Ready, Set, Go

First week of classes completed. I'm feeling better about this semester, no surprise I guess, since I know what to expect. My clinical hours have doubled (gulp!) but I expect to be able to handle that. One good thing is that my big clinically-oriented class (Primary Healthcare Concepts) has two papers instead of a weekly quiz. Papers are my strong suit, I did so many of them for my on-line BSN classes. And I finally have a psych class. It's Intro to Counseling Skills and the professor is the woman mainly in charge of the Psych NP program, she'll be teaching the majority of our classes next year. I was anxious before the class (what if I don't like her? don't respect her?) but I liked her a lot. She made funny little remarks about psych things - (oh, tell me what you mean when you say that), she was relaxed, and I thought her presentation was smart. It's a group of only eleven, so it will be cosy and like a little family. I can only imagine how well we'll know each other by the end of this thing -- ha. So far only one person kind of bugs me & I can handle it. 

My other classes - Research and Pharmacology - appear to both be taught by excellent instructors. The Pharm guy has been nominated for a teaching excellence award & I see why. First class was fascinating. He encouraged us to take the class for a grade -- not pass/fail. I'm debating what to do. I gambled wrong last semester & gave up my A points on Pathophysiology. Really don't want to do that again, but OTOH, I don't want to be any more stressed than I need to. My research class will be a social experiment. We were assigned to random groups of 6 students (big class - 50 people - all nursing grad students have to take it, not just NP's). I had never met any of the other 5 people in my group. We have 2 big projects to do together. Who doesn't loathe group projects? And I really think 6 is too large for a group. I hope I don't have to discover new things about myself but I bet that's how the social experiment plays out.

It's been interesting to think about transitions this week. Beginnings and endings. On Thursdays, I have another long killer 12-hour day at school, but I do get a break from 2-4. So I decided to revisit some significant places on campus that I had not seen in 26 years, since I graduated in 1984. I haven't done much of that yet because I didn't have a long enough break in my schedule & seems like I was always in a hurry to zip home. I walked from one corner of the campus (the nursing building is across from the Erwin Center) up to the women's co-ops, where I used to live (across from Kinsolving dorm). Let me tell you, it was one of the most intense emotional experiences I've ever had.

Memories just flooded over me, it honestly felt like I was back in time. Let me try to give you a flavor. I passed by the business building and remembered when they tore down the old hall across the street. We lay on the grass and watched the wrecking ball hit it. I passed by the lawn of Batts Hall and remembered when Bret taught me how to whistle with a grass blade between my thumbs on a break between classes. I saw the computation center and remembered my job as a freshman at the counseling center (see? even back then, I knew what I wanted to be when I grew up -- ha). I had to carry card decks of computer data to the center for processing. I walked by the big rusty communications building - still rusty - and remembered the day my boyfriend left for Germany and I was crying on my way to class. I ran into an old roommate in front of that building and had to explain why I was crying. Anna Hiss gym - laps and laps and laps in the pool, then hurrying home to the co-op for dinner. The Academic Center reminded me of many hours studying with Lori. We went there because we'd fill out a slip to request albums we'd listen to with headphones off reel-to-reel tape. Little different from an ipod. The Union reminded me of seeing concerts there - like Joe King Carasco in 1982. The Varsity Theatre is gone (most of the mural is still up); I watched a lot of art films there. And finally, I got to the co-op where I lived - Shangri-La. They have some silly name now, "Living/Learning Center". I couldn't go inside, all the doors require access codes (security is much tighter on campus these days). The big live oak in the courtyard where we did so many things - like our chili cook-off - is so huge. The back steps are still there where Kari and I would smoke clove cigarettes in the evenings (we were so cool). The tower chimed - same tune. Wow. It's all still there. It's such a privilege to be back.

P.S. to last post -- something important I forgot to mention is how important our guts are to our immune system and to healthy metabolism. There is a lot of research focus right now on the gut and the "good" bacteria that live there (natural flora). Some research shows that obese people have differences in their flora. So what can we do to take care of that? Eat yogurt or Kefir -- pro-biotics. It really will make you feel better and function properly.  

Seminar Learnings

I spent all day Thursday at a seminar on Food, Stress and the Brain. It was interesting and detailed, but did not cover much new ground for me. Which made me realize that I'm very plugged into all the current research on this stuff. I learned quite a bit in my Advanced Pathophysiology class on this topic - probably enough to fill up an entire lecture, scattered over the semester - and I read the Health section of the NY Times daily, pay attention to national news on this topic. You get the idea. Working out, wellness, and health is my hobby and I'm just lucky that it fits into my profession.
So not a lot of new details -- here's some of that stuff I already knew. There is a lot of current research into epigenetics, which means that our environment literally shapes the expression of our genes. If you repeatedly eat unhealthy food, it can "turn on" genes that make you fat. If you are sedentary, it can turn on genes that make you fat. Really. The hormone leptin plays a large role in appetite and weight set-point, and the drug companies are searching hard for a leptin analogue that they can give to people as a medication that will cause weight loss. There is an interplay of serotonin and dopamine neurotransmitters that create mood, which has a correlation to appetite. People with mood disorders frequently medicate with food, although I've rarely seen a severely depressed person("MDD" - major depressive disorder) that hasn't lost weight because they've lost interest in virtually everything. Mildly depressed -- oh, they eat all right. Frequently, and the wrong stuff, and then they feel better for 10 minutes. It's not a mystery to scientists that psychotropic drugs create problems with all our pleasure receptors -- they interfere with appetite and sexual desire or function. That's because we don't have the knowledge yet to target the drugs to only the proper receptors -- we're basically hitting them all with a big hammer. But it's getting better all the time. Newer SSRI's have less of those side effects than the original drugs that were introduced back in 1990.

High fat and high sugar combined in the same food should basically be regarded as a nuclear weapon to make you fat. Natural food can't compete with that stuff. They cause your brain to release chemicals similar to both marijuana and opiates. It's not a lie that you can feel addicted to that stuff. The message was, think hard before you eat something like that. Now, I believe in an inclusive diet with no bad foods, but I now think that these specific foods are just not going to be in my realm of choice after hearing that. It's interesting -- the speaker mentioned early on that of course, a primarily plant-based whole foods diet is the best choice. And that's about all she said about what exactly to eat -- the evidence is so overwhelming and so obvious on that point, all the health professionals in the room knew that and didn't need further instruction.

High calorie liquids give you about 1/3 the satiety effect of the same foods in their whole state. So if you eat a 900-calorie smoothie, you feel like you only ate 300 calories. They really shouldn't be part of a weight-loss plan if feeling hungry bothers you. There's no chewing, no bulk felt in the stomach, no fiber. And those things - the action of chewing, the bulk - set off hormone effects that cause you to feel full. If you eat too fast, you end up eating too much because you're outpacing the response. Another thing is that variety is not your friend when it comes to your regular diet. Lots of variety causes you to eat more. We find variety more palatable. This is why you feel stuffed, but can still fit in dessert.

So I realized that the overarching themes of the seminar taken as a whole was really what was new to me. The main thing was that what you do with the rest of your life (when you're not eating) is more important than adherence to any particular diet. Exercise is so obviously required for normal function that it shouldn't be regarded as an option. It's simply what the human organism has to do if you want to grow old without a heavy disease burden. Meditation, which can be in the form of yoga, properly balances neurotransmitters. People who are overly stressed are high in cortisol and low in serotonin. Meditation has been shown to balance these to normal levels. The speaker also talked about having goal-directed activities in our lives. Watching TV and going out to eat will not create a sense of accomplishment. We need things like knitting, art, volunteering. Live your life in a meaningful way and eating twinkies doesn't hold much appeal.

So at first I just dismissed the seminar, thinking to myself, Oh I learned nothing new. Not quite. The information was presented to me in its totality in a new way, a more holistic way. When I think back to the many NYT articles I've read over the years, then yes, certainly these themes emerge. Sometimes it's nice to have it all put in front of you. I'm thinking more about my anemic meditation practice and how to fit more yoga into my schedule. And about avoiding the cake balls at Whole Foods. Ha.

I walked Crabby today. She did the best ever, I think we were outside for 10 minutes. She did run up to the door 3 times but I just waited and then she went back to exploring. This stuff is working. Dani has her winter formal tonight and about 20 teenagers will converge on my house at 6:00. Pictures later. Austin's Star of Texas Tattoo Art Revival is tomorrow and we'll be there. It's a fun last weekend before school.

Crab Walk

I haven't worked in nine days and since I'm out of school that means lots of vacation. Lots of yoga, lots of spin. Ha. I read a NY Times article about teaching your cat to walk on a leash (http://www.nytimes.com/2011/12/29/garden/training-a-cat-to-walk-on-a-leash.html?_r=1&scp=1&sq=walk%20cat&st=cse) and decided that would be good for Crabby. So I have spent the last week on that process and I'm happy to say that her first real walk today, outside, went well. And yes, it took a week of prep work to make that happen. I ordered the little walking vest/harness that the Times article recommends and kitty treats are essential. It's completely different from walking a dog but I'm so encouraged by the results today. She is going to make a great walking cat. We did have a visit from Mitt Romney over the weekend (Holly's cat) and he didn't participate. Mr. Romney was an observer only.

It's a rainy day in Austin today and it's funny, Ken and I were out at Whole Foods and Performance Bicycle and at both places everyone says with a big smile - hey! It's raining! The drought has totally changed people's attitudes here about rain. A grey, rainy day is a very welcome thing. Instead of walking around Town Lake, a spin class was a much better idea. But eh - can I complain a little? - the gym is so crowded with the resolutioners. At 10:00 this morning, it was hard to find a parking space. I said, don't these people have jobs? (I mean, I certainly don't have one and that's why I'm here....ha). When we had lunch with Holly, she pointed out that many people have more flexible work arrangements now (like her) and can schedule in gym time in the middle of the day. OK, so I guess my 4:15 a.m. workouts aren't going to change any time soon. Not this month.

I just got an order of books in. $620 for nine books. Yep, you have to be rich to afford grad school nowadays. Kind of ridiculous. I thought I might be able to save money by ordering electronic versions but turns out those are almost the same price as the paper books. And illustrations are a problem. So I stuck with the real deal. Here's a list of the titles, I'm actually quite excited about reading some of them.

Diagnostic and Statistical Manual of Mental Disorders IV - Text Revision (this is the bible of the psych world)
Interview Guide for Evaluating DSM-IV Psychiatric Disorders
Drug Handbook for Psychiatry
Psychotherapy for the Advanced Practice Nurse
A Guide to Family Assessment and Intervention
Family Therapy - an Overview
Theory & Practice of Group Counseling
Essential Skills in Family Therapy, from First Interview to Termination
Synopsis of Psychiatry (this is the biggest, scariest one)

Now, you may be thinking what the heck's all this family therapy stuff? Aren't most people treated as individuals? Yes, they are, and that's where the primary focus of training will be. The family term just refers to the fact that I'll be trained and qualified (and licensed, once I pass boards) to treat all ages --  including kids, which scares me. And yes, certainly some families need therapy in an inclusive way, as do couples. But most people seek therapy as an individual and I expect that will be most of my client base.

This is my last free week before school. I am going to a continuing education seminar on Thursday called "Food, Stress, and the Brain". It's for medical professionals to get their credit hours for licensing, and doesn't that sound interesting? It's all about the latest research on appetite, hormones, weight loss/gain, and the impact of mood/stress. I'll have to post the pearls that I glean from the seminar.

Paranoia

Had a mini family vacation in Houston and then it was back to work on New Year's Day. You'd have thought that would be an easy day -- no discharges, everything is closed, docs stay home, right? I did. But I was wrong. I discharged a patient, accepted a transfer and then admitted one to the PICU. And the admission required me to do a full work-up. During the week, an admissions nurse does all that work but not on weekends/holidays. But it turned out to be interesting. (Again: details changed to protect confidentiality). The young woman I admitted was having a acute pyschotic break, her first. She was taking her cat to the vet with her boyfriend and basically did what we'd call "a freak out". She ended up pushing the vet tech to the floor (nobody was hurt) and ran into the woods behind the clinic. Boyfriend couldn't get her to come out. The police were called and brought her in to us. It seemed logical to her at the time because of paranoid delusions. Paranoia is actually pretty interesting to think about. It's such a common problem in psych, I would hazard a guess that it's the number one complaint. Most schizophrenics are "P.T." (paranoid type). People who aren't psychotic, what we might call normal (I word I don't like....I mean, who's normal?) have a little dash of paranoia, I guess we call it vigilance, skepticism, mistrust.

Personally, I can recall a time in my life where I said to myself, "gee, I feel paranoid." I was working as a aerobics instructor at a gym where the ownership changed hands from  the husband to wife following a divorce. The wife then started dating one of my fellow instructors (a guy, BTW). I noticed that there seemed to be this strange little clique develop that consisted of the wife, her boyfriend, and two of the other instructors. They worked out together, went out to eat, socialized. I wasn't part of it, but I was such a gym rat that I was around these people a lot and ended up feeling very separate. I didn't particularly like them and didn't want to be included, but I also felt at times that they looked down on me and didn't like me. My instruction style was always based on safety and effectiveness - I didn't include exercises for abs, say, that I was taught weren't effective or could strain your back. I noticed that this "clique" seemed to be more about what looked cool -- for example, make your oblique exercises with big arm movements because it looks like you're doing a lot, when actually it is easier than forcing your core to do the work. Do 50 hops on one leg - nevermind that could injure your achilles. It's more imporant to feel like a badass & scream "Alright, do FIFTY!". I got the impression that they talked about my style being uncool and boring. Did I ever hear them say that? No. I think it was more when I would enter the leg room where they were all doing squats together, they'd look over at me and get quiet. It was more expression and affect, not words. Now if I had thought I heard them whispering about me, following me, and that they wanted to kill me & take my classes, well, then I guess I'd have been a psych patient. As it was, it just made me uncomfortable and I quit. But right before I quit, they reduced my schedule of classes, and I wasn't surprised. See, my paranoia had prepared me to expect that.

We went to the Better Than Ezra show at ACL Live (Moody Theatre) the night before we drove to Houston. Good show, excellent seats, but I had a very drunk and horny youngster next to me. I had to keep out of the way of her flailing limbs. She and her date would periodically make out, his hands all over her ass, tottering next to me, I just knew I would have to catch them. And to be honest, I didn't really want to touch them. A paranoid schizophrenic I'll touch, certainly, but not some obnoxious drunk strangers with no boundaries. Ha. She did kick me once. It didn't hurt.

We had a laugh at work - as I mentioned the most common type of schizophrenia is paranoid type. The unit secretary that entered my new admit's diagnosis into the system, however, didn't quite grasp that and typed it as "paranormal type". So we had a discussion about how that could make for an interesting patient. Could they move objects? Hear our thoughts? See ghosts?

I was reminded at work of the value of just listening. I had a patient, one of the read-the-chart-and-weep variety. When he was a teenager, his abusive father gave him a head injury that rendered him mentally retarded, with a significant seizure disorder, and with mental illess. He was upset because my discharge was his roommate and he really wanted to be discharged too. He started making threats about "causing trouble". I judged that he's been in the system enough to know how to create a problem and get what he wanted. But what did he want? Anxiety medication? a shot (some patients like those)? to force someone to pay attention? So I started a conversation with him, letting him take the lead and the charge nurse (someone I normally like and respect greatly) horns in to state that he won't be discharged and why. Apparently she was assigned this patient yesterday and felt the need to remind him that his discharge was delayed. Now this just served to make him more angry. I could see it in his body language and face. He started arguing back with her, and incredibly, she just got louder. She clearly wanted to be right. (and duh - of course, she's right, but who cares?) I had to give her a look (a "shut up" look) and lead him away to talk to him privately. All I did was listen, say "uh huh" a lot. He wanted to vent. We talked ten minutes and then he was fine, didn't even need a pill.

I see this often, it's got to be the most frequent staff error. People want to be right. But you just don't argue with the mentally ill. You really can't convince them that their paranoid delusions are wrong. Sometimes they are asking for information and don't like the answer - like, how long can I be held here on a protective order? Really, 72 freaking hours?! But I know basically not to get into it with them -- let them talk. Listen more than anything. Ask them about their feelings, their behavior but don't lecture, for god's sake, about why they're wrong. It's not therapeutic! Look, I'm not a genius and I'm definitely not the best nurse there, but I did figure out early on who were the best nurses (Kathy, Curtis, and Gilbert if you want to know). I noticed they all shared this trait of letting the patient talk more -- you'll never see them making long-winded speeches to patients, showing irritation, or being insistent, unless it's insistence about delivering an emergency injection (but even then, very little needs to be said).

Yeah - paranoia, the destroyer. (apologies to the Kinks)