Stories on the PICU

Been enjoying my time off. And I have worked a few shifts and some funny stuff happened. On one of my days off, I had a very Austin-centric day. It started with aerial yoga with my sister Holly. We bought a few classes off AmazonLocal, a Groupon competitor. It's this small studio in Hyde Park and proved to be great fun. Plus I'm sore in unusual places, a little bonus there. http://www.austinaerialyoga.com/

 

After hanging upside down and sideways for an hour, we went to Mother's Cafe and Garden (http://www.motherscafeaustin.com/) a few blocks away to eat a really good vegetarian lunch. And after that, we visited the Austin Faces AIDS photo exhibit. I've mentioned this already in my blog, one of my fellow volunteers is pictured in it, and surprise, surprise - I discovered someone else I know is also in the exhibit. It's beautifully done and it's free; you should check it out. Here's a link to the video work of the exhibit. http://vimeo.com/channels/austinfacesaids. It was a warm, sunny gorgeous December day.

So on to work the next day. (Again, I'm changing a few details to maintain confidentiality.) Not a bad shift, working with two of my favorite people, Curtis in charge and Gilbert. The PICU wasn't too riled up, we weren't in the med room sharpening our needles too often. I discharged four patients and part of the process is that we hand back their valuables that were locked in the safe. The patient goes over everything, verifies it's all there and signs for it. One of my discharges is thumbing through his wallet and I see a big "Registered Sex Offender" card. Interesting, because I didn't get any information about this in report and I realize that I was alone with him in the room at various times during the day -- and yes, I probably would've done that even if I'd known his history, but still....it's nice to know and plan how close your back needs to be to the door. Of course, the most likely explanation is that he didn't disclose any of that when he was admitted. That's a very big issue in mental health -- figuring out what is true from patient stories and surmising what gets left out. It's quite an important skill and one I know that I really don't have yet.

Amusing moments were provided by use of the phone on PICU. We have a phone for patients to use on each unit - but the PICU's (that's psych intensive care unit) wasn't working. So we pulled a phone across the nurse's desk and placed it at the dutch door for patients to use at various times. Normally we don't hear their phone conversations, but this day we heard them all. Several times I felt sorry for the government worker on the other end of the line as patients attempted to sort out some problem with SSI, their parole officer, or some kind of assistance. I wonder if they received special training on dealing with the mentally ill caller. Calls to family and friends sometimes offered insight. One caller was offering a long, rambling explanation of how she ended up with us. It involved her driving around the whole Austin metro area, trying to pay off all her parking tickets. Somehow that whole experience was too stressful for her, she ended up losing her cool with the friend taking her on this errand, and he deposited her at PES (Psych Emergency Services). As she recounted her frustration with this, her voice got louder and louder (apparently, the boyfriend didn't offer a sympathetic ear), "I said...I had to pay these parking tickets!" Then quickly, in the blink of an eye, she's calm, chuckles a little and says, oh it's snack time....I'll call you later. And it's over. I have new empathy for the patient, for I can only imagine the stress of driving through Austin traffic all day, and on such a depressing errand. Those of you not from here may not understand - Austin traffic is particularly bad, on many lists it's in the top 10 worst cities of the nation. The city council thought in the 1970's and 1980's that if they just didn't build a good highway infrastructure, people wouldn't move here. Austin has always had a thing about wanting to keep itself small & funky - which I totally appreciate - but look how that plan turned out.

I've been looking at the charts a little closer, especially at the forms and documents that I'll be responsible to fill out after I graduate. I noticed that a new term seems to be emerging, and I don't like it. Some of our patients are admitted after a confrontation with police where they make gestures that they hope will incite the police to shoot them and end their misery. In the past, we called this "suicide by cop". I noticed that the newer term (I guess more politically correct) is "police-assisted suicide". I really think that creates a false impression -- like, are they Dr. Kevorkian, standing there with a syringe? I think not. I'm going to stick with the old term.

In the rush of the morning, something absolutely funny happened. Mornings are busy because the majority of medication is given then, discharges are being prepared, and all the office personnel are at their desks. So at our nurse's station, we had two social workers, two doctors, three nurses, a unit coordinator, a rec therapist, and a mental health tech. Oh, and a pharmacist. Gilbert drops his pen while he's standing at the dutch door having a patient sign their discharge papers. After he picks it up, the patient says loudly "Hey, I saw your joker tattoo.". Gilbert looks startled, says, "What joker tattoo? I don't have any tattoos." "It's on your ass. I saw it when you bent over." Now everyone at the desk (me included) snaps around their head and is looking at Gilbert. He's blushing, starts to argue again with the patient....then realizes what he's doing and just shuts up. (note to self: don't argue with patients on PICU) Things move on and we get back to work. Later, Gilbert tells me he definitely does not have a joker tattoo on his ass, and I believe him. I remark that the only way he could've convinced all of us at the time, however, was to show us his ass. So where did the patient come up with that? If he was angry with Gilbert, that certainly was an effective way to get back at him. I bet half the people that witnessed that exchange now think Gilbert's a huge fan of Batman villains. That's the thing about mental illness....someone can be so intensely incapacitated yet still be one sharp cookie, capable of something so sneaky.

Overachiever

I'm done with the semester! And I definitely am an overachiever, I even got an A in my pass/fail class. Oh well. I learned Advanced Patho really well, sure that will come in handy. And here's something else that's cool -- I figured the skills I acquired in Advanced Health Assessment was just nice-to-know, but a classmate who currently works as the nurse-manager of a psych unit said that the NP's and psychiatrists also do full physical assessments on admission and bill for them. I need to get a fuller understanding of what my new role will entail & what I will be able to do. For example, I'm not even sure if the collaborating physician that I am required to work with has to be a psychiatrist or not. Over the break, this is something that I plan to investigate. Along with some fun - hey, never forget the fun - I went to see Ken in Houston last week and we took some wonderful long walks. He lives in the museum district, right by the zoo and Rice and the medical center. One morning we walked thru the medical center - that place is breath-taking for a medical professional. Ha. It's a beautiful park around the zoo - they have a pathway thru oak trees that I swear, is almost as beautiful as Oak Alley in Louisiana. Here's a few shots of that.

We also visited the King Tutankhamun exhibit at the Museum of Fine Arts - wow. http://www.mfah.org/ It's well worth the time and cost. They don't have every single item from the tomb, but what they have is lovely, including the iconic funerary mask that was placed over his mummy. I particularly liked the enormous statues that were in place around the tomb. We need to get Nile back to Houston to see this -- maybe interest in Egypt is genetic -- I mean, we did name him Nile for a reason. Ha. Speaking of my man/boy son, he had to go to school dressed as though for a job interview today. We went to Dillard's last night and bought him some dress clothes - that's right, he didn't own any. In the Men's Department, too. We bought this lovely deep-crimson (Roll Tide) dress shirt by Michael Kors and he looks great. I said, gee, you may find you enjoy dressing up. Nah. But it was worth a try. It did prompt me to have those predictable "gee, he is growing up" feelings. Don't have those for Dani. She's already a grown up -- just ask her.

I go back to work tomorrow. I'll be working two days a week on the break, exactly what I wanted to do (aren't they sweet to me?). So I should have some interesting thoughts and experiences for the blog while there. I definitely will be looking at the psych ward with different eyes - even though the focus of this semester wasn't yet on the nitty-gritty of psychiatric disorders (but we did cover the basics in Patho), I learned an enormous amount about the role of a "provider" as they say, which refers to the person making the care decisions & writing the scripts - whether that's a physician, a Nurse Practitioner, or a Physician's Assistant. NPs and PAs are often called "mid-level provider", which means we're between an RN and a physician. Recently I found out that some of us don't like that term -- thinking that mid-level means the care we provide is somehow reduced from that of a physician -- I can see that viewpoint, but I don't mind the term. I mean, graduate school for me is only 2 years, I just can't equate that with medical school and residency for a psychiatrist. Studies show that NPs provide equal-quality care, and that's what counts.

We covered the H&P (history and physical) to the nth degree in class -- so I plan to make time to read over those in the charts for my patients and see how practice relates to theory.  I also want to talk to the psychiatrists more about what they do. And if I get a chance to talk to the single Psych NP that is employed where I work, I'll talk to her (they're not very progressive with that. Maybe that will change). I'm also going to look more at the meds - I take Pharmacology next semester, so my head will be crammed full of that data soon.

I just finished Jeffrey Eugenides' new novel The Marriage Plot. He wrote Middlesex, which my book club in NJ introduced me to & I loved it. It aggrieved me greatly that Mr. Eugenides came to Austin to give a talk on his new book and I couldn't attend because I was taking a mid-term exam right at that time. It was the time of the semester when I thought, good god, this is just too hard, what was I thinking? And I have no life, I can't even go see one of my favorite authors! Anyway, I survived and imagine my surprise about this book -- this wasn't even in any of the reviews I read -- it's basically about mental illness. Bipolar disorder, to be exact. And I found the portrayal realistic. One of the things I think he really "got" was how wonderful manic phases can be (and yes, eventually, how destructive). If  you talk to someone who's bipolar, you often see this expression come across their face when they talk about what it's like when they're manic -- you're so verbal, so energized, so positive, so up -- who wouldn't love that? The expression says Oh god, it was just the best thing in the world and I miss it terribly. The book really nails it.

I've been thinking about my post last week ranting about what people do wrong at the gym. Specifically, why does what other people do bug me so much? Who cares if they wear a visor and sing along to their ipod, right? I really am an open-minded, bed-wetting liberal type of person -- I actually had a conversation recently with my dad (ok, an argument) about why I like gay people so much -- it's because they are interesting, brave and different. I so admire that. So why am I intolerant of the people brave enough to wear their visor to the healthclub? I guess it's because I spent many years using only my home gym with workout DVDs from my guru/idol -- http://cathe.com/ -- going back to the gym is a relatively recent thing for me, and going back to school has enabled me to go there every morning. I'm having a social-adjustment thing, learning to share my toys and space. So please be tolerant of my intolerance. I'll get it eventually. Then you'll see me running barefoot on the treadmill, singing tunelessly to my ipod, with my bright-yellow visor on. Oh, and my muddy shoes by the side. Ha!

Books, Otoscopes, Visors

It's finals week. This is all I'm doing this week except for clinical hours. I have basically 3 finals - one is a physical demonstration of a head-to-toe examination and corresponding chart write-up, a Pathophysiology comprehensive final, and an Advanced Physical Assessment final that's also comprehensive. Oh it's fun, let me tell you. I don't know anyone that enjoys taking exams. I think the worst feeling is sitting in your little seat with your pencil in your hand as they start handing out the exams. Even worse is reading about the first 4 or 5 questions and thinking, oh god, I should've studied more. But anyway, it is all that I'm doing. My psychosocial class had no final exam (yay!) -- just a paper, and that is one thing that doesn't bother me, writing papers.

Interesting happening at clinical. I'm going to change some details in this to protect anonymity, but a child was brought into the office for a rash all over her body. We thought it was an antibiotic reaction, something called Stevens-Johnson Syndrome, which can be quite serious. When I walked in, they rushed me over to see the kid because the family was preparing to leave and go straight to the Emergency Department and the docs wanted me to see this. It was an incredible rash, covering the entire little body, very red. I noticed however, that there was a really big stretchy bandage (called Coban) on the child's antecubital, where blood was probably drawn. I thought, why on earth did they have to use that? I guess because I've worked in woundcare, I'm attuned to bandages and dressings. Anyway, later the Doc comes into the nurse's station and asks his aide to tell his 3 waiting appointments that he'll be late. It turns out the child didn't have Steven's-Johnson, she had leukemia. He had just gotten the lab results. The rash wasn't even a real rash, it was acute bleeding under the skin. Her platelets were only 40 (normal is 150 to 450). So the doc had to call over to the ED, where the parents were and tell them that their daughter has leukemia. Kind of ruined the rest of the day for everyone. But you know, I realized that a big goof was made -- that Coban was there because when the lab drew blood, she wouldn't stop bleeding. The doc should've been alerted and that should've raised alarm bells. I suspect they wouldn't have narrowed the diagnosis down to Stevens-Johnson quite so quickly.

My sister's cat is visiting with us for 10 days because she's in Goa, India (doesn't she lead an interesting life?). His name is Mitten, shortened to Mitt and so of course, we call him Mitt Romney. It's a hoot. The first night he was upset and mewed all night. The next morning, of course, we had to say many times "Mitt Romney is a cry-baby." Ha. But now he & Crabby are friends and play together a lot - they even eat off the same saucer together.

I managed to get sick about 10 days ago, and that's been awful. The worst part was that I missed 4 days at the gym, and when I did go back, the first few days I needed to go in later - not at my usual 4:15 am - and there were all these people there - like, what, people at my gym? To cope, I made a mental list of what I hate that other people do at the gym. (Skip the rest if you hate to read rants, that's really what's coming. And I saved this for the end for that reason.)

I hate:

- people who wear hats, especially visors at the gym. It looks silly - are the fluorescent lights too bright for you? And don't they know that most heat escapes thru your head, so that hat is why you're sweating like a pig?

- people who wear dirty shoes to the gym, and leave little trails of dirt or mud at the machines where they stop. Ditto people that wear inappropriate shoes - I've seen sandals and Crocs.

- people who crowd me at the free-weight areas. If I am working shoulders, do not sit on the bench close to me. I should not have to move and readjust just because you are either clueless about what kind of space people need for shoulder work or (& this is worse) - you are trying to strike up a conversation with me. That leads to the next one.

- people who do things to strike up conversation. Hey - notice I am wearing ear buds. Notice how hard I'm working. I am not there to chat. Sure, I'll say hello and/or smile if you're a crack of dawn regular like me - but darlin', that is all. And I don't feel guilty about that.

- people who stand directly in front of the rack of free weights to do their sets. This is always a clueless newbie -- how am I supposed to get my weights while you're standing in the way? I never say excuse me when this happens -- I say oh, excuse you -- funny, I don't think they get it.

- people who want to use 2 or 3 machines at one time to do super-sets. This is fine to attempt, and you'll probably succeed if it's 4:30 am, but do not say to someone, "hey I wasn't done with that machine" when you are busy on another one. I saw a ____ (insert derogatory term) actually say that to someone on the leg press -- a woman had removed three 45 lb plates from each side, then he finally sidles up to her and says, oh I wasn't done with that machine. Look, dickhead, I saw you busy on the hamstring curls over there. I wish he'd said that to me, because I would've said, "oh, show me where your name is stamped on the metal." And he did that when the gym was really busy, mid-morning day after Thanksgiving.

- people who tunelessly sing along or hum to their ipods.

- people who wear too little or too much. Please, I don't want to see up your tiny shorts when you're working abdominals. If you plan to do that, wear capri's or longer shorts. And I get nervous when I see idiots wearing thick sweatshirts in spin class. I think they are trying to sweat off weight - but dehydration is dangerous and doesn't make any fat go away. I know CPR but I really don't want to have to do that.

- people who grunt or moan loudly while they work. Please, unless you are a world-class power-lifter, that is just ridiculous. You really can't hold that in?

So I could go on but I won't. I guess I'm a curmudgeon. But I'm trying to become more tolerant. Yesterday I was getting a drink of water right before spin and I notice that the floor is shaking. So I look behind me and a very large guy is running on a treadmill with absolutely terrible form - massive foot falls, thud thud thud. He's wearing too little, I see way too much skin, and he's even barefoot. And he's singing to his ipod. It's a trifecta. But I smiled and went into spin. I thought to myself, that is absolutely great that he is working out and he's so happy that he's singing. I'm happy for him. Hope he doesn't break an ankle and need CPR.