, and yelled, "Wake up!"

Precious seconds had passed. I noticed the Robinul had not had any effect on increasing the heart rate. In fact, the QRS on the ECG tracing had widened, and the heart rate was down to the 30's. I commented on this to Dr. Inetto, pointing to the ECG monitor. She barely glanced at the monitor, then slapped the patient's face again. I still held the oxygen mask close to the patient's face, trying to get it on the patient to ventilate him. I pleaded, "Please let me ventilate the patient."

Dr. Inetto looked up at me, anger all over her face, and said, "I told you we don't need that !" She pushed my hand away forcefully.

A quiet small voice in my head said, "fuck. this. shit."

I leaned around Dr. Inetto's body to get the attention of the circulating nurse. She had been doing her charting at her desk on the other side of the room, not realizing that the patient was having difficulties. I said, "I need you to come pay attention over here." She immediately came over.

"Have you been working here a long time?" She responded with a nod. "Is there a way to quickly call for help without raising a panic?" She nodded again and quickly turned away to get help.

Seeing that I was getting other anesthesiologists in the operating room, Dr. Inetto took the oxygen mask from my hand and hipped me to the side so she could ventilate the patient. She wanted to look like she was in control.

Within seconds, another anesthesiologist, Dr. Schnell, came in the room. He said, "What's going on?" Dr. Schnell looked at me for answers, ignoring Dr. Inetto, who remained quiet.

As I told Dr. Schnell about the decrease in respirations and the loss of the pulse oximeter reading, I saw that he was quickly assessing the patient himself. Before I could finish my synopsis of events, he noticed the slow heart rate and the widened QRS and appropriately, thankfully asked, "Are you even perfusing with that heart rhythm?"

I felt relief. I felt relief that someone intelligent was there who could help me and help the patient. I said, "I was just wondering the same thing. I took a blood pressure a couple of minutes ago, but it was lower than it had been, and I was just on the verge of starting chest compressions."

He felt for a carotid pulse and said it was very weak. He told the nurse to call a code to get more help, and he immediately started chest compressions. A "code" is an abbreviated word for Advanced Cardiac Life Support, or ACLS. During ACLS, practitioners provide interventions to manage life-threatening medical emergencies. These include managing the person's airway, starting chest compressions, initiating IV access, reading and interpreting electrocardiograms and laboratory results, defibrillating by providing electrical current to the heart, and administering emergency medicines.

Dr. Schnell asked, "What drugs have you given?"

I responded that I had only given a dose of Robinul.

Dr. Inetto spoke for the first time. "Give some atropine."

Atropine and Robinul are similar drugs, functioning the same way to increase heart rate. So I asked about giving epinephrine instead, but she condescended, "When I say to give atropine, atropine is what I want."

So I quietly said, "Okay. I just wanted to be sure since I'd already given Robinul. What dose do you want?"

She said, "0.5 mg." So I gave the 0.5 mg of Atropine. It might not help at that point, but I figured it wouldn't hurt.

I then asked about intubating the patient, but was ignored. Dr. Inetto was still mask ventilating. I noticed she wasn't ventilating the lungs well, and I offered an oral airway, which she took and placed in the patient's mouth.

By that time, three other anesthesiologists were in the room and interventions were happening simultaneously. One asked about giving a dose of epinephrine. I clarified the dose and immediately administered it.

A defibrillator was applied to the patient's chest, and two more doses of epinephrine were given. The decision was made to intubate, and Dr. Inetto yelled at me to give her the supplies. She asked for a Mac 3 laryngoscope blade, and I handed it to her. She scolded me for giving her a Mac 2. I held up the blade and showed her the inscription on the blade: "Mac 3". After she intubated, I set the ventilator settings at 500 ml tidal volume with a rate of 14.

She looked at the ventilator machine and said, "That's too low. We need to ventilate him more." She turned the tidal volume up to 850 ml.

I calmly said, "I was just thinking that the higher tidal volume might interfere with venous return." Dr. Inetto ignored me.

I noticed the heart rhythm had changed to a wide complex super ventricular tachycardia, but the blood pressure was still low. So the decision was made to shock the patient, and that was done twice. The heart rhythm changed to a better rhythm, with a rate in the 90's. The blood pressure increased to 110's systolic. On the next check, it had gone up to the 190's systolic.

Lab work was drawn and analyzed, including an arterial blood gas reading, which showed respiratory acidosis. Sodium Bicarbonate was given, and one of the anesthesiologists reached around me to increase the respiratory rate. He commented that the tidal volume was too high, and turned the tidal volume back to 500 ml. I whispered, "Thank you."

Decision was made to transfer the patient directly to the intensive care unit. Transport monitors were applied. I connected an Ambu bag with an oxygen tank to the endotracheal tube. I stuffed my pockets with emergency drugs, in case the patient's status deteriorated while in transport, and with a new endotracheal tube and laryngoscope, in case the endotracheal tube became dislodged from the patient's trachea.

Tears

After taking the patient to the intensive care unit, giving report, and speaking with the Intensivist, I went back to the operating room to clean up from the code. The circulating nurse was in the operating room too. She said she hadn't worked with Inetto before, and was shocked at how condescending and rude she had been. I just shrugged my shoulders. She continued, "But you really handled that well."

I said, "Thanks. I was really impressed with you too. You were so calm during the whole thing." We agreed you have to be calm in an emergency situation, and that yelling only increased the tension. I added with a grin, "Afterwards, after it's all over, you can fall apart then. Actually, I can feel my adrenalin surging through my body now."

When I went to the anesthesia office, I was told to go to lunch, which I did. After lunch, when I checked back in the office, Dr. Rahaa, one of the partners in the anesthesia group, was there, discussing the code with the other anesthesiologists. He said, "Let's go to my office and talk about what happened."

I replied, "Good idea" and followed him out the door.

I gave him as many details as I could recall. He asked me several times about Dr. Inetto, saying that he had heard things from other people. I have a reluctance to talk bad about others, and told him so. He didn't press me. I did tell him that Dr. Inetto had been critical of every thing all day, and that I had been "yes-ma'am-ing" her to try to calm her down.

Dr. Rahaa told me that the other anesthesiologists had spoken highly of me, but his comments did nothing to make me feel better. We ended the conversation with his saying, "I'm just like you. I beat up on myself when things like this happen. But I don't see that you did anything wrong."

I went home and cried.

Not Today

The next day, I was assigned to work with Dr. Inetto again. I asked for my assignment to be changed. The anesthesiologist said, "I don't know what to do. No one wants to work with her."

I said, "Not today. I can't today, not after what happened yesterday."

Thankfully, she changed my assignment.

The Quiet Dark

Each morning after the code, I went to the Intensive Care Unit to see my patient. Every morning, I arrived at the hospital early, in the quiet dark of the night shift. I just stood by his bed, wide eyed, exhausted, and tormented, looking at the monitors and listening to the soft rhythmic sounds of a silent intensive care unit: the double zipping whispers of the intravenous pumps as it administered each drop of medication, and the soft whoosh of the ventilator as it pushed oxygen through his endotracheal tube into his lungs.

I would check with the night nurse to see how things were going. Comments were: "He's been seizing," or "We tried to get the Levophed drip off, but his blood pressure went down too low," or "Things aren't looking very good." And then a surprising comment from his mother, "The mother seems pretty cheery. She said her son has been through worse in his life, and she thinks that he'll be okay."

I was feeling the full weight of the incident on my shoulders. What could I have done differently? What could I have said to make things better? If I had been aggressive back to Dr. Inetto, could appropriate interventions have happened sooner? I shook my head; I didn't think aggression would have helped. Being aggressive to Inetto would have only made her become even more hostile back to me, at a moment in time when cooperation and communication were essential. I had realized that the best solution for the patient's welfare was to bypass Inetto all together and get help, which I did.

Over and over, I replayed the events in my head. I was not sleeping. I was exhausted. I felt like I was constantly struggling to hold back tears, not only at night, but also during the daytime, at work.

While walking in the hallway a couple of days later, I saw the circulator who was in the code with me. She asked how I was doing, and I told her I had not been sleeping well since the code.

She said, "I'm so sorry, Elize." Then she hugged me.

I Can't Stand This All Day

I was still being assigned to work with Inetto. Since the code, Inetto had ramped up her rudeness and cruelty to me. Because I was not sleeping at night and was worried about the patient, the escalation of Dr. Inetto's cruelty made my life a living hell.

So I thought to try a different tactic. I thought to myself, "If you don't like what I'm doing, do it yourself?" So whenever we started a case together, instead of beginning the case myself, as is usual in the Anesthesia Care Team, I would step aside and ask, "Dr. Inetto, would you mind starting this case for me, to show me how you would like it done?"

Dr. Inetto would smile and stand up tall and say, "Of course." Each time, she would totally fuck it up. She would place a mask over a patient's face without turning on the oxygen, so I would have to reach around her to turn on the oxygen. After giving the induction drugs, with the patient not breathing, I never once saw her ventilate a patient before intubation. Also, she often would start giving induction drugs without putting on any monitors, not the heart rate, blood pressure, nor the pulse oximeter.

Once, a patient was receiving Vancomycin as a preoperative medicine, and induction drugs should ideally not be infused at the same time. So I turned off the Vancomycin and turned on the IV infusion, and announced that I had done so. Dr. Inetto reached over, turned the Vancomycin back on, and turned off the IV infusion.

Another time, before giving any sedation, she placed the peripheral nerve stimulator on the patient's wrist, and turned it on. The stimulator was giving the patient a painful shock each time it cycled, and the patient's face grimaced in unison with the shocks. So I reached around and turned it off.

When she tried to place the breathing tube, she would make several attempts before she placed it properly. Once, she smiled to the staff and said, "Before I'm done here, I'm going to show everyone how to really do anesthesia." That time, I counted seven unsuccessful attempts at endotracheal intubation, with the patient's oxygen saturation decreasing to the low 80's. A normal oxygen saturation is in the high 90's, so a saturation in the low 80's meant the patient was not getting enough oxygen to their body. I offered to try to place the tube myself, but she would not even consider it, saying sternly, "No." I offered to obtain a Glidescope for her, which is a specialized laryngoscope with a camera on the end, often used for difficult intubations, but she soundly said, "No." One of the nurses brought it into the operating room anyhow, but she continued to refuse to use it. I wondered if she knew how to use it. She used a bougie, a specialized instrument to help guide the endotracheal tube into the trachea, but placed it in the esophagus instead. Finally, she allowed me to call another anesthesiologist, who pointedly gave me look of curiosity and annoyance when he came in the room. I had a feeling he was thinking, "Why didn't you put in that breathing tube?" and "Why the hell am I being called to do this?" He placed the breathing tube on his first attempt.

Many times, she would start to intubate before the medications had a chance to take effect, so the patient was moving, perhaps even still aware. Once, I saw the white induction medication, Propofol, uninfused, clearly still in the intravenous tubing. Another time the patient was moving while Inetto was trying to intubate, Dr. Inetto complained that the intravenous line was not working. All the staff in the room, fully focused on Dr. Inetto, pointed at the intravenous site and then at the infusing fluids and shouted in unison, "It's working!"

One patient woke up painful and grimacing, so I gave the patient a 50 mcg dose of Fentanyl, an opioid narcotic. Dr. Inetto scolded me for giving it, saying, "There has to be an indication for giving pain medications."

I replied, "The patient had been in pain. That was my indication."

When Dr. Inetto left the room, the nurse said, "She's awake and in pain ! If that's not an indication to give pain medication, I don't know what is ! I'm going to talk with my manager about this."

After each case which Dr. Inetto started, after she left the operating room, I had to adjust medications, dials, and lines to stabilize the patient. I frequently heard the staff tell me, "She scares me!"

I said, "Every time I work with her, it's criticism and abuse about anything I do. So since she's so abusive to me when I do anything, I'll let her do everything."

One nurse looked at me with real sadness and said, "I'm so sorry about that."

Another nurse said, "I can't stand this all day."

They would ask who I suggested they report her to. I suggested Dr. Rahaa, since he was Dr. Inetto's supervisor. One nurse said, "This is the third time I've had problems with her in my room this week. I'm not going to take it anymore."

Brutal Self Reflection

So, each dark and quiet night, with my thoughts to myself, I would peel back the layers of my brutal self reflection. Why did I want Dr. Inetto to start the cases? What was the core truth?

Yes, I was totally fed up with her constant barrage of criticism, abuse, and cruelty. I was fed up with being condescended to and argued with, and I knew that her abuse was frazzling my nerves. Yes, I thought that if she started the cases herself, then I would be off the whipping post.

But I knew the impact of her aggressive incompetence, and I knew where responsibility lay, and I was mad. I was mad about Dr. Inetto's part in the fiasco with that code patient. Mad that I had to work with, and continue to work with, such an incompetent, aggressively inappropriate anesthesiologist. But what else? I knew myself well enough to know I had other reasons.

When a CRNA did a task and all Dr. Inetto did was criticize and argue with that CRNA, it confused the issue as to what the problem really was, and who was responsible, especially when things went bad. A non-medical example of this having several cooks in a kitchen, all working on one recipe. If the recipe is a disaster, which cook is responsible? So, I wanted to clearly see her skill level. And, admittedly, I wanted the staff to clearly see her skill level as well. I wanted that to happen without my covering her incompetence. My getting involved would only gloss over reality.

Another reason was because I heard from all the other CRNAs that they had complained about Dr. Inetto, yet she was still gainfully employed. I could not fathom why Dr. Rahaa was keeping her on. I wondered if he fully appreciated the extent of how bad things were with Dr. Inetto. I knew since I was a temporary employee, my opinion would not carry much weight. So I thought it might take pressure from other sources, namely the surgeons and operating room staff, to get rid of her.

Help For The Holidays

I had become friendly with a couple of the anesthesiologists. I asked one of them why he thought Dr. Inetto was still employed there. I said, "All the CRNAs and many of the OR staff and surgeons are complaining about her. I don't understand why Rahaa would keep her on."

He said, "Yeah, we all know about Dr. Inetto. She won't be here for long. We are just really short over the Thanksgiving holidays, and Dr. Rahaa is keeping her on to cover for us so we can all take our vacations. The breaks will be over next week, so she should be gone by then."

I replied, shaking my head slowly, "So, help for the holidays. So much risk to patient well being, and such a stress on staff morale. I just don't get it."

He said, "Well, she takes some of our shifts. She's here almost every day."

I just sat there, wide eyed.

Her Incompetence Made Me Look Bad

One of the CRNAs gave me lunch about a week after the code incident. She told me that I needed to do something about what was happening. She said that everyone was complaining about Dr. Inetto, but the stories with me and her were the worst, adding, "It's really making you look bad. You're a locum and no one knows you. You're expendable."

I told her that since the code, Dr. Inetto had been nothing but cruel to me.

She said, "You need to talk with your recruiter about this." I told her I had.

She continued, "Then you need to not work with her." I told her that I had already requested not to work with her. She just looked at me, unable to offer more suggestions.

But that CRNA telling me I looked bad because of Inetto's incompetence depressed me even more. She was telling me that instead of the anesthesia group choosing to get rid of an incompetent anesthesiologist, that they might choose to cancel my contract instead. She was telling me that I should do something to fix how Dr. Inetto's incompetence made me look, but I had no clue what it was that I should do. I was beginning to realize I might have to do something which I had never done before. I might have to cancel my contract.

All my locum life, I liked to go into a new job and be as calm, as confident, and as capable as I could be. I had started that contract looking that way. But things had become horribly wrong, and according to that CRNA, people were losing confidence in me and in my abilities. I wondered if the staff would ever be able to fully trust me again. I would have the negative stigma hanging over my head because of what had happened with Inetto. I couldn't stand the thought of that.

I Got Your Back

That same day, one of the nurses who had been in the code caught up with me in the hallway on the walk back from lunch. She asked me if my day was okay.

I said, "They have put me with Dr. Inetto again today and things haven't been good. Honestly, I'm on the verge of quitting."

She looked sad and said, "Don't do that. You're one of the good ones" and hugged me. While hugging me, she added, "I got your back." I almost cried from her kindness.

Kiss and Make Up

At the end of that same day, Dr. Rahaa asked to meet with Dr. Inetto and me. I could have lived my whole life without meeting with Rahaa and Inetto, but of course I went. For 40 minutes of the 45 minute long meeting, Dr. Rahaa and Dr. Inetto talked and pretty much ignored me. They discussed Inetto's habit of questioning everything the CRNAs did. Rahaa questioned Inetto's medical rationales and judgment. Several instances, Rahaa would say, "That's common practice," or "What's wrong with that? That's what I would do," or Why would you even question that?"

I just sat there, listening; Rahaa was doing a good enough job on his own questioning and challenging Inetto's opinions about anesthesia practice. But in the last five minutes of the meeting, I learned the real reason Rahaa called the meeting. He had tallied the risk versus the benefit, the profit versus the potential loss and had made a choice.

He said, "We need to clear the air between you two. We need to get past what happened last week. I can't have the nurses, the staff, and the director of the operating room come to me about incidences which have occurred. I've never had two people be at odds like you both are." Rahaa made it out like it was a personality problem between the two of us, that if we kissed and made up, all would be well.

I left his office knowing exactly what he wanted: He wanted to not be bothered or called about problems in the operating rooms. He wanted the CRNAs to cover for Inetto's incompetence. And he wanted Inetto to continue with her contract; she was going nowhere.

......................................

I resigned my contract the next day.

.......................................

The World Just Did Not Make Sense Anymore

When I first resigned my contract, I thought to just stop working with that particular anesthesia group. My plan was to start another contract somewhere else. I had even asked my recruiter to start looking for another position for me.

But within hours, literally within hours, the idea began to grow on me to stop doing anesthesia altogether, to just retire. That idea felt good. I had had a meeting with my financial counselor the year before, and he had told me then that I was in a decent position to retire. But I had continued, out of habit, and because I thought I was too young to retire.

I wondered if maybe I had become too sensitive to do anesthesia. Maybe I was taking too many things to heart. Maybe all the yoga and Qigong I had done over the years had softened my soul. Perhaps I was not tough anymore. Perhaps all that was true.

But I knew that my being sensitive was not the truth. I knew that I was not too sensitive to do the work. Yes, I was an empathetic person, but I had always been an empathetic person, and I had managed to put in 34 years of nursing. Being sensitive was one of my qualities which was both good and bad, a yin and yang. It helped me to be compassionate and caring, understanding and feeling, but sometimes I cared too much.

I knew the real truth of why I wanted to quit nursing was because I had burned out in my last full time job. I had been so bullied and marginalized that the pleasure of going to work and the pleasure of my competence left me. I dreaded getting out of bed in the morning. I was tired all the time, which made me stutter. The stuttering made me self conscious. I had difficulty thinking when I was tired, which made me dread the day even more. I had wanted to leave anesthesia then, but I had thought locum work would offer me more flexibility and time off, and would help me to love my work again. It did, it helped.

But the code had crushed any residual desire I felt to continue. The world just did not make sense anymore. It did not make sense that humankind suffered so much from nursing shortages, yet nurses had to tolerate so much abuse. Nurses all over the world struggled against obstructive bureaucracy, hospital politics, and coworker backstabbing. We fought against casual cruelty. We pushed against sexist behaviors; the #metoo movement had not filtered into the health care industry.

A quote from one of Lee Child's many great books fit: "For years, you've laughed off the small things, but they come so thick and fast that eventually you realize an avalanche is made up of small things. Snowflakes, right? Things don't get much smaller than that. Suddenly you realize that small things are big things." All the abuse that I had seen or experienced over the three and a half decades of my professional career had finally caught up with me, and avalanched.

I loved doing anesthesia, and occasionally I was even told I was good at it. It was everything else which made me turn away from nursing and made me never want to set foot in a hospital again. I was tired of the games, of the manipulations, and of the fights for control and domination. I was so tired of the fight. Perhaps, simply, I had just had enough. I did not have it in me anymore to do anesthesia. To do nursing and anesthesia well, you need passion and drive. And .....

All I wanted was relief.

All I wanted was out.

Stay

The day after I resigned, I was in the anesthesia office early in the morning after having seen my patient in the ICU. I found myself alone with one of my anesthesiologist friends. He said, "I hope to have Dr. Inetto gone by the end of the week."

I asked, "Really?"

He continued, "No one wants to work with her. And the surgeons don't want her in their room."

I sighed and told him, "I resigned my position yesterday. I gave my 30 day notice. I'm just so tired of the fight."

He said, "If I can get rid of her, would you reconsider and stay? We aren't like this! We're a good group here, and really do care about the patients. I liked you from the first day. I wish you'd stay."

A CRNA joined us in the office then, and said, "It sounds like you're talking about something interesting."

When we told her I had quit, she echoed her desire not to see me leave. Another CRNA came in and said the same thing. Then Dr. Rahaa came in the office, and we all separated.

AccidentalImpacts.org

When there's an unintentional tragedy, more than one person's life is harmed. More than one person's life is changed forever.

I remembered hearing about a death in the operating room 20 years prior. An experienced gynecologist I had known back then was performing a laparoscopic tubal ligation, and had hit a major artery with his trocar. Trocars are sharp instruments which are necessary for laparoscopic procedures. The patient bled out and died before they could get both enough blood and a vascular surgeon to the outpatient surgery center. But that gynecologist was so shook from the death, he quit being a physician. Last thing I knew, he was a real estate agent.

I have known of a couple of nurses who committed suicide after accidentally harming a patient, tormented by what had happened. A decimal point in the wrong spot when calculating doses, or misreading the label on a medication bottle and the wrong one is administered, and more than one life is shattered.

There is no doubt about the tragedy and devastation of the innocent victims, and of their family and friends. But I wonder. I wonder about the conscientious, caring person who unintentionally caused that tragedy. I wonder about and am concerned for that moral person who is even just peripherally involved with the tragedy. I wonder how their soul survives the 24 hours that make up each day. I imagine their grief and torment. I imagine their second guessing themselves over and over. I imagine their reliving the events, wondering if they had done this or changed that, if the outcome would have been different. I wonder if they crucify their hearts.

Is a person a monster if they cause harm unintentionally? If they put a decimal point in the wrong place or misread a label, but catch their mistake just before administration, are they still reprehensible? If a child runs out in front of a car, and the driver is unable to stop in time so that the child is hit, does the driver deserve moral condemnation? Is the parent whose attention was temporarily diverted from the child any more at fault? Or if someone forgets to turn off their heating blanket before leaving their apartment in the morning, so that the apartment building burns down, should they be criminalized? What if they remembered in time to return to the apartment and turn off the blanket? Is the guy who returned to correct the lapse in memory any more moral than the one who forgot?

Yes, I did what I could to protect the patient who coded. But my strong sense of responsibility made me grieve for what happened during my watch. In trying to make sense of what I was feeling, I went online to learn how others have lived through a tragedy, how they had survived. In my search, I found many resources, web site, blogs, and help for the victim and their families.

Yet for those who had caused the harm, with the exception of only a few online message boards, I found only one single web site. Only one. The web site is called Accidental Impacts, started by Maryann Gray after she accidentally hit someone while driving, killing them. She states the web site is for "good people who have unintentionally harmed others, in accidents occurring on the roads, at work, at play, or around the home." On the web site, she shares information and resources, and offers recommended reading. She relates short essays she has written on the subject. She has opened up her web site to comments and to a blog. Gray does nothing to publicize it and rarely posts updates. Still, Accidental Impacts receives an average of sixty hits per day. This is a web site for people like myself, who have been the unintentional perpetrators of a tragedy.

I thought that maybe when I finished that month, caught my breath, and regained some bearing to my life, I would write a formal complaint to the American Medical Association, and probably also to the State Medical Board, to tell them about Dr. Inetto. I would have to study it, to find out what to do, since I had never done anything like that before. But I shrugged my shoulders when I thought about following through with it. Nurses, scrub techs, OR managers, CRNAs, and even surgeons had expressed concern, even alarm, about Dr. Inetto's competence, but her contract had not been terminated.

I thought of a physician I once knew who punched a hole in the operating room wall because he didn't like something. His penalty was to have lunch at the Country Club with the Chief of Staff, and to go to a handful of anger management classes. And I remembered a frustrated surgeon throwing a scalpel across the operating room so that it lodged in the wall, barely missing a nurse. His only punishment was to have his surgeries cancelled for the rest of the day so he could cool off. What difference would my singular voice make? I felt like sending in a complaint wouldn't make any difference; doctors protected their own.

So I still woke in the wee hours thinking the same thing I had felt since the day of the code. That going to work every day was a sheer act of bravery. Hell, just driving down the street was a sheer act of bravery. I was seriously afraid to drive the first week after the code, and I was still skittish even a couple of weeks later. Life is so fragile.

I wondered, how could I work the last two weeks of my career? Every day, every case, I had to remind myself that I knew how to do anesthesia. As I walked into an operating room, I would take a deep breath. I took a deep breath and I put on my brave face.

You Are Like This

A couple of weeks after I resigned, I was again alone in the office with the same anesthesiologist who had said that Inetto was going to be gone by the end of the week. I said, "I guess you weren't successful ending Dr. Inetto's contract."

He said, "All I can do is suggest, but it's not up to me. It's up to Rahaa. But what I can do is not schedule you two to work together."

I said, "That's good."

But I was thinking how a couple of weeks prior, he had exclaimed "We're not like this!" I thought, I guess you are like this.

It felt like a slap in the face from Rahaa that he had so many complaints and concerns about Dr. Inetto's safety, but his response was to accept my resignation and then to leave for vacation.

Back to Baseline

The next morning, I went to see my code patient in the Intensive Care Unit. I was totally amazed, pleased, and incredulous to find him awake, extubated, even eating ! He had had a complete turnaround the previous two days. He was back to his baseline. His mother had been right after all.

His recovery was so fast that the very next day, he was discharged to a long term care facility. I breathed a sigh of relief that he was okay.

His recovery did not change my resolve to leave my profession, though. The bullying, sexism, and incompetence I had witnessed over the years of my career had worn me down and burned me out, and the incident with that patient hammered the nail on the coffin of my career. The bullying and incompetence in the healthcare industry affects patient outcomes, and I was tired of it. I was tired of it affecting my emotional well being and I was tired of it affecting my patients' well being. But I was over the moon with happiness that that patient had lived to breathe another day.

My Last Hurrah

My last day of work, I was assigned to do anesthesia for a complicated ICU patient. The poor woman had had several surgeries to repair injuries sustained from a fall. The procedure was scheduled to last ten hours. The staff felt tense with concern, wondering if the patient would even make it through surgery.

By early afternoon, since the patient had been stable all day, the tension lightened and the staff in the operating room started to talk more casually. During the day, a few of my co-workers had come into the operating room to hug me and to wish me well, which made the operating room staff curious. So when they asked me about it, I confessed that it was my last day to work.

They clarified, "So this is your last day to work here?"

I said, "Yes, this is my last day to work here. But it's also my last day to work. Ever. I'm retiring from anesthesia. This is my last case."

They were shocked. "You can't leave! We like you! You did such a great job with this patient today!" I just smiled and thanked them. What could I say?

I was relieved early to go home, at 2:45. After giving report, I went to the door of the operating room and turned to face the room. Everyone had stopped, turning to smile at me and to say goodbye. With a big smile, I looked at each person individually. I then gave a grandiose bow, bending deeply at the waist and scooping my arm low, comically performing my last hurrah. With the sound of laughter and best wishes from the staff, I turned and walked out the door.

The Ashes of My Career

I had a dream. In the dream, I had a cousin who went to a female family member and said, matter of factly, "I'm ready".

I did not know who the cousin was, only that she was a cousin. And I did not recognize the female family member. She was tall and slender, a stately, distinguished woman. Our family member simply responded, "Okay."

Apparently, they had prearranged something. My cousin then very calmly laid down in a big white box, and our family member lit it on fire. It instantly burst into bright, hot, yellow flames, and my cousin quickly became ashes. Standing there, calmly looking at the ashes, our family member said, "It's done."

I asked, "Aren't we going to bury her ashes?"

The family member said, "No. No need to." And she walked away.

I thought, well, I am going to bury her. I decided it was best to bury the ashes in the vegetable garden, under the mulch, so that my cousin's ashes could help nourish and grow future plants. I put the ashes in a black plastic trash bag and carried it out to the garden. I lifted the mulch and dug a trench, and when I was about to dump the ashes out of the bag, I thought, "I think I'll check to be sure everything was completely burned up."

So I looked in the bag. Sure enough, my cousin was all gone, not even any teeth or bone remained. She was completely burned to ash. But amazingly, some lipstick and some jewelry remained among the ashes, so I picked them out.

The lipstick, I threw away, throwing it into the bushes next to me. I had no need for it. I offered the jewelry to a family member, who only wanted one piece. I didn't want any of the jewelry, but decided to keep a ring which I thought was the prettiest, to remember my cousin by. It had a large pale yellow-green stone on it, like a citrine. I had always liked citrine stones. The rest, I just gave to friends, to anyone who wanted them.

As is usual for me, I woke from my dream knowing what the dream meant. I knew that burning my cousin to ashes represented the end of my career in anesthesia. The cousin, like my career, was all ashes, nothing left to be resurrected. The tall, stately woman, she was my inner self.

I buried the ashes in the mulch pile because I hoped the ashes would provide nutrients to grow plants. I hope the ashes of my career can teach lessons to others. I hope my experiences can help others learn from the difficulties I faced.

The jewelry is this book. The citrine ring is this book, written as a gift to myself, to remember who I was during my long career, and to remember what happened to end it. This book, I wrote as a way to try to make sense of the end. I wrote this book as a way for me to heal. This book is to be given to anyone who wants it, so others can know me and can know my life.

Afterword

By far and away, the majority of health care professionals are good, caring, people. Professionals who have saved countless lives, and who have worked long and late to help others. People who have held hands, given a listening ear or an encouraging hug to those in need. The quintessential caring professional still exists everywhere, and I have worked with so many, I have lost count. To you, I give my humblest thanks and most heart felt regard.

But there exists a substantial number of health care workers who want to tyrannize and control those caring professionals. There are those who want to keep their helpful, professional facade while they do their less than adequate work, putting patient care at risk. The culture of the health care industry allows these people to exist. These are the ones I wrote about here.

I feel frustration that what is unacceptable and unbelievable and shouldn't be happening, is happening. I want change, but I dare not hope for it. Because I don't expect change, I left my profession.

The abusive culture is too entrenched. There are just too many people who have a personal investment, emotionally and monetarily, in things staying as they are, in keeping the current status quo. And there are just too many people within corporate healthcare who believe and have accepted this status quo as normal.

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