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.