Bullwhip

Ah, not feeling guilty because I'm not studying. Best feeling in the world. Even if I'm sick. Yes, I worked two days last week and everyone on the unit was sick. Seems to be just a cold, and I haven't missed any workouts yet.

Got another job offer, one of the docs at work. I'm starting to realize that I won't have any problems finding work. I knew that intellectually, but it's another thing when six months before you're available, offers come in. What I don't want to do is just take what's offered, I want to find the best fit possible for me. The day before Xmas was really awful on the unit - we even had a "code purple" in the admit area right at shift change (of course at shift change). That's when people are getting aggressively out of hand and we need extra staff to either restrain them or just a show of force. Our PICU (Psych ICU) has 10 beds, and the types of patients that are in those beds is very important in terms of what kind of day it will be. We had three young antisocial men, which is absolutely terrible. One is bad, two is awful... We ended up moving the "best" one over to the open side because the three of them just created an untenable situation. Too much hitting and threats and tempers flaring, which makes the nurses get in the med room and sharpen the needles. And a few of the other patients on there, not young men, were intensely psychotic. It was a rough day, and I wasn't even assigned to the PICU. Just the overflow of dealing with all that affected every single staff member. And this disturbs me - about half of my patients simply weren't improving, in spite of being on antipsychotic meds for at least two weeks, some more than a month. They seemed fine until you questioned them closely -- then the delusions came out, "Well, since I'm a doctor, they said that I can write my own prescriptions..." This came from a patient that was decidedly not a physician, and was in fact on court-ordered medication. Meaning we will hold you down and apply it via an injection if you don't swallow this pill. Not that physicians can't have mental health disorders - one of the saddest cases I ever saw in New Jersey was a psychiatrist that was hospitalized with major depressive disorder after his wife had committed suicide. I watched him waste away over a period of months.He blamed himself for her death.

I had a really odd dream. It was after the doc made me that job offer, I dreamed that I was at work as a Nurse Prac, and it was my first day. And get this, I had a venomous snake with me that I used to bite the patients to provide their meds. All the docs had their own snake, but since I was new, my snake was very badly behaved. He kept trying to bite the other docs and slither across the table as we were in treatment team meetings. I would grab him back and apologize. Talk about weird.

So moving the young anti-social man over to the open side turned out to be a really bad idea, he ended up calling 911. Now that has happened before (obviously) but since this guy is antisocial, he is as slick as, well, a snake, and super skilled at gaming people. The EMS team that responded was two newbies, so they were quickly sucked into Mr. Gamer's web. We spent at least two hours on that. Finally, the medical director insisted that the patient not be transported to the emergency department. His little game was foiled after all, but all of us were stressed and angry. What a waste of resources. Why doesn't someone so clever put their skills towards good instead of just jacking everyone up? The eternal question with the antisocial. And honestly, I would say that he's more borderline personality disorder than anything else, but I've noticed that there seems to be a gender bias when it comes to those two diagnoses. Men are classified as antisocial, women as borderline. He was a yawning black hole of attention-seeking behaviors all day long. For example, when I gave him his meds, he comments on how cool my nails look. I say thank you in a brusque way, I've already pulled on my no-nonsense schoolmarm persona, which I find works best with these types of patients. He moves on to initiate a conversation about his anxiety (right, he's sooooo anxious) -- he's appealing to my expertise and desire to offer therapeutic communication. I don't take the bait. The next time I see him, he's got a strange marking on his face that he applied with a magic marker. I don't even remark on it. Each interaction, he rachets up the "look at me" stuff. That's clearly borderline to me.

One of the super-psychotic patients was in group therapy when they were asked to write down their goals to be ready for discharge. It was so interesting, I copied what they wrote (with minor changes to preserve privacy). This is how the psychotic brain works. He wrote:
"Can live with Ma,
like John Wayne,
living for Dragnet,
miles away with Old Yeller,
and my bullwhip."
What's interesting to me is that you can sort-of see the grains of truth in there - maybe living with his mother is an option, sounds like she lives in a rural area, is Old Yeller his dog? Would he watch Dragnet on TV? But that last line is a little disturbing.

I've started my supervision work for my therapy skills and finding that works. Rob is my supervisor and I think we "click". I have three patients that I see regularly now, with three different diagnoses. I've already had to ask Rob, does just therapy work for this particular disorder? Because I so badly feel this patient needs medication too, it feels like I'm hamstrung in terms of helping them. Yes, he was quite reassuring, and offered some specific approaches that I should use when meds aren't in the picture. But man, I am so glad that I will be able to do both in the future. It just feels like I'll be able to offer well-rounded, comprehensive care.

I'm reading all kinds of great stuff while I'm off. Some of it applied to my job. One of the books is about psychological masquerade, when patients look mentally ill but it's due to an "organic" disorder, such as a brain tumor. (I dislike that term "organic" because mental illness is organic, too.) Another book is a memoir of a bipolar woman. And I'm reading Margaret Atwood's Positron series, which is a disturbing view of the future. I had to order Christopher Hitchens' last book, on mortality. Having a Kindle is the best.

But by far, the most exciting thing about having time off is going to yoga more than once or twice a week. I can usually get there three or four times now, which just makes life so much better. It's funny, I want to recommend yoga to every single patient. I do always talk about overall lifestyle choices - I think that's one of the keys to good mental health - and I mention yoga, but I don't tell them how actually rabid I am about it.

Starting to Feel It

Things are great, the semester is winding up, but man I sure am glad it's almost over. It feels a little ungrateful to complain - I mean, I'm so lucky that I'm able to go to grad school.  But I basically took too many classes. And the delay starting clinical just compressed everything starting in October into this miserable so-busy-all-day-long Monday thru Friday gig. Like I said, I couldn't even schedule a haircut in the the month of October or November. (Actually, I just got that done today, after I had my first final exam. Yes, I can finally breathe.) I'm working as a therapist on my own now at one of my clinical sites and finding my way as a new clinician. It's exciting and humbling, and I don't take it for granted. As I told someone recently, I have a proper sense of terror when I close the door and it's just me and my client, looking at each other. It's one of the hardest things I've ever done, I can say that. As Ken says, it's a puzzle. People tell you what's on their mind, but you have to figure out so much more - like, what do they not fully realize about themselves? What are they hiding from themselves (and trying to, from you)? What formative event have they left out that needs to be discussed? In the last - I don't know, maybe 20 years - the psychiatric community has found proof that many of our disorders are rooted in genetics and neurochemical/structural makeup - it's not all "bad parenting", although that is a factor. And how do you assess that? It's not like I can do a head CT in the office, and the differences at this point are rather subtle. Diagnosis is hard work - makes me appreciate the TV show House all the more. For instance, one of my therapy clients came to me with a very specific diagnosis in mind. And it took her almost the full session to reveal this. She has a set of expectations now around this, and we have to discover this territory together. But I certainly can't dismiss her ideas - even if I flatly disagreed (which I don't). Because she is the expert on her own inner life. I'm just someone who's a trained guide. Hope it's worth the money (ha).

I have realized that I certainly don't want to work at the state hospital on the kids' unit. I like the vast majority of the patients - but the subset of kids that don't really belong there (those with severe conduct disorders that basically disrupt the environment completely) have ruined it for me. This facility is not the place for them, but unfortunately placement is such a problem in Texas that they end up there anyway. And I can't be a part of that. The other kids - those with treatable psychiatric illnesses - I really liked them. I look forward to working with kids in the community that need help. (And yes, I know that theoretically Conduct Disorder is treatable but not at ASH. We are not staffed or trained to treat that.)

I've managed to work some fun into the semester. Ken and I saw Duncan Sheik perform at the Paramount and it was such a treat. I've been a huge fan since 1993, with his big #1 hit Barely Breathing (which he did a smooth-jazz version of as an encore), but it was nice to introduce Ken to him. Duncan was so funny and generous and just what you want a singer/songwriter to be for you, up on that stage. He sure has a wicked self-deprecating wit. I love how he said to introduce one song "Have you ever noticed how every sensual....seductive....arousing....hot....(this went on for a while)...thing is better in the anticipation?" Anyway, it was funny. I obviously am not as good a raconteur as he is! And he sang my favorite song (Wishful Thinking).

Let's see....what else happened....AIDS Walk Austin was fun. Beautiful day, good cause. My biggest baby had to evacuate for the hurricane in NYC. Is that weird or what? We live in Louisiana (yes, we survived Katrina) for 20-odd years, and Dani goes to New York and is hit with a hurricane. We flew her home the day before it hit, and it's a good thing because it was a nightmare. We had to send her back after a week because classes resumed at NYU but she went back to a freezing cold dorm with no heat or hot water. Luckily, late the next day it was fixed but we were a little frantic. She spent a really shivery night.

The diagnostic bible of psychiatry (DSM-5) has been updated and it's quite controversial. We've been talking about it in class all semester. I didn't realize that I was getting involved in a profession that has such controversy surrounding it, but I am. The public is questioning pathologizing that may be going on - is hoarding really a psychiatric disease in its own right, or just a case of OCD? Is severe bereavement the same as clinical depression? Are kids over-diagnosed with bipolar disorder (yes)? Are the drug companies in bed with mental health providers, seeking to smooth over every bump in the road with a pill? One of the things I like about working now as "only" a therapist, before I graduate and have prescriptive authority, is that I'm forced to treat patients without turning quickly to drugs. My personal belief is that drugs are needed in some cases, but are probably over-prescribed in general. My goal is to not be in that camp. The other part about prescribing is do it right. I've already seen several patients that were prescribed a low starting dose of anti-depressant by their family doctor, and followup wasn't really done. They are still on that dose, and not feeling better after months. The doc wrote a quick prescription without a thorough psychiatric exam (maybe as part of their standard 15-minute office visit), and didn't titrate the dose. If you need psychiatric care, you need to see someone fully qualified in that arena, or expect sub-standard results. Just my biased opinion, folks.

And another biased opinion is something that I've changed recently. As a result of my experiences on the kids' psych unit, I no longer support legalizing marijuana. I can't tell you how many kids I've seen that think that's the answer to all their problems, but what is does is just suck all the motivation out of their brain. I have no problem with adults smoking a little here & there, but its effects on the developing brain are scientifically documented as terrible. And yes, I know that if it's legal, then you have to be 21, but how many of you drank alcohol before it was legal? Yeah - all of you. Me too. And the other thing is the brain is still in a high state of development until about age 25 or 26. I've always supported legalization, but I have changed my mind. I think society has to protect these vulnerable teenagers that choose this horrible thing that frankly, puts them in a fog and robs them of a future. The other thing is that I read the cartels don't really grow marijuana any more because the in-state cultivators have basically taken over the market. Ever watch Weeds on Showtime? So that's not a good reason any more to make it legal.

This last pic is just two cute kittens from the shelter. Don't you just want to kiss that little pink nose? We are still consumed with kittens there. It's been the worst year ever. If anyone out there wants a kitten, please please please visit the Austin Animal Center. Open every day from 11-7. http://austintexas.gov/department/animal-services

The Naked Eye

I got a little extra time, but it's being redeployed immediately to clinical time. We finished our psychopharmacology class, which is abbreviated (ridiculous -- it needs to be a full-semester course) so I can stay at ASH all day on Wednesday instead of running off to class at 4:00. Last night I stayed until 6:00, so this could work out well. Get even more hours in, then December won't be miserable. Anyway, last week I spent one day at a Psychopharm conference that UT put on - it was an utterly huge room of people interested in this stuff. Here's the sessions I attended - really fascinating: placebo response, bipolar in kids, new psych drugs, treating refractory schizophrenia, and alternative therapies in depression. The one I found most interesting was on new psych drugs, not because of the new drugs planned (there basically aren't any, which is a real disgrace), but because the man teaching it put up so many helpful charts on choosing the right drugs, particularly antipsychotics, from all the choices. And people - take your Vitamin D. Every day. 

Nile is a black belt now in Tae Kwon Do. He is technically a black belt candidate, which is the first level, but - hey - the belt is black. It counts. Dani blew into town for ACL, with her bright red ombre'd hair tips. She's back in NYC now. I barely got to see her, but my sister Holly and I did get to take her to dinner the last night. We talked about Holly's twitter guy - this is interesting. Holly had been following the tweets of a cool guy on twitter, she was in Vegas & discovered (via a tweet of course!) he was too - they met up, hit it off, and now they may have a thing going. He's coming to Austin to see her. It's just so fun to say "your twitter boyfriend", I hope it works out so I can keep saying it. Ah, the new rules of dating in our networked, social media, 24/7 age. 

So on my first exam in Advanced Psychiatric nursing, I think I was the only person that passed, and that was by 2 points. Really. Ridiculous, I was mad for days about that. Then she gave us all a monster curve, and everyone passed. Yes, all us morons had to be yanked by our heels to the "acceptable" line. I was under a silly illusion that things like that wouldn't happen in grad school. 

Now I'm going to comment on a couple of juicy news items that I can't resist. First is this fungal contaminated steroid injection problem. A compounding pharmacy sent out vials of injectable steroid solution that were so contaminated with a fungus that you could see particles with the naked eye, according to the NPR report I listened to. I have noticed that medical professionals that I've dealt with in general are very against these compounding pharmacies and what they are doing. In my class that covered supplemental hormone treatment for women (compounded "bio-identical" hormones are all the rage), the lecturer flat out said this stuff is bad, there are absolutely no standards and no monitoring, they can put whatever they want to in there, and there's no guarantee of purity or strength. Or apparently of safety.

The other thing that caught my attention is the Lance Armstrong story. It's not playing out like I expected. I really don't understand why, after all these years, they are doing this. Now you may think to yourself, "because it's true" -- well, maybe it is, I certainly have no way of knowing it, but Lance won seven Tour de France titles, the last being in 2005. That is seven years ago. I can't believe that they had investigators working on this for seven years. Just seems to me like there should be a statute of limitations for them taking your medals away. I have to add that I have tremendous respect for what Lance has done with his LiveStrong Foundation. Did you know he started that before he won his first Tour? How many celebrities do that before they hit the big time? Hell, how many do it after they hit? Anyway, I don't like how this went down. It's just wrong. But one thing makes me happy - donations are up at LiveStrong. 

My clinical days are intense. I am at two sites that couldn't be more different - the children's unit of the state psych hospital and then a private therapy office. I literally go from seeing the most challenging, saddest, difficult to treat cases of kids with profound mental illness to sitting in a quiet, comfy little office listening to a couple talk in quite tones about improving their communication. It's hard to keep perspective at times. And I find this tidbit interesting - the kids that I see at the state hospital, in my opinion, are getting better care than they would at a private hospital. I would even say much better. Mostly because they don't have the mad dog insurance company snarling and growling at them to hurry up and discharge the patient. Most patient stays are at least two weeks, I've seen many longer, sometimes months if there's significant placement problems. And let me add, these kids need that time. OMG, I had one really bad day in treatment team review where I listened to so many stories of troubled homes. Thank goodness that is not every day, and certainly not every family. So when you hear "state hospital", don't think snake pit or that Jack Nicholson movie. It's really a pretty good deal. And it helps us all, these are our friends, relatives and neighbors that need these services. We're all in this together. A child that's been properly treated, appropriately accommodated at school, and had the necessary social support applied will grow up to be a tax-paying citizen instead of the homeless guy on the corner, getting bucks so he can self-medicate at the liquor store. Speech over.

A Little Extra Time

I'm currently immersed in a social experiment, it is called how much can I take. My week Monday - Friday is wall to wall school and clinical. And when I'm at clinical, it is often late. Tonight I have a therapy group to co-facilitate for parents of seriously ill kids and I won't be home until 8:30. That is, if nobody needs a little extra time. I just tried to make an appointment for a haircut in October and failed.  The only times open on the weekend would have gobbled up my exercise time on Saturday -- and sorry, that is sacred. So is this really so bad - come on, right, I'm a full time student, not working? Well, a couple things are killing me, the first is that I have to drive all over for clinicals. And Austin traffic is terrible. I have to drive up to Dell Children's Hospital tonight, for just a one hour meeting. The second thing is my professor (for 3 of my 5 classes) is pathologically disorganized. She has many other good qualities -- she's smart and experienced, and not a hard-ass, but I'm so tired of things not being posted for class until a couple hours before, and things forgotten, and .... if I was not the opposite kind of person (you know, the one always early to the meeting), it would be easier. I hope that when I graduate my family doesn't have to visit me in jail. Because I so want to strangle her with my bare hands (please....just a little strangle....I'll stop....I promise). So since Mon - Fri is taken that means my weekends are all study, all the time. Ken and I make it point to go to Vino Vino (best wine bar ever) one night, but that's all the fun I get, folks.

Clinical is fantastic. It's humbling to be allowed into such personal interactions, where people reveal their innermost fears and tribulations. I'm at a private therapy office, I'm the only NP, everyone else is a social worker. But that's good -- they offer a different perspective, and frankly I have so much to learn. The range of issues is huge. From serious abuse and addiction to just learning better relationship skills. I can't wait to see patients on my own. That may not happen this semester, but I'm gratified that I want to get there. Soon. My other clinical site is the Austin State Hospital Child and Adolescent Unit. It's dramatically different, but the two psychiatrists I'm paired with have been very generous with me, treating me as a junior colleague. I'll have some stories for my next post, but they will be heavily disguised. I will make absolutely sure that no personal data gets transmitted. I guess the biggest surprises I've felt so far are these: it's amazing how hard parents have to work to cope with a mentally-ill child. Just the school accommodations require a great deal of discussion and involvement. These parents are incredible; and the other thing (in the therapy office) is that boy, we sure don't have perspective on ourselves. I've heard jaw-dropping things where I struggled to hide my reaction that the patient minimized (oh, I smoke pot every day, but I'm not an addict because everyone does that), and OTOH I've learned to discount it when a patient says "this session will really be a big deal." (the ex wants to reconcile, sorry....well within the realm of normal.)

Dani is busy making a list of famous people she sees in NYC. Here's it so far: Edward Norton, Carla Gugino, Alec Baldwin, Coconut Records guy, Louis CK, Pineapple Express actor, a Sprouse twin. Some of those mean nothing to me, but I'm not 18. Ha. Every interaction we have, it's "I'm so stressed because you mean parents have me on a budget." Yes, Dani, this is a task that most of us in life have to learn. Get cracking. She figured out, though, that she can go try on Herve Leger dresses for fun in SoHo. It was a revelation - hey mom! I don't have to buy them! I told her I'd buy her one if she gets straight A's. (Well, it would work for me. You should see those dresses.)

Grumble

I don't have time for this (blogging) but I'm going to do it anyway. Grumble. I seem to be doing a lot of that lately -- I think it's how I express my worries that I've bitten off more than I can chew. I'm taking 5 classes this semester, specifically because there's an instructor I really like who's only teaching (get the name of this course) "Nursing Phenomena of Concern" in the Fall. I want to take it from her. And I want to have a better attitude, but I have 240 clinical hours to complete by the first week of December, I'm supposed to start next week and I don't even know where I'll be for prescribing hours. ARRRGGG. For a planner, it's a disaster. I had my interview Wednesday for my therapy hour placement, it was at the private practice office that's close to home. Looks good, I'm waiting to hear back from them. (Yes, it's Friday and I need to start Monday and I've checked my email 50 times this morning!!!) I will be learning how to do individual, group and family therapy with them if I get the nod. The two directors interviewed me over their lunch hour, it was fine but they were obviously rushed. Nobody screamed and they only laughed when I expected, so I hope that means I passed. Some interesting little extras this semester: I will be observing family court, going to NAMI meetings, and going to Al-Anon meetings.

We got Dani ensconced in New York. She gets along with her roommate and seems to be OK. We went to the Cloisters while there, which was really quite nice. It's a building way up in North Manhattan where the Met houses their medieval European collection. It's an incredible scope of art, including the architecture. Beautiful. http://www.metmuseum.org/visit/visit-the-cloisters Two pictures below are from there. We stayed at Times Square, mostly because I wanted to get two queen beds in one room and choices were few, and here's a piece of advice: don't ever stay there. Any other part of Manhattan has to be better than that. It's like the dirtiest, nastiest Mardi Gras parade you've ever been to, but 24 hours a day.

I've done a little volunteering at AIDS Services, doing their TB tests and even some foodbank days. We ask clients to bring in reusable grocery bags and the guy next to me opened up someone's bags and roaches scurried out. Really. Oh well, that's the only time that's ever happened. I love doing that work, but I'm pretty sure it's going to take a backseat for the next three months. Nile and I are still taking care of kitties over at Austin Animal Center, and I think we'll be able to keep doing that, mostly because we can do it on Sunday evening.

I read a good essay in Newsweek by Ira Glass - isn't he great? And his show on NPR, This American Life, it's great too. His piece is about love and the way life sometimes presents it to you. Be open to it in all its forms, I think is the message. He hooked me from the first two lines: "I’ve definitely had a f--ked up life in a lot of ways, but not because of big turning points where I made the wrong choice. It’s more like character flaws that played out slowly over time."
http://www.thedailybeast.com/newsweek/2012/08/26/ira-glass-on-rescuing-a-pit-bull-dog-with-a-ridiculous-diet.html

What do I know?

Well, most of August's fun is over. I've worked four days, and man, I am not used to that. I'm used to Zumba classes and pool swims. But it was interesting and difficult and at times, upsetting. For whatever reasons, I drew the short straws on a couple of shifts and had very difficult days. I processed 6 discharges in one morning, and then the next day (of which I stupidly said out loud "this will be easy") actually had a worse day with no discharges. Hospital work is like that - very unpredictable. The part that continues to try me, and that is so very different from office work, is that many things can happen at once. A patient starts screaming and beating on the walls, another one slips in the hall and falls, the lab guy just walked in and needs you to unlock the door for the samples, the doctor was in mid-sentence to you, and you have a handful of narcotics to give to a patient down the hall. And guess what - you must deal with it all. Yes, ask for help, but eventually you must deal with it all. If a patient's assigned to you, you are the one who documents everything. And believe it or not, that's the soul of the floor nurse. Charting. So here's what happened that bugged me the most. One of the most challenging types of patients is those with the Axis II diagnosis (personality disorder) called Borderline. This is a bad name for the disorder - it's not like it straddles any borders - not sure what the origin is - but it's usually a female, very dramatic, has serious intimacy problems, lots of approach/avoidance and passive/aggressive (and real aggressive, too). High risk for suicide. And the worst part, as with other personality disorders, is that very few patients change, very few get better. Mostly because they don't want to. Not that they're exactly happy with their lives, but they are unwilling to do the hard work to change their behavior. And boy -- I'd like to hang this sign in my office: In psychiatry, only those that want to change will do it.

Anyway, I had a borderline patient. This was a young, 30 y.o. woman, many medical problems already from a life of living too large and extremely drug seeking. I was discharging her and she was apprehensive about that. But she'd been with us for a couple of weeks (a long time for this facility) and we had a solid out-patient plan for her. It was appropriate. I started working on the discharge process, reviewing her prescriptions with her, going over her valuables from the safe, having her sign off on instructions and commitments to attend meetings, etc. She fights it in various, frustrating ways. Takes hours to pack in her room. Gets tearful and has to rest in her room. Then the kicker is when she asks where her necklace is. There's no necklace documented in any of the forms. And we document it all, carefully, on admission. The tech that processed her admission, luckily, is there and remembers her well. There was no necklace. But the patient insists she was wearing it when admitted, even though she was so high at the time and off her psych meds, that she really remembers little else. She says it had sentimental value and screams and cries. I get the supervisor, who (excuse me, I must speak frankly) is a worthless sack of dirt that rarely does her job right and always complains about it. I ask her for the form the patient needs to fill out for a missing item. She shrugs - I dunno where the hell it is. So I have to ask some of the more seasoned nurses on the other floor to get me the form. I'm running around, this takes time, I have other patients standing at the desk that need me. It's starting to turn into a circus. She's still crying. I'm feeling a little overwhelmed when I look over and see that one of the docs just completed rounds and has put up 4 charts with orders for me to process. This is not atypical.

I finally get this woman out the door; it's really, really hard. She came in with a ridiculous amount of stuff, clothes and toiletries. And there are 4 big bags of prescription drugs, each contains about 10 pill bottles. Mostly highly abused things, like Xanax and Oxycodone. Many bottles are the same stuff from different docs. She had these in her bags when she was admitted, we just count them, seal them up and secure them, and return them when she leaves. Yes, seems crazy, does it not? And this is the capper -- as we're leaving in the elevator, I'm helping carry it all down to the car waiting for her (something I normally don't have to do, but whatever it takes to get her out at this point), I start giving her a little positive pep-talk about how she can get off on the right foot after discharge and she stops me. She says pointedly, "What the hell do you know about mental illness? You've never had a problem like me." And it stops me. Because (thank goodness) I am not jaded enough to ignore this and dismiss it out of hand. Yes, I definitely do not have a problem like her. Now, I haven't talked about this much on this blog, but I have had issues in my life and I have had treatment. I am doing great now. I am working towards a place where I can be completely open about that, I'm not there yet. Sometimes with certain patients especially, I will talk about it. When it's therapeutic and appropriate, and in a limited way (because it's not about me). But no way do I have any experience like her. And truly, can I know what that's like? No. So I get to think about that for a while. It will certainly inform some of my clinical experiences this semester.

On a lighter note, I'm reading an interesting book that a classmate recommended called Stumbling on Happiness. It talks a lot about the current research on what we humans do in pursuit of happiness and how we try to set up our lives and make choices to create a future of happiness. The main thesis is that we usually do that wrong -- because we assume that the way we feel now about things is the way we'll feel in the future. But research shows that's not true. I haven't finished the book yet, and haven't gotten to the part where he recommends what to do about that conundrum. Ha. But he does provide lots of good data to support his points.

I have more to say, but I'm tired. We leave in the morning to take Dani to NYU.

Ken and I went to Baton Rouge last weekend to see Karen and Jim and celebrate her retirement. She made boiled spicy peanuts for us! Oh my -- sitting on the patio, eating peanuts and drinking wine and laughing for hours. It was heaven. And here's the absolute best part - she loves retirement. Isn't it great? And yes, Karen's still good for a flash. Throw me something, mister.

Clever Title here....song lyric I think....

I should be studying, so of course it's a perfect time to blog. I also need to go to the grocery for cat food and put towels in the dryer. Yes, perfect.

I sometimes jot down little things to blog about on the back of an envelope when I'm in class or leaving yoga, whatever....I did that this week and then lost the envelope. And let me tell you, it was some clever bullshit this time. Including the weird title, which was some song lyric, I think from the new Shins album. (BTW, they are coming to ACL. I looked at the lineup a few days ago, and wow, it is really something this year.) I've been listening to their new album on my Nano at the gym, and I have to tell you James Mercer really is quite a lyricist. Some words he puts together truly take my breath away. I think the title I planned to use was something about bridges engulfed in flames....you know, burning your bridges....something about not getting what you expected. Anyway, imagine that I put it up there.

One of the things on my mind has been this Chick-fil-A controversy. I posted an invite to my Facebook female friends to meet up and kiss last Friday and one of my "friends", a long-ago coworker, a conservative guy that I haven't seen or talked to since 2005 (yes, not really a friend, huh?), posted this as a reply "Now that's classy." I wasn't sure how to take this -- but I'm pretty sure it was an insult to me, saying that my proposition was uncouth. Well, I read this right before I left to drive to school so I got to ruminate on it for my 30 minute drive. I came up with so many clever ripostes. I'm so good at thinking of snappy retorts after the fact, when it doesn't count. Here's some, I had at least 6 on the envelope.

• Oh, "Joe" (not his name) -- you can come too and watch. I know you like that. 
• Yes, being a doormat to bigots is much classier. 
• Why yes, Joe, you get it! It's a class session type thing -- look, Chick-fil-A, here is reality, same-sex couples exist and kiss in your store and deserve the same civil rights as other people. 
• Classy? Boy, if you are looking for class in my FB posts, you're on the wrong page. 
• I have lesbian friends. They are classy. You, Joe, are not. 

I was talking to a friend about the whole Chick-fil-A thing yesterday over lunch and he brought up an excellent point. This is all a manufactured controversy. The media is sticking it in our faces. The CEO is a known religious bigot, and he was speaking to a Southern Baptist group when he made his hateful remarks. That's nothing new. The media whipped it up. And look at all the profits the company gets now. Not OK. But I can tell you this, I won't ever purchase their products again. 

Nile has his black belt testing. This is the first stage, the provisionary or probationary, or something. But the belt is black and that's what counts. He was supposed to test Saturday but woke up sick. Drag. Now he has to wait for October. This is a huge deal. He's been taking Tae Kwon Do since fourth or fifth grade and has had to basically start over twice when we moved and he changed styles because the schools are all different in parts of the country. This last time has been the worst -- he was a senior red belt in NJ, and was six months away from black belt when we moved. It's taken him 2 years to catch back up. He had to re-learn every form. 

My class is still interesting. Our lecture this morning was on attraction and love. Some good socio-biology (and just plain ole biology too). Here's an interesting tidbit: there is a known phenomenon called misattribution of arousal. When we're physically aroused (by lots of things -- it can be fear, exercise), if we encounter a suitable partner (that is, someone within the framework of who we deem as acceptable in terms of age, gender, ethnicity, social status, etc), we are more likely to be attracted to them and pursue them. In fact, some theorize that we often mistake a good sex partner for love that way -- we're aroused and we start down the romantic path. When the truth is, we're just aroused. The professor suggested that we do active things on first dates - go jogging, for example. That is, if you want to activate that pathway and start down that road. I guess if you want a one-night stand (like Ryan Lochte's mom advocated), you should avoid that. Including no swimming. Ha.

I'm very much anticipating next semester, which will be the most challenging and most critical of grad school. I've applied for two clinical positions, one is at the University Counseling Center working with eating disordered clients (definitely an interest of mine), the other is working at a private therapy practice. They see a variety of clients and work on sliding-scale fees, but here's the kicker -- they are on Bee Caves Road, down the street. Yes, can you say "10 minute commute"? I'd be super happy with either of those. But before the circus starts back up, Ken and I go to Baton Rouge to see Karen and then up to New York to deliver Dani to NYU. Oh, and I'm working two days a week for the next two weeks. Some fun stories to come!

I'm going to close with two fun photos. One is Crabby, all tucked up in bed. Yes, I'm sorry you're jealous but I have the cutest cat in the world. The other is me at Vino Vino, our favorite little bar, Ken took this. I look tired, but that's because it was Friday night and I am tired by the end of the week. Hey, my life is hard! The other day I had to spend at least 10 minutes getting leaves out of the pool before I could swim laps after a hard day of attending my sexuality class that morning. The yard guys had come that morning and a few things ended up in the pool. And the pool guy only comes on Thursdays. It's rough. 

Wag more

I have a lot to talk about, a lot rattling in my brain. First, important thing in my life: I ostensibly switched gyms. Gold's has an on-going problem with the employee scheduled to open at 4:00 not being on time. Well, about 3 weeks ago, they opened an hour and 20 minutes late. I was fed up. The problem is that the nearest alternative is 15 minutes away and it's thru a very bad Austin intersection (the "Y" as we call it). But I decided to give it a try after all - they have a great pool system, and I miss being able to swim in a nice long lane. This new place cost a lot more - and they purport to be the Taj Mala of gyms. Turns out they were more focused on style over substance; the locker rooms were beautiful, plush with lovely dark wood. The kicker for me was the uneven quality of instruction in spin, yoga, and zumba. People complain about the robotics of Les Mills programming -- but I'm here to tell you, it's not always good when you allow individuals creative control. I made a list of the objective problems I observed (no, I didn't say the yoga instructor on Friday at 11:30 sucked, but she did) and sent an email to the manager -- things like the spin bikes are in poor repair (even the instructors complained), the glute machine rails are damaged and the mechanism sticks, there's only 2 neck pads for the squat bars, etc. He thanked me and then did nothing. So a week later, we cancelled. I'm back at Gold's. Occasionally I will have to turn around and come home to work out. I accept it.

 This obviously mentally-ill shooter in the Colorado theatre has me thinking about schizophrenia and how widely it presents. I worked last week and had two schizophrenic young men assigned to me who couldn't have been more different. One was the classic negative-symptomatic guy: very silent, very low energy, dirty and unkempt, made no eye contact. His roommate, on the other hand, had many positive symptoms and although this is rare, his auditory hallucinations were positive. He giggled and laughed to himself at odd moments all day. But he also attended group activities and came out of his room. I had a conversation with him and he was fully lucid and had some grasp on his problems and his prospects (insight, as we say). Some of my classmates and I had lunch yesterday with a woman who's a PMHNP (Psych Mental Health Nurse Practitioner) already in practice (she's actually the mother of a classmate, and she's a professor at the Nursing school in UT-Arlington). I asked her two things: what were some of the hardest things when you first started practice, and what extra stuff should we be doing/focusing on now? In answer to the first item, she said, working with schizophrenics. Guess I already knew that - based on what some of the psychiatrists have said at work.

I went to a musical with Cathy, we saw Chess at the Austin Playhouse and really enjoyed it. Yes, it's that play with the song "One Night in Bangkok" that was a late-80's hit. It was well done and in quite an unusual setting - a big tent. In July in Austin. It was hot at first, but they did an excellent job of coping. Apparently they are building a new site.

I'm still attending my Human Sexuality class. It's quite interesting usually. I have been pretty silent because I'm uptight about being seen in a motherly role to my classmates - I mean, nobody wants to talk about sex with your mom around - but I decided that was kind of silly and when we covered the chapter on adolescents, I did talk about having "the talk" with my teens about contraceptives and STI's and handing over the big box of condoms. There's definitely some folks in there who have a streak of exhibitionism though. When we covered the unit on sexual orientation, one young woman (with a really impressive shoulder tattoo, I sit behind her) felt compelled to tell us that her lesbian lover has a thing for gay male porn -- because she just wishes she had a penis so badly. Yep. Really. You should have seen my professor's reaction. It's fun, I think I'm finally relaxing and enjoying the class. The topic of abortion and gender-selecting the fetus came up and I found that I was the only one in the room that knew some of the laws around that, so it was nice to offer a little education (I'm sure my pro-choice bias showed, but so be it). One of the guys grew up in boarding school and mentions some of his experiences. Sounds like it was a good place to learn bad information (ha).

The DeMouys came to visit from Baton Rouge and we bowled Wednesday at Dart Bowl and then had a pool party the next day. It turns out Laura is going to honors college at LSU - which is great for them, she actually went all over the country checking out music schools (this is a young woman who was in all-state band). In Louisiana they have something called TOPS, it's a program that pays in-state tuition for the very best students in an effort to keep the smarties in Louisiana, so Laura gets a free ride. Guess a Hawaii vacation's in their future - ha.

I learned this really cool manicure technique off Jezebel - my favorite web site next to NYTimes - it's distressed, shabby chic nails. Very cool, you just need fabric paint and regular nail polish. And since I can do it myself, I save $35 a week.

Bumper sticker seen on the way home from the Animal Shelter: Wag More, Bark Less. Indeed.

Semen

Dani had a party. Here's some pictures. She invited mostly 16 to 18 y.o. girls and it was a pretty good time. Her NJ BFF Idil was here (that's them - the two little white-bread suburban princesses doing a gansta pose). Only one tiny hiccup -- one of the girls had an older brother come along - who showed up with 3 friends and proceeded to hide a 2-quart bottle of vodka behind the pool. Ken observed this and rectified things. Problem averted.

I bathed Morris, our old kitty. I had bathed a cat at the shelter with a blind woman (a fellow volunteer - she did most of the work) so I felt like I could handle this. He smells much better.

Summer school is half-way done. I've started the second session and it's not exactly what I expected. I'm in a class with a bunch of really young ones (all undergrads) and it's a little painful. This is the human sexuality class. Today we did an exercise on the scripts that we have for how sexual relationships progress and it was obvious that none of the volunteers for the exercise have ever been married -- or maybe that was my interpretation, it is possible they were presenting the "ideal" to the class. But seems like they had this fairy-tale expectation. Once you've lived through a few marriages (and especially had a few teenagers), you feel much more relaxed and nobody needs to follow a bunch of rules. I guess it rubbed me the wrong way. Judge for yourself -- here's what the group of class volunteers (about 10 students) produced.

Meet and agree to a date
Date 1 - kiss
Date 2 - fondle
Date 3 - fondle more and start conversation about sex, including contraception
Date 4 - oral sex
Date 5 - intercourse
After Date 5+ - say "I love you"
After Love - meet the parents
After Parents - get engaged
After Engaged - marriage

You know, when I look at that now, I think to myself, that can't be what these kids are actually doing. One of the guys had the energy to suggest that intercourse be moved to date 2 -- he was voted down. Hey, at least he's being honest about what he wants, right? But the outcome is so....predictable. I bet if it was a bunch of 50 y.o. women up there, we would've come up with a little different answer. I couldn't rubberstamp any specific timeline to be honest. People aren't like that - we rebel against that.

I've worked a few days. Friday I got to work with my favorite two guys - Curtis and Gilbert. We had a woman on the PICU that was very manic. You know, I'd never seen someone truly manic before I started working here. It takes some getting used to, you need to grow a thick skin for one thing, because they usually are saying a lot of things, and much of it isn't nice. I actually wrote down a sequence of what she said, just one interaction that I had with her. It was how we started the day together at about 7:30 am, I came out of the medication room and she was at the dutch door. Here's what she said. "I need a shirt and toothbrush. I came in last night and I can't find them. And don't try to give me that toothbrush you guys have - I need my special brush that I use with my organic toothpaste. Oh, but you can't give me that, can you (makes a face and slaps her hands down loudly). The class-action lawsuit that I've filed will take care of that, you will just see (voice is rising). You're looking at me like I'm dumb, but I'm not, my IQ is 1000 so we have a communication problem and it's on you, bitch! (I start to turn away at this point). Hey, when you come back, you need to wipe semen off me."

That's really what she said. About 10 minutes later, in the med room, Gilbert asks me, "Hey, did you get that semen wiped off yet?" And I did look into getting her a warmer shirt and her toothbrush. Just because she's manic doesn't mean that she doesn't have legitimate needs.

Really Crazy Side

We added someone to our family. Meet Morris. He is a forlorn 13 year old cat that we took home from the shelter. I'm already in love with him, Ken hates it when I say that (you can't love something you own!). But he's so sweet tempered, and so skinny and in need of good lovin' and a hot meal. When we first brought him home, he was vomiting and eating poorly and was incontinent. So we spent a lot of money at the vet to find out that a) he's not in kidney failure, and b) he doesn't have cancer. They ended up scratching their heads and giving him a whopping antibiotic shot and IV fluids over 2 days. And it worked. He's so much bettter, we think he'll make it. By the way, Crabby hates him. Really. Turns out she's not a meek, mild little girl after all. Why doesn't she hate Mitt, my sister's big ole boy kitty? I don't get it.

I've worked a lot the last month, it's been been mostly routine. As much as a psych ward is routine. Very few emergency injections, I think I gave only two, and one of those was a big learning experience. We had a young 21 year old woman, very slight, she weighed about 90 lbs. and she had a little freak-out that involved pounding on walls and screaming. She clearly needed sedation. One of the docs (not her assigned doc) was there, so we quickly got an order and did it. Within minutes, we put her to bed. But later, she stumbles out and almost falls. She's very pale, we take her blood pressure and it's scary-low. We force her to sit up and drink fluids, she's able to respond to questions although she keeps asking to be put back in bed. We call the doc and he says to force more fluids and assign a watcher so she doesn't fall. And he was mad -- the thorazine dose was much too large for someone so small. We repeated this little event a few hours later. Important lesson-- dosing is important, and ask about the patient if you don't know them. Overall, this is a lesson I'm familiar with: Don't be in too much of a hurry. Check it out. We've had a lot of younger patients, many college students, who got in trouble with drugs. That stuff they're selling called Bath Salts or Spice (synthetic marijuana) is really lousy crap that needs to be illegal. You should see how kids behave after ODing on it. And how long it takes (ever?) to return to normal. I think they've permanently damaged their brains. Makes me mad.

Conversation overheard between two patients starting to make an acquaintance: "How long have you been here?" "Oh, three days, they just moved me over from the other side (meaning the PICU)" "Oh! Isn't that the really crazy side?"

Class is almost over, it ends July 5th and it feels like I just started. It's been shockingly easy, basically show up, do a little reading, write a few paragraphs each week and do one group project. That's it. Wish I could've knocked out two nursing classes like this. I start Human Sexuality after that. If that's not a fun-o-rama, I'm going to feel cheated.

My class is on Healthcare Policy, and it's actually quite interesting and I've learned a lot. It's inspired me to become politically active, so much about healthcare needs to change. I'm going to attend my first PAPNA meeting on Wednesday, that's the Psychiatric Advanced Practice Nurses of Austin. So next time, I'll talk a little about that.

And It Starts Again

Started summer school Thursday. Feels like nothing really ended, but that's OK. The class, on Healthcare Policy, appears to be very manageable. I'm even planning to work about one day a week. Enjoyed my review class in Boston, although I'm very angry at Expedia and will never, never use them again. I paid for my room, at $440 a night, at the Boston Sheraton because that's where the course was held. I paid for this 2 months in advance. Friday night before I leave on Monday, Expedia tells me that due to a "system error", they have to move me to a hotel 5 miles away. I talked to them for over an hour, spoke to the supervisor, to no avail. The hotel contact really wanted to help, but they were having a telecom conference at the same time and were completely booked. She said that Expedia does this all the time -- they oversell their rooms and then move people. So if you care about where you stay, don't use them. 

Nile and I have had some good times at the Austin Animal Center performing cat care duties. Here's Nile with "Noisy" as they named him. He is a tiny kitten who can't bear to be away from people & will cry and fling himself against the bars when left alone. Someone really lonely needs to adopt this little guy. We clean cages, talk to customers, feed cats, and of course, play with them a little. It's great. And they really need cat volunteers badly. Seems like everyone wants to work with the dogs. We are thinking about fostering some kittens, we got an email Friday that the shelter is "negative 8" for cat space -- meaning, eight cats are sitting in carriers because the cages are full. Look at these statistics (shocking): in May 2011, the shelter took in 750 cats. This year, we took in 1000. Something is terribly wrong with that and it points to a serious spay/neuter need in this community. I know that Austin offers this service free, but obviously people aren't utilizing it. I wonder what we could do to make it easier and more accessible? 

Dani graduated. Here we are at her graduation party. She has a summer of nothing ahead - well, nothing required, let's say. Idil will visit, she's going to Houston for a week, and we've talked about her taking a nurse's aide training class, but it's a lot of time relaxing. We bought tickets for the NYU delivery in August, we'll spend about 3 days in the city. (that's what they say up there in Jersey - "the city". I'm cool, I know the lingo. ha.)

My good friend Karen retired early from XOM so I'm going to Baton Rouge at the end of June for her party. I'll see some people I haven't seen since I left in 2005, should be interesting. My life is so radically different now. I'm a nurse! I'm a student! And I'm so lucky - I live in Austin!

I've worked a lot in May. I've had two patients with interesting cases - one has Renfield's syndrome, which if you look up, is clinical vampirism. Yes, he believes he's a vampire, namely he receives sexual stimulation from consuming blood from his partners. And he really looked the part, I must say that he put some effort into that, down to the blue nail polish. Won't say any more to preserve his anonymity, but this is the first case of this I've observed. The other patient was someone who we first believed to have squeaked in through the cracks - we are not a forensic unit, meaning we don't take patients who've committed crimes as part of their recent hospitalization, but we certainly have a gray area around that. For one thing, they can be under investigation but not charged. And we have many patients with a criminal history - every day I'm there, at least one patient has a tear-drop jail tattoo on their face. So this guy was under suspicion of killing his wife, then making a suicide attempt. Last year, I had a patient with this exact same scenario (who ended up being convicted) and both of these guys had a very similar affect -- they were wooden, dead, "flat" in our terms. How are you today? "fine". Are you feeling suicidal, as you were when admitted? "no". Have you attended group therapy and found that helpful? "no". Tell me why you haven't gone to that. "don't want to." And so it goes. Eventually you give up. Later, I was told that murder charges weren't going to be filed against him, just domestic violence ("just") although that could've caused the death. Not a good, solid endorsement.


I've been able to swim almost every day now - it's divine. Ken and I walked the Lakeway trail last night and the little streambeds are all full of water. Vastly different from last year. Cross my fingers that it continues.

May

The semester's over and I have a little time to do less and not be burdened with constant thoughts of "oh, this is great, but I should be studying...". I've worked a few shifts and will work some more. Friday I was on the   PICU, so the fun really started.

I was driving home from my last clinical day at the pediatric clinic and was listening to Fresh Air. You know, Terry Gross on NPR, station WHYY (that was my station in Jersey). She was doing an anniversary show, a "best of" and it was good. Nick Lowe sang his song, "What's so Funny about Peace, Love and Understanding", a song I've always liked, mostly the Elvis Costello version. And I had just read an article the week before -- Nick gave a concert in town, and he did an interview with the Statesman, talked about that song in particular. I think this all happened on the day that our President came out and stated his support for gay marriage. I thought, wow..... not a coincidence. I mean, that's what always, always pops in my head when people make bigoted remarks about the civil rights of the LGBTQ community -- tell me, exactly what's so funny about peace, love and understanding? Because make no mistake, that's what we're talking about here. You can stand behind your book all you want, but I notice you're not doing it for some of the other topics in that book, like trying to bring back stoning. So. Let's reelect this guy, alright?

I got sunflowers and chocolate-dipped strawberries for mother's day. And I got to eat some of them this year, Dani held off until I got home. Ha.

The last 3 weeks of school were hard. I found myself thinking, why does this feel worse than the stress of work? It usually does, I guess I can think of a few work-related times in my life where the stress was higher than school. Is it just all in our heads because it's such a discrete unit of time, a semester? I think that's a big part of it, but it's also the artificiality of test-taking. In the real world, you're tested every day, but it's not something that you can usually go home and cram for in advance. Now, I do expect to be looking things up and consulting others in my off-hours the first year (maybe years), but still. I wonder if nurses that sign time-limited contracts (a lot of travel nurses do that) have a similar experience. And I have to tell ya, I'm a little ticked off. I got an 89.9% in Pharm -- that's right, I squeaked out an A in my pass/fail class.

Nile and I are volunteering at the Austin Animal Center and had our first working shift last week. I picked him up from school and headed over. We were in the cat house. The day before, they were all over the media because the shelter was way past capacity and appealed to the public to please come adopt a pet. They stayed open til almost 10:00 that night, and I heard that over 100 animals were taken from the shelter - at first I was excited, that's a huge number of adoptions, but then read the fine print and about half were foster families. So those animals are coming back. So, if you're reading this and you live in Austin, think about adopting a new pet. They've slashed the prices, all animals over 1 year old are free -- and they come neutered, microchipped and fully vaccinated. Such a deal. That's where we got our sweet Crabby, about one year ago. Here's a link: GetAPetNow

My sister was invited to the White House and was there on May 7th. She's worked at Texas School for the Blind and Visually Impaired almost her entire career, she currently teaches math there. (yes, she really teaches math to blind kids.) She nominated a blind chemist for an award and got to attend the ceremony. Here's a link: STEM Innovators

So here's my interesting experience from work on Friday (details withheld/changed to protect confidentiality). One of my patients was a young woman who's had schizophrenia for about 7 years. She periodically goes off her meds -- she starts feeling normal, starts thinking she doesn't like the side effects (which are significant) and stops with the pills. (I always think of Billy in Six Feet Under, when his relationship started with Claire, and how he started doing the same thing. Throwing his pills in the toilet because...well...he was in love and just felt so good. Who needs drugs?) And of course, the delusions start intensifying, she stops paying attention to things in life like job, friends, eating, etc. and then she's back with us at the hospital. She's a frequent flyer, as we say. Her delusions this time were quite specific -- the weather is causing her schizophrenia, so she was focused on getting all her medical records since diagnosis and getting weather pattern records and carefully correlating them. I asked her -- then what? And I guess that was a mistake, because she absolutely crumpled. She became so tearful, so hopeless, so lucid  -- she suddenly realized the futility, that no matter what she can prove, she'll still have schizophrenia and she's never getting better. That's exactly what she said. I tried to talk to her about getting back on meds, how she'll feel better, things aren't hopeless, but since she's off the meds now, none of that sunk in. And to be honest, she's right. She's not going to get better. Schizophrenia is always a decline. And the meds are horrible. They're better than schizophrenia - but the personal price is terribly, terribly high. Tears ran down her face and I just stood there telling her I was sorry. And she wouldn't take the medication in my hand either. I think we talked for 30 minutes before I gave up and asked Gilbert, the charge nurse, to take over. He was a little more directive (and he's a rather imposing man, that counts for something) and she took the med from him. But I have a lot to learn. And these are my peeps -- the chronic mentally ill. I prefer working with them, because any little bit of help you offer to move an inch forward means so much. So I just hope that a year from now, I feel better equipped to deal with them.

Cinco de Mayo

Last week of classes. And I've been sick for two weeks. Started with a rather bad URI (upper respitatory infection--a cold) and then turned into a sinus infection. I waited too long to see the doc, I had to leave school and go to an urgent-care clinic on Thursday. It was a good reminder to me of how bad "just a cold" can feel, and how absolutely lousy it is when you get a secondary infection. (Never again will I scoff at all the UT students who run to the clinic two days after they get a cold.) Also I really should've paid attention to the day count -- I know that if you're still sick on day 10, it's turned bacterial. But I needed a lesson. And one lesson is that antibiotics are the best stuff on earth when you need them.

My darling daughter is graduating if she can tamp down on the senioritis for one more month. I put together some pictures for a slide show at her party, here's one from Baton Rouge and another from winter formal. She's a big girl now. And next year both of us will be in college. The past 3 weeks have been really challenging, on one day I turned in 2 papers, gave a presentation, and took an exam. Glad that's not the norm. This week I just have 3 exams and 2 presentations. Ha. Really, no kidding.

I'm working some in May as an RN at the psych hospital, so interesting things will happen and I'll have some musings to report. I tell you, I can't wait to get my hands on those MARS and look at the meds with my newly-educated eyes. And talk to the psychiatrists about med choice, like take Risperdal. That is one dirty drug. It's top of the list for nasty side effects in every category -- why is it prescribed so much? Is it cheap? Super effective? That wasn't obvious to me from my lectures.

Summer school starts May 31. I'm taking Healthcare Policy first, then Human Sexuality. Gotta have a little fun. Crabby is no longer a kitten - she turned 1 on May Day. It was wet food all day long. And Ken and I have 23 years together on Cinco de Mayo, so some margaritas will be consumed. Nile and I are volunteering at the Austin animal shelter, we orient on Saturday. Tomorrow night is the Roger Waters concert of the entire album of "The Wall". Typical busy May.

I mentioned in my last post that I heard on NPR that 1/3 of the people in Who's Who have lied about their military honors - that is, claimed those honors and actually were not awarded them. Some did not even serve in the forces. I was astounded at that - seems patently ridiculous, does it not, that someone would put on display in a database/book (whatever it is now) such a bold-faced lie that can be easily checked out. In my line of work, I often think about the line between truth and lie, between fantasy and reality, between what we wish and what's real. Dani and I recently talked about how we lie to ourselves when we want something badly. In class, this came up in lecture last week, and my professor (who is really good at therapy - I mean, I could sit at her feet and just watch for days) said it in an interesting way. She said that you take the truth that the patient chooses to give you at that time. But their truth will change as they open up to you. Be willing to see the change. Here's a link to an interesting NPR story about this, a different story - more specifically about fraud.
NPR fraud story

The gym is still fun-o-rama. We're doing a new "release" in spin and the lead-off song is that awful infectious thing about moves like Jagger...ick, I have to hear it every morning at 5:30 am. I am about to punch someone. Let's see Jagger do that move. One good thing (the absolutely only thing) about being so sick was that I missed 4 days at the gym so my hip now does not hurt.

Not G-Rated

Warning: If you're prudish, you should stop reading now. Ken and I went to AIDS Services of Austin's Art Erotica fund raiser. This is an annual event, very Austin, where erotic art is displaying and bid on. All the money goes to the Kirby Fund at ASA, which provides funds to people with AIDS that are in a financial crisis. It's such a worthy cause, and let me tell you....so fun.

I've displayed some pictures here. But here's the scene: a large empty warehouse, dark, techno throbbing beat, with fences all along at different angles, art hanging on them. There's dancers up on catwalks and the cutest young gay guys serving drinks on platters -- all they're wearing is tight little briefs. Big bar in the middle, your ticket gives you unlimited libations. The art is so wide ranging....some of it quite amateurish, some so sophisticated, some absolutely filthy, others abstract and refined. It's a treat to dive in visually. And -oh- there's some aural stimulation as well. There's a big booth on one side where you put on headphones and listen to someone's erotic experience as a performance piece. At the end, you get a little card that explains what was really happening as you listened. It's designed to allow you to experience erotica without visual input, which is not what we usually do. I enjoyed that. I think ASA's young people's group (called Q? or something like that) put that on. There was also live art taking place - three tableaus of models posing, with an artist painting or drawing their likeness on canvas. No pics allowed of that - too bad, cause it was pretty arresting - but one thing did rather irritate me. So the women are nude, right? But the men - nope, they've got their business covered up in a teeny-tiny g-string. This struck me as sexist, but then later I thought, you know it may a legal issue. You know how it is - the authorities are soooooo fearful of women's sexuality. We see a penis and we totally lose control.

I was thinking about how much of my life is not G-rated. As a nurse, and especially as a psych nurse, I am privy to the most personal parts of people, the parts that we hide from everyone else. Things as simple as showing me that rash on your groin that is really bugging you, to talking about the funny uncle that touched you inappropriately and now you keep having nightmares about him. It's so interesting. What I was born to do. I can speculate about why, but the core is that I've felt different than everyone else my whole life and finally, I truly appreciate it and embrace it.

I have more to talk about, I will do that when I get this week done at school. I am so busy my brain hurts and I feel guilty about writing this post but didn't want to wait. I read a super-interesting article about how 8 mentally-ill people in Austin accounted for 2700 ER visits over a span of 6 years. Can you imagine the cost of that? That's no typo -- only EIGHT people. It's incredible and points to a severely broken system. Also, weeks ago I heard on NPR that 1/3 of the people in Who's Who had lied about their military honors. So I thought I would write a bit about both of those topics.....so much there to ponder on. But next time.

Enjoy the pics. (Not you, Dani).

Downhill

Mid-semester has passed, I can feel the momentum of racing downhill. And yes, did a little of that Sunday at the Capitol 10K, the 35th annual event & the fourth largest 10k in the US. It was fun, kind of hot, but no complaints. Ken and I cheated a little and actually veered to Lady Bird Lake trails near the end. It was just so shady and nobody on them. We weren't timed anyway. After that, we had a big family lunch (excellent Thai food) at Holly's house, my aunt Pam was in town.

I've got two big projects left, well I guess it's actually three. Two are papers and the other is being videotaped while I do a psychiatric assessment of a "patient" (really a classmate). Tricia and I are doing this together, we take turns playing the role of the patient. We read a secret script of a patient with a particular disorder and we get to impersonate them. It's not strictly scripted, we choose how to respond, and we have to demonstrate an understanding of the disorder and its manifestations. But ick...who likes being videotaped? I have managed to settle my nerves by thinking through how much of this I've done in real life as a floor nurse on a psych unit. It's a standard routine for new admissions, and that actually was one of my favorite tasks.

The other projects are a health assessment of a family, which was quite complicated, it involved interviewing someone, drawing diagrams of her family health history and analyzing the psychosocial functioning of their family unit. Plus identifying a health problem that they are willing to address and developing a plan. Anyway, it's 20 pages long (really), with 3 attachments. The last thing is a paper and presentation (with a partner) on the new cervical cancer screening guidelines and how best to explain them to patients. The new guidelines actually decrease most women's screening to less than annually, and I've seen some patient reactions in clinical - most aren't very happy about the idea. So the assignment could have some validity - it's a difficult thing to explain the science behind it, and takes some finesse.

And there's the day-to-day fun. A pharmacology test every Thursday, other tests sprinkled in, yes like jimmies on an ice-cream cone. I actually ....gasp.... got a 100 on a pharm test. I really had decided that he just didn't give that as a grade. But I'm still taking it pass/fail. And there's the big group presentation in my research class. The topic my group chose is pain management in post-cesarean section women and an association with post-partum depression. Let me just scream now --- I hate group projects. I don't mind things with a single partner, but our freaking group has seven people. Yes, that's not a typo.

Clinicals are still the most fun on the block. I just wish they didn't take 14 hours a week to do. I have Peds now on Fridays, and I'm paired with a Pediatrician (a physician, not an NP). I have to say, she's great. She's young, just graduated last year, couldn't be more helpful. At the end of our first day, I hugged her and said I wanted to give her a best preceptor award. (yes, I hugged a doc -- ha) We see patients at a community clinic, most have no insurance and are covered under Medicaid. I got to see coxsackie virus on the first day. And it was an amusing day at the University Health Center after Spring Break - literally two days after the kids returned - they were all sick as dogs. I mean, no sleep, too much sun, too much beer... I think I saw Sherry hand out antibiotics to every single one and she never does that. It was highly instructional -- like, this is what happens when you're stressed, you compromise your immune system, you have a tickle in your throat but you go out all night anyway...yep, this is what you get. A monster sinus infection, strep throat, a terrible exacerbation of asthma, etc.

I've got my summer lined out. I'm taking a required nursing class first, Health Policy. Then I get to take my elective, and I am still researching that. So many choices, it's just way cool. Things like the psychology of health in AIDS patients, human sexuality, deviant behavior, the advertising of health promotion, etc. But before all that starts, I'm going to Boston for two days for a review course for my board exam. I know, it's a year early, but it gives me a heads-up on what's important this last year. And what's really valuable is the manual - I can then study that whenever I want to start, I'm not dependent on scheduling of a live class.

So I'm going to leave with a cool quote I got from a fellow nurse at a lecture.

Philosophy of Sharing Ideas (K. Kirksey)
A large group = culture
A small group = cult
2 people = love
1 person = psychosis

ha!

Catching Your Breath

It's almost Spring Break and I can't wait to have some unstructured time. It turns out that I'm going to write 5 papers. Really, yes, five of them. Two are fairly straight-forward patient write-ups like I will do with an acute-care visit as a real NP (it's basically all the documentation that's done in the chart), but in much greater detail. Like, 5 pages of detail just for a sore throat. But it's all good, one of my papers gets to be on Carl Jung's Red Book, and I actually ordered a beautiful replica of that off Amazon as a visual aid. I've been interested in Jung for years, when I first heard some lectures about him at the Unitarian Church in Baton Rouge. A truly great church that does incredible good work (the atheist says).

I'm starting to inhabit my role as an NP student. I realized today at clinical as I was introducing myself and examining patients that I really feel completely comfortable doing that now. Last semester, I felt a bit like an impostor in that white lab coat. I've had some excellent role models and teachers, and that is really what's made the differences. I do like most of my classes, but the clinical -- it's just plain fun. I so look forward to it. I'm going to end up doing extra hours because I have Pediatrics yet to start, but hey -- it's only going to help. I was reminded today that I have a privileged role in the full arena of human experience -- which is to say, sometimes awful things happen. I mentioned a child with leukemia in my blog months back, well I found out today that the child died. I was shocked because childhood leukemia has become an eminently treatable condition - I know the cure rate is over 90%. But not everyone survives.

Even though my clinical experiences are not in a psychiatric setting, I still see patients with mental health issues. I learned something valuable Tuesday when a young man came in because he's training for a marathon but having strange shortness of breath spells. His assumption was that it's related to overtraining. He described his HPI (history of present illness) to Sherry, and she immediately asked him about recent changes in his life and his stress level. And sure enough, he'd had a terrible loss recently and these breathless spells were anxiety. Now it took her a while, probably 15 minutes of quiet conversation to elicit that conclusion, but she pretty much recognized it right away. Afterwards, when we de-briefed, she explained to me that his breathless spells were happening when he was still and quiet, and able to think about his loss. He was having no symptoms at all while exercising. She said that in her experience, many people having severe anxiety of this nature for the first time in their lives will present in just this way -- feeling like they can't catch their breath when they're still and their mind starts turning over the problem. A big learning for me.

Some random things that I find interesting/amusing: there is an entire section in my psychiatry book on what they call the "drug-assisted interview process". Yes, they are talking about truth serum. Just like from the 1970's spy movies that I watched as a little kid. I have to say I was pretty dumbfounded reading this - I mean, I know that trying to ascertain exactly what's true in what a patient tells you is difficult - but really? We need to do that? Somehow, I'm pretty sure that won't be part of my practice. The UT campus went smoke-free on March 1st. I know -- it's 2012, I wonder how many places are left in America that aren't smoke-free. There must have been a powerful regent that smoked is all I can assume. Even psychiatric hospitals have been smoke-free for years, and believe me: those patients all smoke and one could argue, need to smoke when they're hospitalized. Can you imagine dealing with all your demons, maybe detoxifying from alcohol and drugs, and you have to quit smoking at the same time? I keep having these nifty little memory-lane experiences around campus. I met with a classmate to study Pharmacology (and by the way, I have an 89 in that stupid fricking class now. I will not let myself make an A in that thing) at a little coffee shop on Lamar. I drove by the little dog-leg intersection where Lamar meets San Gabriel -- and I immediately remembered when I burned my leg on the back of Bret's motorcycle on the way to class right there, back in 1983. He had to yield there quickly, and my leg pressed against the tailpipe. Ow. This happens a lot -- I mean, those were memorable years and it's just weird to be back now.

So one last thing: if you wear those cool canvas Toms shoes that all the young hipsters have now, wear socks. They really make feet stink. Summer's going to be fun.