Wednesday, November 26, 2014

Trench Warfare

 Trench Warfare

Emergency nursing is a battle, and the enemy is illness and injury: automobiles, motorcycles, guns, cancer, obesity, suicidality, violence, heroin, amphetamines, and narcotics.  The enemy never sleeps – and neither do the nurses in the trenches.

Each shift we see unspeakable harms; babies, children, men and women, preyed upon by our own species, serious injuries incurred by the technologies of man, and predation by unseen viruses – mutating, hiding, eating. Our academic training falls far short of the reality of it all. It dwells in the archaic principles of a bygone age of nursing; an age of divine care and heroic selflessness - an age before antibiotics, before MRI, before genome sequencing, before daVinci surgical robotics, cost centers, ICD coding, case management, and the cats cradle of legal bondage.  Academically, we do not produce nurses for this kind of battle – they are seasoned in the field, in the trenches with the enemy – and they either fail after only a few years, or become ED veterans, legends of tenacity, inkwells of black humor.

Your only allies are your comrades. You are part of a crazy dysfunctional family of misfits, somehow brought together by adventure, a sound background in herding cats, and the unwavering ability to withstand the abuses of mental and physical pressure. There is no personal space, and sometimes you are cheek-to-cheek to complete a task. Through human sickness, you are all bound together by touch, and smell, and sight. You know your friends by the scent of their shampoo or the boniness of their elbows. We engage in bizarre sudden games of Twister, putting our arms and legs all this way and that, often times holding down flailing screaming nakedness, or cleaning diarrhea from an anguished soul, their minds murky with Alzheimer’s. We cry over a dead baby, and then bring a demanding meth addict his pain medicine, apologizing profusely for the delay, hoping they won’t file a complaint over their slow service. We can sense the seriousness of a patient’s condition by the eyes of our coworkers - no words needed - only that look. These trench warfare nurses are more than just office mates – they are deeply bound together from being elbow-deep in atrocities.

There is also a sixth sense that develops over time – one where you see dead people - although they don’t know it yet. It’s an unnerving feeling, to know the future of certain patients, to see the walking dead - and its even more unnerving to know that, short of a miracle, you will soon be pumping their bodies full of semi-toxic drugs, pumping their chests with battery operated machines, covering their brains with gauze. This sense grows more powerful with time – and as it grows, you accept it as a grace, for with it comes the ability to prepare for the worse, to stay a step ahead of the downward spiral, perhaps even to alter the course of fate.

Experiences are drawn from an endless pool of suffering and the complex machinery of the human frame that is its host. Terminal injury aside, your shift in the trench is made up of a relentless flow of strangers - strangers who want something. Some are legitimate in their request – to repair their fractured femur, to breathe, to once again speak and move the right side of their bodies so that they can tell their family how much they love them – but many are not, and it is this complex set of customers that bring theater to the Emergency Department.  We, the nurses, are on stage – and we are the primary actors. It’s an art really, to be able to go from room to room and change your performance to fit the scene, to get the job done, to be so convincing. This constant play, however, requires a tremendous amount of emotion, and only with great effort can it be played out for the entire twelve hours.

Compassion is a finite emotion. You can run out of it – and once it’s gone, you hope the shift has ended.  Strangely enough, it seems to regenerate. Once your car leaves the parking lot and is pointed toward home, the day starts to fade. The images, scenarios, little victories and disappointments, things that no one outside the theater would ever understand – they all just wither as you drive home to your family, a friend, a dog, or a good glass of wine. By the next shift, your compassion meter seems to be back within operating range. ER trench nurses dole out compassion carefully; it is a need-based commodity, and a very valuable one at that. Once the words fucker or cunt are directed at you a few times in as many hours, you know very quickly who gets the compassion, and who might not. Empathy – we have loads of that, its part of becoming a great actor on the Emergency stage, to step into the shoes of our patients, to know what they feel and want, and to change our language and bodies to deal with their needs. Compassion though – that is precious.

Human interaction is a complex thing - even more so when you, the nurse, are guided in your speech by the haunting cloud of legal gloom that hangs over each of your words. Some patients have a known future, a certain future that you can predict from your thousands of previous experiences. However, you are compelled to avoid the truth, to keep your thoughts and knowledge at bay, you skirt the fact that no matter how much money is consumed by the institution, their loved one is going to die. Instead, you lie – or, better yet, remain silent. Oh yes, a miracle might be conjured, but probably not. You remain silent because people don’t want to hear it – that their weight is the cause of their medical problems, that their smoking caused their chronic back pain, that their addiction was the reason they pulled their own eyes out. Truth is clean, but brutal - and we know it could result in an unsatisfied customer, reduced reimbursement, a chain of migraines for the managers, and possible termination. The truth could leave you without a job. It’s frustrating for sure – but these harsh realities will also wither on the drive home, slowly shaping a shell of invulnerability - every so slowly.

Dealing with these concerns is not taught in school – it comes from experience, from thousands of mistakes made, and the learned ability to repair a mistake. It comes from stories told by your comrades in the trench – both of success and failure. You drink in the wisdom and knowledge of their startling tales, add them to your own, slowly building an empire of knowledge. Emergency nursing is both science and art, and from science comes known facts – kidney functions, ejection fractions, clotting cascades, neural pathways, and ligament insertions – but from art comes the soul of nursing. The ER is a sweeping pallet of colors, and with time, you begin to mix the colors together, blending, learning, discovering, sometimes having to start over, but in the end, hopefully leaving each shift with numerous finished paintings. None will be masterpieces – but perhaps one will be worth framing.

Nursing theory, nursing statistics, research, history, models of care, concepts of nursing, community nursing (collectively known as jumping through hoops, by some) – these are great course for those yearning for work as directors and educators, but for those who desire direct patient care in austere venues, all encompassing hard science and live preceptorship seems the most logical path. Experience is understood as knowledge gained by repeated trials, and without a series of supervised trials, experience will be slow to foster, frustrating, overwhelming, and potentially dangerous. Under real world conditions, we perform tasks over and over, perfecting each step, understanding the reason for each move, until the task is performed efficiently, and with an elegance of purpose. We work closely with each other, double-checking our work, transferring our knowledge up and down a mental conduit, a hierarchy of skills and experiences. ER nurses work on common sense, street smarts, evidence-based science, protocols, and past knowledge – not a modified Roy model.

No theoretical lecture will present you with the truth of the battle – that at any moment you could have your gloved fingers in a struggling vagina, and ten minutes later you would be eating a slice of pizza; that you will become a master of urine concentration, that the nauseating need for diarrhea will pass, and that the three meals a day of peanut butter and graham crackers are all you really need anyway. Some of your patients will hate you, and tell you so every time you give them a meal tray. Some of your patients will love you, want to touch your hair, ask about your family. Everyone you see driving a car will be a potential murderer, high on crack, to be watched and avoided, the children in your car more valuable than anything in your life. The constant coughing of aerosolized infection will drift into your open mouth – and your immune system will strengthen, becoming impenetrable, like the amour plating of a panzer tank – and you’ll wish that just once in a while you could get sick.  

The fellowship of nurses in the Emergency department is a coalition of shared sorrows and triumphs, of near death experiences and close calls, of comedic interactions, violent brawls, blood, urine, and vomit. It’s a place of chaos; old men dying and babies being born, of wailing and sobbing, and of laughter.  We crave the ability to produce a lasting contribution, but are often times tethered by the very profession we live. We work in the muck, on the front line – feeling quite alone, standing apart from the greater architecture that is the hospital, nervous, but so alive. Every day we see the insides of people, splayed open or draining, but always in awe of a creation that is beyond one’s understanding. Goodness and evil live in curious harmony within the ED, fighting it out as we try our best to feed the goodness, starve the evil, and not be taken down in the process.

And yet, every once in a while, when it’s dark and the beds are strangely empty, the trench nurses creep outside and lean against the wintery walls of the building, each feeling the heat from the others shoulders – and silently watch the snow come down - like swirling stars, trapped within invisible cones under the lights of the parking lot.

My friends who work at normal jobs always ask me why I stay. And always, after a pause, I say,  “How could I leave now?”

Rob Hart

Monday, May 5, 2014

Portrat Update

Well, for the past couple of months I have faced some complex Photoshop challenges. No, nothing spectacular like I had to upgrade software, or a computer crashed, nope – just detailing some portraits from last fall, and working on big stitched panoramas that needed some cleanup work and cloning, so that they would print at the desired size of  - huge! Two of them are printing with super accurate detail at six feet across.

Things were going along just fine until I slowly realized how little I understood the colossal machine that is Photoshop; the shortcut key strokes, smart filters, writing scripts, grouping layers, cinema grading, creating brushes and presets, drawing with a tablet, jitter and scatter and randomness, etc. Sure, I can dodge and burn, correct color balance, soften skin, eliminate the occasional beer can that I didn’t see floating in a lake, I can even image-blend with a fair degree of reliability.  But, to really progress to the next level of photographic expertise – I needed to learn; to stretch and bend what I have been doing, and increase my level of awareness while working within Photoshop.

So I started watching PS tutorials on YouTube – everything from GoAskErin (an underwater photography-based PS studio geared specifically for those environments in the great blue) to (an advanced site mostly for model and fashion photography). I now understand why the retouching editors that work for Annie Leibovitz make so much money. It might not be rocket science – but it’s pretty damn close.

So, I thought I would quickly show a few screen shots, along with a little dialogue, to explain how I now treat eyes in some select portraits. They are subtle, but I think that the extra work shows in the final print.

This first image is the RAW file directly from the camera. No flash, just indirect light from a window and some reflected light from a fashion disk. I do not like to use a flash for two reasons; one – it can be a complex process that adds a dimension of exposure complexity and hardware setup/transportation that I just do not have the experience with, or time for, and two – if I buy any more gear it’s going to be a new tripod!
Warning – Do NOT buy Chinese carbon fiber tripods!

By the way - thank you Chelsie for volunteering your time and face to my experiment, and thanks also to Dixie, who loaned us the clothing and hair.

I first gray-balanced the image with a Curves layer and touched a neutral section of her gray jacket with the eyedropper tool. I do these same procedures with big complex landscapes; only it is much more involved and includes an initial Threshold layer and all of the white/gray/black eyedroppers in a Curves layer. I was not thrilled with the purple cape, so the next thing I did was to create a mask and desaturate the color all the way to gray – one that would not detract from the subject. Next I inverted the mask and over saturated the reds to bring out the Merida-esque color of the hair, and then zoomed in and cleaned up any ‘overspray’.

Now I had a starting point.

This next image shows just her eyes. Don’t get me wrong, her eyes are awesome – but they just need a little touching up and highlights, so that the final image reflects what I was hoping to achieve when I was taking the picture. Without a flash, there are no spectral highlights that often times create an “eye illusion” of being more alive, deep, and rainwater clear.

So, the little naturally occurring vessels were erased with a tiny Spot Healing brush, the white globe was lightened with a Levels mask, the outer rim of the iris got burned a little, iris color was enriched with a mask and a Hue/Saturation slider, highlights were added in steps using the sampled color from the original highlights, and mascara was enhanced with a Levels adjustment and mask.

I did not use any Smart Layers for these steps, as I was not altering the size or shape of any one aspect.

After completing the eyes, I moved to softening her skin with a layer blend consisting of a Duplicate background layer and a Gaussian Blur filter. Once you create this new layer, change the blend setting to Soft Light. Then you add a mask to it and “paint” directly onto the image with a big soft brush, leaving the effect behind the brush instead of a blanket overlay on the entire image. You can then adjust this layer strength with the opacity and fill sliders. To further blend this layer, you can also double click the layer and adjust the underlying opacity in the Layer Style.

In the end, I feel that the final image is much more powerful than what the lifeless digital sensor was able to capture. The openly artistic fairytale interpretation is much more pleasing than the original - with its crazy purple silk, desaturated reds, and weak highlights - exchanged for unashamed Irish red, rosy skin, and a background that sends all of the attention to her face. 

Photography is, after all – art; the ability to learn and practice and create in a world where everything can be interpreted and manipulated as your imagination sees fit. This technology, and those old world contraptions of glass and gears, is a wonderful place to be.

I love this! After finishing one of the images (the one at the top of this Blog) I noticed the giant clip that we were using to snug up her skirt (it was way too big). Thank God for Photoshop!

Monday, March 3, 2014

The Road

 The Road

(no photographic content here - only ramblings)

When we were kids our parents loaded us into the back of a Pontiac station wagon, told us to quit fighting, and drove hours or days into the wilderness. I use the word ‘wilderness’ loosely here, as for us, even the timbered mountains of our own central Idaho were wilderness; in the sense that we were there alone, with primal fire, surrounded by wildlife, and with only a thin layer of Coleman canvas between our huddled bodies and the demons of the night. A National Park was occasionally set upon by our family and the beagle, but mostly we just went here and there. Perhaps just far enough into the wilds that we were alone, in case our parents decided it was time to abandon us or to really give us something to cry about - which was always an intriguing thing to hear them say.

We had no electronic entertainment back then, other than Operation, which was, at best, not a good option in the back of a moving car. And even if you did unscrew the red light-bulb nose a turn or two so it wouldn’t keep lighting up all the time, you still had that terrible buzzer alarm which would surely lead to a spanking. Somewhere in a junkyard is an old white rusted husk of a Pontiac with a tiny plastic butterfly, a wrench, and a wishbone shoved under the back seat. The wrench I could understand, a previously botched appy or a circus prank gone awry, but a butterfly - what the hell was with that?

Other than getting into trouble, reading was all that was left - and you could only do that if it didn’t make you carsick. Vomiting onto the hound’s-tooth upholstery was always a showstopper, and one that always brought the station wagon to a drifting halt. We learned quickly that they wouldn’t stop for us to pee, “You just went”, but if one of us puked down the side of the car or onto the dog, you were sure to get your pee break. Eventually even the well-acted sick look and the simple statement, “I don’t feel good” would accomplish the goal. Without the trance-like engagement of the modern iPod, we had to entertain ourselves; we secretly tossed things out the window, conjured up wonderful imaginary worlds, made each other punch themselves in the face, and just watched the scenery pass by the window. I imagine this is what the prairie kids did during the months long wagon drives into the western territories during the 1800’s – only they died once in a while.

Once we got ten blocks from our house, the world was a fascinating and foreign place. “Wow, look at the size of those monkey bars! What park is this? Was that a prison? Why is that man camping on the freeway? Is this Oregon? That lady has her shirt up. Are we there yet?” It was a nonstop adventure into the unknown, and the landscape blurring past became our extended edition widescreen movie. The complete lack of seatbelt use also meant freedom to roam the cabin at will - as long as goofing off never interfered with the back of my dads head, which, if accidently whacked with a shoe or a GI Joe fleeing a combat zone, would terminate with a premature stopping of the car and some good old-fashioned roadside spanking. Basically it was another pee break.

This, of course, was the very same era where leaving trash in parks, or on the side of the road, and smoking at meals just didn’t seem like a big deal. Ralph Nader, a surgeon general, and the crying Indian on TV soon changed all of that, but for a time there was a sense of driving safety that was magical – and quite deceiving. As if the rigid hull of cold-rolled steel and chrome would somehow protect the loose assortment of pleat-skirted girls and plaid-panted boys from instant annihilation, like a comfortable trip over Niagara Falls in a wooden barrel.

The point was that we entertained ourselves – we had to, no one else was going to do it for us. However, if for some divine reason, a small flat TV were just dropped into my lap from the future, I would have cherished it like nothing else. I would have stared into its brilliant pixilated face for hours, contemplating the next jump toward spinning golden coins. As the sun slowly slipped over the edge of the earth, and its last golden rays pierced through the front windshield of our car and bore deeply into my dad’s retinas, he would break the silence with,  “Jesus Christ, where’s my Ray Bans”. This sudden disruption of the environmental milieu would shatter my coin-gathering concentration. Having heard the Lords name, I would look up from my hypnotic box, thumbs and hands locked in the Kung Fu grip position and my neck frozen in place like I was sniffing nail polish. I would twist my immobile form sideways, wincing with the pain that only comes from electronic joy, and I would look out onto a great ocean of water, its blue-green waves curling in vast arcs toward the rocky shore. Groves of stunted trees, swept backwards to flee the ocean, rimmed the edge of black cliffs. The setting sun would illuminate the waves as they rose up, making them glow from within like emerald glass tubes. It would have been 600 miles to the coast – an entire day – and I would know nothing of the land between the start and finish, other than when we had to try the McDonalds in Portland just to see if it was the same, which it was. So here, knowing that I should speak to the beauty that stretched before us, the only reason we were on this Grapes of Wrath journey, I suppose I would ask, with the great wisdom of a game-master, “What’s this big blue wet thing?”

Today, with the dense drape of lavish electronic gizomotory that envelops us - the trip, the adventure, and the landscape - all passes by un-noticed. Our kids are strapped into climate controlled cabins with NASCAR precision; Skullcandy headphones block out the world with Dub step and Acid Techno; unblinking eyes focus on spastic phone games with the ADD responsiveness of an air traffic controller - fingers and eyes interpreting color and movement at a blinding pace, knowing that so many virtual lives are in their chapped little hands. No plastic wishbones under the seat these days – only spent AA batteries.

Car trips then were somewhat uncommon, and they were carefully planned out - like Cousteau’s deep-sea expeditions. Tires had to be double-checked, oil topped off, spares strapped to the roof with rope; shiny metal thermoses were filled with vile Folgers coffee; toolboxes bursting with wrenches and sockets were carefully stowed; tire irons, jacks, and flares had to be accounted for, and jerry cans of Premium sloshed next to hapless children peering out the back windows of Ramblers.

Today, however, we drive great distances without any fear of the impromptu campout. It is not uncommon to own a car with hundreds of thousands of miles on the odometer. In the 60’s the best you could hope for was about 60,000 before the rings gave out, the transmission lost a gear, and the blue haze of the crop-duster marked the untimely death of another of Detroit’s finest. Every dad worth his suicide knob knew how to fix these problems. Blown radiator hose – no problem, re-jet your carburetor in the Rockies – no sweat, fix a sticky lifter in the parking lot of the Safeway – easy, throw a rod in Fallon– just walk away. It was all so easy back then.

No one knows how to work on a car now days, not even the automotive professionals. “I am sorry friend, computer, it say car – is dead, no good. Like old country, is shit.” Cars are disposable. And yet – they are more reliable. It seems that they run forever, and then just up and die, like that damn stinky cat that you got on a whim - but lived to be eighteen. Now, with this newfound reliability, the adventure of the road trip has mostly vanished. No one thinks twice about going to the ocean, Disneyland, or even Disneyworld for that matter – not even a shred of concern that they might not make it.

The last hope for vintage adventure is to own a VW Campervan from the 1980’s. This gigantic metal cube, obviously designed prior to the wind tunnel, has the same horsepower as a burly John Deere riding mower, and enough poorly designed parts to keep even the most mechanically-inclined improve prodigy locked in mortal combat with unexpected restorations for years. Top speed on the freeway, in southern Utah, with a headwind – is 35mph. This was the vehicle I tortured my own children with. Once seasoned, they never asked “how long” or “when” again. They knew that time was based on the sequence of failing parts, and my ability to repair it with bailing wire and duct tape. It was more like, “What day is it?” or “When is winter again?”

When we were kids, and horsing around in the backseat of the Pontiac, my dad would just reach back with one arm and do a blind sweeping slap motion, connecting with whatever kid and body part he could. Often times the innocent kid would be the one to get smacked, leaving the other to quietly snicker, grateful that those tears he was seeing weren’t his own. And when the wrong kid did take one for the team, the parental answer was always the same, “You were both to blame”, which no kid knows was ever true. If nothing else, it taught us that life is random - and unfair.

In the van, however, the Germans placed the back seats almost a tennis court away from the driver. Perhaps their kids are more old world; well-mannered, passive, polite and fair. Not in America. Reaching back for the blind arm swing would get you nothing but air, and possibly a torn rotator cuff. Nope, it was a big production of escalating threats and finally a drifting halt to the side of the road. This open space did provide some entertainment though. While you were driving you couldn’t just hand snacks or juice boxes to the kids in the back seat – they had to be thrown. It was like feeding monkeys, their little arms all outstretched, straining against their seatbelts, grunting, hoping to snag a cookie from mid-air. Sometimes you hit the mark, and sometimes you were short – and that’s when the show started.

They would work for hours - quietly, as a team, combining their mental powers of mechanical engineering and physics, creating a complex robotic arm from Lego’s, K’nex girders, hair scrunchies, pencils, rubber bands, and shoelaces. Together they would slowly work the arm out onto the van floor, toward the errant Oreo, modifying the contraption as needed.  It was as if I had my very own Spielberg production in my rearview mirror. Of course eventually they would get the cookie - and fight over it. Someone would cry, someone would laugh in triumph, and the van would come to a drifting halt.

They, of course, weren’t quite as inundated with technology as the kids of today, but they had their fair share. However, the unreliable grace of the vehicle (or what we called the brick) gave them a good balance between their Gameboys, reading Captain Underpants books, and hearing the Lords name while I used wood screws and a drill to re-attach the fiberglass campertop back to the metal body. It was a solid ride, don’t get me wrong - the curb weight alone allowed it to float like a magic carpet over any surface, and steering – it was a tight, with the turning radius of a Fiat. It was often times a little unnerving to know that your feet and legs were actually in front of the wheels, and that the only thing between you and the four-point muley was a grill of German plastic, but after a few near misses it didn’t seem to be a big deal.

I think the generation being raised now, on a diet of electronic gluttony - without the Lewis and Clark style camp outs of yore, ensconced in Tyvek homes and sealed within transportation containers of humidity controlled safety - are becoming uncoupled from the Earth. Gone are the days of starring out the window at the slowly changing countryside, wondering why a goat was standing on a cow. Gone are the frequent camps made alongside nameless dirt roads in the desert, waiting for the sun to go down so that you could drive the van again in the cool of the evening. Kids are no longer subjected to the music of their parents, or to the ‘grown up’ conversations that were meant to be whispers  (didn’t the whole family know that our neighbor dressed like a girl anyway?).  No one needs to be mechanical anymore – because no amount of MIT training is ever going to help you with a modern vehicle. I have raised the hood on a 2013 Taurus – and as far as I can tell, it’s just miles and miles of tubing and hoses – not an engine to be seen, let alone a distributer cap or a nice Holly carb.

It seems that with each passing year, with each leap forward in technology, we are separating ourselves from the very world we inhabit. We are safe, secure, clean, and healthy. The natural world, on the other hand, is dangerous, unpredictable, filthy, and – also healthy. Experiencing the wild world around us should not be a yearly novelty, but a wondrous opportunity that we seek out as often as we can; the faint slice of midnight air as a bat changes direction in front of you; a majestic bald eagle just sitting on a fence post along a wintery road in Wyoming, looking for mice and twitching his tail; sitting on a rock, snuggled with a friend, hypnotized, listening to a campfire crackle and spark from the pitch pockets of fresh-cut wood; watching clouds become pregnant with water - heavy and purple, and then birthing a white curtain of hail over the desert. These are the things that we should never miss out on; these experiences are what formed our sense of wonder, beauty, and awe.

I don’t regret the past for its lack of safety or environmental conscious, because we learned a great deal from those years and made changes for the better. However, I do pity a future generation that may be so disengaged that they lose sight of what is important on this planet; that fame and GoPro fortunes will never replace patience and wonder; that there are more colors in the ocean than on any flat screen monitor; and that with only a little bit of hard work, a sprinkling of unknown, and some filth and hope, their lives will be that much richer, their memories greater, and the world a better place.

Rob Hart