Long-acting Injectables

I'm working at a new local psychiatric hospital full time now. I love the work - it's certainly the exciting part of psychiatry - but the unpredictability has taken a toll on my time. And it's new, so there's been staffing issues and census is unpredictable. I cover the house for the weekend about once a month, meaning I see every patient in the place, and those are long days. I work from 8:00 to 10:00 pm, if I'm lucky. The first weekend I didn't really get it, so I arrived at lunchtime. I was there until after 11:00 pm. I've learned so much - in all areas of medicine, because the family practice docs/FNPs are only there a few hours a day. They are required to do a physical on new admits. But when issues come up after that - I handle them. Blood pressure too high? I increase the Lisinopril. Labs indicate that your thyroid is out of whack? I order the thyroid medication. Hit the wall and maybe broke your finger? I order the X-ray. I consult the medical guys when it's too complicated. And then there's the vast array of psychiatric medications for our geriatric unit, our adolescents, and our adults, which includes some detoxers. The detoxing is a whole different ballgame and it's fairly tricky, depending on what and how much they were abusing (if they are honest about that). That's dangerous too, because someone detoxing from alcohol or benzodiazepines can seize and die. I've sent 3 patients out to the ED in the few months I've worked there after they had a seizure. The worst is the people drinking and doing Xanax (or any benzo) - that is a high-risk detox.

One thing I've learned the hard way is when I tell patients on NED (Notice of Emergency Detention) - the guys brought in in cuffs - that I'm not discharging them for 48 hours, I need to have an aide in the room with me. I don't quite get this, but people think that they can do dangerous things, get picked up by the cops and judged as a danger to self/others and delivered to us - and I should just hold the door open while they walk out. Oh, you were choking your mother while drunk and she called 911? But you didn't really mean it? Especially when the cops arrived and you said that really you wanted to kill yourself, not her? Ah, well then, if you didn't mean it, you can go! Oh, there's a gun at home? But you promise not to shoot it at her? Well, then, let me get the door! I really don't like it when they say, oh but let me talk to the person in charge. Look buddy, I'm it. I legally get to make this decision, and you're staying. That's when some of the young bulls decide they need to turn over the table and kick things and yell. Anyway. I'm not telling people that anymore without someone in the room with me, someone whose job is to get in between us.

We were notified recently that one patient didn't make it. A significant number of our clients are there after making an unsuccessful suicide attempt - they were either found and brought to the emergency department, or they told someone right before doing it, or someone found the note, etc. This young man had made several attempts and had severe PTSD. I won't be more specific than that to protect confidentiality, but we all cared so much and spent so much time to line him up with resources upon discharge. I'm the one that discharged him, and I did it several days after the insurance company stopped paying us because I thought he wasn't sufficiently recovered. The news that he then committed suicide about 2 weeks later was heart-breaking. His therapist and I talked a long time about what we could've done differently but at the end of it, you can't save them all. We try.

I've learned a tremendous amount about psychosis. This is something you rarely see in the outpatient world. In fact, in my year of private practice I didn't see it a single time. But I encounter it every day now. There's three main disorders that involve psychosis - schizophrenia, a severe manic episode of bipolar disorder, and then severe depression. Psychosis by definition is hallucinations (usually auditory) and delusions. The hallucinations are often commands or a voice that says terrible things ("you're bad", "you're a loser") and the delusions can be clustered into the common areas of being spied upon (usually by the government), sexually inappropriate, or religiosity. There's also somatic, which seems like we've had a lot of lately. People will fixate on an organ system or body part, convinced there's a problem there and talk incessantly about it. Usually they've been to many doctors, had many workups, all with negative results. "You're fine", they are told, "just go see a psychiatric provider." I ask every single patient, every single initial evaluation that I do, "are you having any strange thoughts? hearing any voices? seeing anything out of the corner of your eye? are people after you?" - again, I've learned the hard way, you never know what that answer will be. This sweet little college girl may be hearing voices because she's so depressed, saying over and over again how terrible she is, she'll never amount to anything, she should kill herself. Of course, that could just be depressive rumination. So it's up to me to distinguish. How does the voice sound? Often it's low, masculine, guttural, horrible, demon-like. When does it happen? If they say, oh only when I'm in bed, trying to sleep, then it could be rumination. But if it's anytime, and it happened Tuesday when I was at the store, that gets my attention.

Another part of my job is convincing schizophrenics to take the new long-acting injectable medications. Schizophrenics are notorious for stopping their meds and decompensating after discharge. We are a revolving door for them. Pharmaceutical companies now offer a single monthly shot of anti-psychotic that can change all that, and in fact Invega has just introduced a quarterly shot. It's the best thing for these patients by far, but one of the features of schizophrenia is what we call "lack of insight" - meaning, they just don't get that they're sick. I convinced 2 guys on Friday to take their first shot, and I felt pretty good about that. I think one only did it to avoid going to court on Monday - we were going to argue for "COM" - court-ordered medication.

I'll finish with a picture of me and Dani at our favorite hang-out: Vino Vino in Hyde Park. We were there a for wine-tasting dinner and had such a lovely evening.

 

Lessons

I haven't written in a long time. The first year of private practice really chewed me up. I routinely saw patients from 9 to 7 and then would finish charting on weekends. I learned a lot, but here's the ugly part: I'm not doing it any more. At the end of my year, I told my collaborating physician that it was time to renegotiate my contract. He tried to stall me, said that he wanted to do it about a month later. Nope, I said, let's do it as we planned. A really bad sign. And it didn't get any better. We couldn't reach an agreement, and so I walked. There were other friction points with this doctor that made it easier to leave. It was awful leaving my patients, especially the eating disorder ones that followed me from Cedar Springs. But I did it. And I learned a huge lesson: Get it all in writing, up front.

I'm working in geropsych now because my contract included a non-compete clause (which I'll never sign again) and I can't do that same work for 6 months. But you know what? I really like the geriatric work. The patients are happy to see me, I can help them, and the visits are quick. I set my own schedule and everyone caters to me - when I show up, it's time to do it. I am completely untethered to a schedule. The other cool part is that my doc doesn't just do nursing homes and assisted living, he also is medical director at a new psychiatric hospital north of town. It has all ages, including adolescents, so there's a wide variety. (And baby, I know some stuff about psychiatric hospitals - as an RN, I worked in a few.) I was recently granted practice privileges at the hospital and I am there about 2 days a week. This is generally some of the most interesting work in psych, you can see people in acute crisis. It's exciting and feels like you're really making a difference in their lives. Not a bad deal, huh? And here's the sweetest part - it pays better. I could whine about having to learn another electronic charting system all over again and lots of complicated office scheduling things, but I won't. I am learning lots about geriatric-specific medications, like Alzheimer's drugs, and I enjoy that. Oh, and I need to mention this, my doctor is a genuinely good guy and he respects me and treats me like a colleague.

So another new thing starts. The rest of my life is fine and interesting, I'm still at the gym every day, my enthusiasm hasn't diminished a bit, and my kids and husband are healthy. Austin is still the most fun to be had on earth, the sunny days are long and luscious. I went to ACL and saw Spoon amongst many other terrific bands, Carnaval was big fun, Art Erotica is coming up in 2 weeks. I'm doing my volunteering at AIDS Services again.

It's easy to write about my little travails, but there's a lot going on culturally. The change in acceptance and legality for sexual orientation and gender fluidity is quite interesting to watch. Yes, I live in this little patch of tolerance in Texas and the rest of the state is stuck in the 1950's but things are definitely going "our" way in the United States. The cultural discussion about campus rape is happening. And police shootings. It seems to be a time where people are tired of the "same old". We are restless. There's this human tendency to move things along -- I see it in my patients so much -- we resist change, in almost any form. I think we are witnessing a tipping point. Minds open to one thing, and the questioning remains.

Did you know there's a podcast revolution going on? I think it started with Serial for many people, I got into it when I discovered Dan Savage (my hero), and I listen to his Savage Lovecast every Tuesday which schools me on all things sexual so that when my patient tells me they are a non-binary-gendered polyamorous into furry, my mouth doesn't hang open and I don't need to drill them with questions. Serial was this investigative reporter's looking into a cold case of a high school kid convicted of murdering his ex-girlfriend. It was great. I listen to a bunch of them now, Ben Greenfield's Fitness podcast, Invisibilia, This American Life (yes, the NPR show), Runner Academy, The Heart, Bret Easton Ellis (wicked smart guy), and Death, Sex and Money. It's part of my morning routine, as I put on makeup and sip coffee, my brain is getting all fired up with ideas. Ideas. Ah. Love them.

And best of all in this life, funny things keep happening. Like Saturday in spin, the guy in front of me had butt crack showing about 2" long (really). Like, dude -- center front row with that?

I'm going to close with a pic from Carnaval. There was no butt crack involved. Well, on my costume there wasn't, actually there was quite a bit of butt crack elsewhere, boob crack...what else is there? It was all there, on display. Such fun. Oh, plus a terrific picture of Spoon from ACL. And one of Nile after he got his Black Belt. Yes, he had to have knee surgery a week later. It's better now. I'll stop. But one more thing...follow me on Twitter. It's a good time. @LuvMyYoga, that's me.