Decibels

Seems like best I can do lately is one post a year. This is not what blogs are supposed to be and I guess I'm wondering where I lost my enthusiasm. I do this because it helps me get perspective in my work, get better at what I do, and not get burned out. I think it was a clue that I couldn't fit this in with my life when I worked at Unnamed Big Psych Hospital north of town. It sure as hell was - driving an hour to work and an hour back, never knowing how many patients I'll be assigned, getting to know the security officer really well, geeeeez.... that couldn't go on. And it didn't. But interestingly, it wasn't for the obvious reasons just stated. It's because the new corporate suit had values that I simply couldn't live with. I tried but eventually, I feared for my own safety and left. I had a meeting with the CEO and gave my notice the next day after listening to him. I feel fortunate that my delegating physician chose to leave also, but it was me that pulled the plug. So now we're at another unnamed psych hospital, in a different part of lovely Central Texas. It's much better on all the fronts. Better commute, better management and a much lighter workload. I make a little less money but it's all OK. I rarely work past 5:00. I have time to do things that matter that I couldn't before, like call families and discuss discharge plans. It's like a new life.

Nile and Ken after the Swampfest

My sister got engaged at Whip In

And I have some new life in me. We sold our house and moved downtown. I like it. I can walk wherever I need to go, the bank, dinner, yoga. I walk to the gym every morning, dodging the homeless guys. It's a good life. Ken retires in 2 weeks and things will start to get real. Dani lives a 10 minute walk away in another high rise. Nile is still with us, going to school.



My new place is geropsych but with an Intensive Outpatient Program for all adults. IOP has been slow to develop, but in the past week the admissions have picked up. So in many ways, I have the variety of all adults, and I don't have the dangerous unstable young men in the inpatient side. I've learned a tremendous amount and I still have so much more to learn. Most of our patients have dementia and aren't doing well, have gotten combative either at their nursing home or at home. We change their medications (and usually there's quite a bit of change needed), get them stable and better and then send back to a nursing home or back to their families. We don't cure the dementia (we slow it, nominally) but we make them fit to live with. We take ages 55+  in the hospital (gulp! yes, that's what geriatric is!), so we get people in that lower age range with a wider range of problems -- mania, suicide attempts, with no dementia. It's absolutely never dull. The hospital is new, and the disorganization when we started was trying. They were thin on policy and procedures, and the staff was not experienced. Things would happen, and be handled the wrong way. Critical lab values not recognized as such and we weren't notified, orders written Friday and not done until Monday, things like that, medications not administered correctly (you can't crush some meds for the poor swallowers). It took us over 3 days to get a lithium level once and that's really dangerous. Lithium too high can kill you. We have a new director of nursing, someone we used to work with and knew was fantastic, so that's looking up. I'm happy to say that when things get difficult, the CEO has always deferred to our medical judgement. I do not get pressured to do the wrong thing. Which is really pretty impressive, because I know it's hard to make money in this business.

Dani, Trey, Nile at Whip In

A lot has happened. We had our fun annual stuff, including ACL and Carnaval and Art Erotica. ACL this year looks so tasty, I see so many bands that I'm listening to, and we can WALK to it this year. I said to Ken that's 90% of the reason I wanted to move here. Ha. We have more time for family, because seeing them doesn't require a 45 minute drive.

Kitten needs food - Dani & Nile volunteer at APA

One of the new things I'm doing is going to this spin studio called Ride. It's waaaaaay different that the RPM from Gold's that I'm used to. Here's a hint: I go there for my first class and one of the trio of cute young gals at the desk shows me the locker room - unisex. It's got dark blue lights and the locker combos are teeny tiny. It's so dark, the font is so small and I'm not wearing my glasses (who wears glasses to spin?). The place is so not designed for older people. The decibel level of the class confirmed that, but I'm got my earplugs in place. I do like it, and I don't need to use the lockers since I walk there, so hey, everyone's happy and I can dance on that bike with the young ones. Especially when they play Prince.

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.

 

A Bad Day

It's been seven months now, and I have an inkling of what I'm doing (ha). Sometimes days go by and I don't need advice - really. And I'm starting to see some things differently. For one thing, suicide is such a big deal. I end up talking about and dealing with this way too much. Two of my patients now have made attempts and been hospitalized, both were overdoses which, frankly, we providers classify as low-lethality. It usually doesn't kill you. If you want to die, you should jump off a high place or get a gun. And now I feel like I should backspace over all that and erase it, but no, it's the truth. I need to say these things so that I don't cry. And I guess that's the point - this is heavy stuff. There have been days I leave my office and feel as though my body is full of mercury. And I'm not the one that's suicidal! I can only imagine...and I do, I imagine because I think that's important. And at the same time, I realize that I can't truly fully experience what they do. I have no trouble getting up and feeling good about lies before me each day. They go weeks, months, without a single day feeling that way. I am just surprised by how many times each day I discuss suicide with a person. As in, do you feel suicidal? Yes, I do. How often? What's in those thoughts? While I listen, I'm toting up their past in my mind - have they felt this way before, have they attempted before, what did they use, etc. Then we get to the really ugly parts - Have you thought, gee I'd like to do this next Tuesday? (and that sounds like planning a dinner party, which absolutely makes me go cold) and finally, Do you have a gun? Have you looked for spots to jump when you drive over Pennybacker bridge? I have one patient that I asked to remove a gun from the house.

This is exhausting. I can't seem to do this and shake it off. And I want to quickly say, I'm not whining. I love my job, and I intend to keep doing it and get better at it. It's just, JFC, I am slayed by how much I have to deal with suicidality and how difficult it is emotionally. Sometimes I wonder, gee, is it me? Is is some quirk that I ended up with these people? I kind of thought this would be easier....you know, the perception those of us that have been in the trenches of mental hospitals have is that private practice is the easy route - the mildly depressed and anxious. And you know what? That's just totally screaming wrong. People out in the community have significant issues. This is no small potatoes - let me just say Robin Williams. I heard on the radio driving home that he had killed himself. Oh god, we didn't save him. Think of everything he could've done if he'd stuck around.

I had a particularly bad day recently. Let me describe it. I'm going to change up a few details to protect identity. First of all, one of my patients came in manic. A manic person is dangerous, they are impulsive, make poor choices (have unprotected sex, buy new cars, walk alone at night) and if they have suicidal or self-harm tendencies, that can be a bad mix. So the first order is cool them down and protect them. That's hard in an outpatient environment. I need them to use good judgement to follow my instructions, and they don't have that now. What I try to do is hand them a sample medication to knock the mania on its ass - a good stiff antipsychotic usually does the trick. Don't really trust them to get to the drug store. But that messes up the day - they take more time than a 30 minute followup. So I start the day behind already.

Then I have a new evaluation that was a borderline personality. Fit it to a T - the history of drama-filled relationships, F'ed up childhood, the dependency and poor coping in life, the rushing from this to this to this to fix her. It was hard to listen to, and then there's the thought in the back of my mind: these patients rarely make any improvement. I have only an hour for new evals and it's hard to cover everything in most cases. This person was killer - I had to interrupt several times, "Gee, I'm sorry, but I have to move on and ask you some questions or we won't finish". Frankly, she wasn't capable of following that simple instruction. Finally I wrap things up and discuss a few medication options and she then reveals, Tah-Dah! - she already knows what she needs! She read about it in a magazine and sounds like it's just the drug for her. And it's a new antipsychotic. Funny, when I say that word, most patients don't react too well, they hate the idea of psychosis. I explain to her that none of her diagnosis fits the criteria for that drug. But, but...she protests. It sounds like it would help me. I said, it's not FDA approved from your diagnosis. It's unethical for me to prescribe it and I won't. You are free to leave and see another provider, no charge. Jesus. She decided to go with what I recommended. As I'm checking her out, our receptionist tells me that she got a strange call and had to refer him to me. A guy goes thru the process to book an initial eval, gives all the info (which is a lot), then at the tail end - Tah-Dah! - reveals that it's actually for his wife, not him! And she doesn't want help, so he's going to trick her into coming to the appointment! Of course, Angela tells him we won't accept that. He'll have to get agreement from me to have the appointment booked. I listen to this rambling voicemail, and this is the ridiculous part - he won't say what's going on. I suspect that his wife is using drugs or alcohol but JFC if you want help, at the very least tell me what's going on. I call him back and leave a message saying, look I suspect she has a substance abuse problem and you need to consult with an interventionist, not with me. I refer him to two places that have interventionists on staff. Luckily, he doesn't call me back. I am always highly suspicious when an adult calls to make an appointment for another adult - even if it's a college student - it just immediately tells me that the person isn't really motivated to seek treatment for themselves. Let mommy do it. And that never goes well.

Alright. Think that's enough? Well, the day goes on and three of my follow-ups are struggling with suicide so we have to talk about that in some detail. See the first paragraph of this blog. That alone would be enough for one day, but there's more. I have another new eval at the end of the day, and he's pretty much in crisis. Panic attacks, can't sleep, missing work. Cries thru much of the hour. We get about 1/3 of the way in, and he starts asking me rather strange questions. Would you stop writing things down? Can you keep a secret? I explain the limits of confidentially - namely, if I believe you are at risk to harm yourself or others, I can call the police, and if you are abusing a child or elderly person, I have to turn you in. OK, not a show-stopper yet. He keeps hinting around, finally spills it. He did some illegal activities in the past. And we move on.

So there it is. That's what a bad day looks and feels like. I think next time I'll explain what a good day is like - I have those too. Really.

Overdose

Working a lot. Learning a lot. One of my patients overdosed last night, so maybe I'm not learning the right stuff. Nah, this was a high-risk situation from the outset and I knew that. It's interesting, one of the things that Dr. S. used to tell me when I trained with her my last semester was that some providers play it safe. They only accept patients that haven't been in mental hospitals, patients that have never made a high-lethality suicide attempt, patients that are not in the "CMI" category (chronic mental illness). I really pride myself on not doing that - I want to help people, even the ones that scare me and that I worry about. And this patient was one of those; 3 recent suicide attempts, one of which landed him in the ICU and 2 hospitalizations in the past six months. And I saw him twice last week, as we tried to head off some incipient mania, but obviously it just didn't work. One of my colleagues was on-call over the weekend and talked to ER doc, and he's still with us, outcome seems pretty good. But it's a wake up call. If they didn't admit him, first item of business is serious discussion about exactly how to take meds and when and maybe you don't get a whole bottle of sleeping pills now.

So, it's hard to follow that with some light remarks but I'll try. Some friends of ours from Baton Rouge made their annual pilgrimage to Austin and had a party at Dart Bowl. Nile, Dani, and I went and all of us bowled this time. Know what? That was really some fun. Makes me want to go bowling again. It's such a cool retro bowling alley, not exactly close to us, but worth the drive. www.dartbowl.com Here's a photo of my handsome son and his friend.

Here's something amusing: almost all the correspondence I get from pharmacies, insurance companies, and therapists all address me as "Dr." I cross it out and write Provider, or NP. But jesus, NPs have been prescribing for many years, decades in fact, in the US. And it's not like we are hard to find, there's actually more than 200,000 of us in this country. And Physician's Assistants can prescribe too. One patient asked me recently why I didn't go to medical school and I said, jeez, I like being a nurse. I like being an NP. It may sound corny, but we see the patient holistically. You are not a diagnostic puzzle to me (like Dr. House), I think about all parts of your life and how that helps or hurts you. I'm not afraid to ask if you have a dog or cat (pets are great for mental health) or what your exercise routine is.

I've gotten a lot of substance-abusing patients lately. Another thing that many providers just won't touch. And let me quickly say, that I appreciate my doc not restricting my practice so that I can't accept those clients. But do they scare me? Yes, mostly because I feel that I can't truly help their mental health problems (usually depression and/or anxiety) if they don't either stop or cut way way back on their drinking or drugging. And every single person, when I bring up the subject of rehab or detox, starts with the song and dance to the tune "I Can't Do That", it just won't fit in my life right now, my job's too important, my husband will freak out, blah blah blah. OK darlin'. But you know what they call it when you keep doing the same old thing and expect different results. Yes, I'm a little fatigued by the excuses. It can wear me down. I try hard not to lecture, that's really one of my core principals. I'm not your mommy. But I will speak my truth, especially when I hear baloney, I'll simply point out that's what it is. I'm not going to smile and say "Sure, you get high three times a day, I'll throw 3 different pills at you, and you won't feel any better. Let's keep doing that."

Today a patient walked out on me. In tears. No fun, and that's why I'm up at 2 AM writing this. It was an initial evaluation, and at the end of the hour I tell her what I believe can be helpful in terms in medication. And she didn't like that. You can probably guess why (if you've read previous posts); yes, she wanted Xanax. Such a screamingly awful drug, I must say. And for multiple reasons, that was a very bad idea. I said no, I didn't want to do that, and I even said I wouldn't shut that down forever, just that I wanted to try some other things first that didn't have the serious potential problems that Xanax has in her case. So then she got angry, and insisted she needed relief now. Oh darlin', I said, mental health recovery doesn't work that way. This is a long, slow process and I can't make it all better today. Especially, in my opinion, with that medication. But hey, you're free to go, get a second opinion, and no charge for today. And that's what she did. I'm relieved, so why is that keeping me up? I think two things: I was surprised (usually I see that one coming) and I almost made the wrong call. In fact, I was going to go along with the Xanax until I stepped out of the room at the end of the hour and reviewed it with my doctor. He immediately advised against it, and it wasn't hard to persuade me, he just reminded me of the elevated risks for the situation, which frankly is one I don't see very often (very specific disorder). I am deep in rumination on all the choices I made today,  I am a real champ at anxiety it seems. I know it well. God, that learning thing....how many months in on this gig am I? Oh that's right, only five. Five!

Yep, you're wondering what the hell I'm doing in this profession. Ha. Really, it's freaking amazing when it works. So how often is that? Well, sometimes you get dramatic results and boy does that feel good. I have 3 of them right now and I'm so, so pleased to see them in my office. One has postpartum depression (talk about scared the bejesus out of me), one has an eating disorder, one has suicidal depression. All three are basically back to normal after treatment. Happy and able to take care of baby and returning to work this month, gaining weight and no more feeding tube, and happy, productive and back at work after 3 months off. It's hard not to hug them and cry, it's just such an honor to be part of their good work and recovery. And yes, it is mostly them, just a little bit of me. I tell them that, too. You did this. You.

Wicked and Meh

It's been a month since last post. New job sucking all my time. I ostensibly have 2 days off each week, but seems like I can only keep up if I go in the office those days too. Now, on those "off" days, it's not my usual thing where I'm driving home in the dark, but still. And I'm not complaining - whining about how busy I am is so lame and boring - I'm happy that I'm busy and I absolutely have the best job in the world.

And now the 2 days off disappear. As of a week ago, I'm an official provider with one of the big insurance companies. I'm happy about that, although it's a pretty steep discount between my published rates and what they actually pay me. I realize however, that people should be able to use their insurance benefits and I want to be part of that solution. If money was a big concern for me, however, I may not be making this choice. But regardless of what I'm paid, I've finally been there long enough I've seen some patients really do better with my help and that's quite rewarding.

So I have some pretty pictures from Art Erotica from AIDS Services about a month ago. The event was actually disappointing however - for several reasons. Seems like it was just so much smaller-scale than last year. Just not as much entertainment, not as much art, not as many people. We did get to see some fun sexy art, a set of 3 artists demonstrating their craft as a tableau of models posed - that was my fave thing of the night, and do some people-watching. One guy came in with his partner half-nude, on a leash with a tail sticking out of his....yes, really. I should have photographed that, but I didn't have the nerve. The other thing that made the evening less than spectacular was the modification to the venue - it was open-air and we had a weird cold front that evening, so it was windy and rainy. I was cold and was thinking about how I could warm up the whole time. And the last reason, which is a huge drag....I fell off my heels and really hurt my foot. It's still not right, a month later. I can finally walk on the treadmill again and I only missed 2 days of the gym but I was a limping fool for weeks. Thank goodness I could still spin or my brain would've stopped working. And those shoes....they are Anthro red suede heels on a platform, must be at least 4", maybe more.  Sob - I can't in good conscience wear them again. Oh the tragedy.

I went to a yoga studio near my office today and it was way fun. They've been in Austin for many years - one of the first places - and it will be a nice option to sneak over there. It's literally less than 5 minutes from my office (I timed it). YogaYoga Austin It's a pretty different crowd, though, I have to say, from the gym. Not to be snarky, but the people at the gym are much fitter and stronger physically. It's funny, I was worried about not being able to really do it "right" since I take classes at a gym regularly, not a studio, but I was able to do all the advanced options that were taught today. Of course, it was not an advanced class so we'll see when I take one of those. But it sure was good for my head. And I need that. I'm starting to feel the effects some days of what I do. Sometimes the things I'm told just stay in my head, particularly when I get to the Trauma section and ask the question, "Has anyone ever hurt you or abused you?" Let me just say, human beings are some twisted creatures. We don't need a devil, he's among us. He is us. And as far as the sexy erotica AIDS thing being bad and wicked? Good grief, I couldn't disagree more. Just keep it safe, folks. Human sexuality is a wonderful thing to behold, in all its variations and themes.

Looping

I am learning so much. I'm finding that much of the work of a new practitioner is hidden, however. When you're not full of experience, research is needed as you encounter new patients and new problems. It's also important to stay abreast of current developments. For example, over the weekend a new study was released that shows an increased risk of pre-term birth when pregnant women are on antidepressants. And not a small risk, I might add, something in the nature of 20-30%. I have two patients in that exact category now, and I will certainly be having a discussion with them. Also, there's this hidden correspondence with other providers. When a new patient comes to see me, they usually have a history with another provider and/or they have medical issues being managed separately. They may be seeing a therapist for just talk therapy. I obtain releases and contact all of them, review records and sometimes call them too. When you're prescribing medication, you need to know exactly what's going on with a person. Beyond just providing better care, it's a safety issue. Many drugs interact. So when does all that work take place? Whenever I'm not seeing patients. And since I'm new, time's pretty short. I'm finding that I need the full time to see a patient, which leaves charting to the end of the day for everyone. That takes several hours usually, for a day's worth of patients. Eventually I'll get faster at this. It's sucking up all my evening yoga right now.

Yesterday was a trying time. I had a suicidal patient that I was very concerned about with means to end things at home. I had to ask him to take steps to ensure that those means were disposed of and then prove that to me. My doctor helped me make all that happen, but I got terribly behind and my afternoon was a wreck. And the patient is furious with me and may never return. That's OK, I did what I needed to do in my small way. Did that fix things? No, but I (may have) prevented a terrible outcome on my watch, and that's all I can control. I couldn't sleep last night after all that -- endlessly charting in my mind. Oh, did I chart that I called the therapist? Did I specify that I requested next visit in 3 days? Did I outline verbatim what the patient said about intent? You see how it goes...I get stuck on a jag while I lie in bed. Which is so close to what my depressed, suicidal patients tell me their experience is like. Is that not ironic? Their minds are often in a loop of rumination over events and choices -- the abusive ex-husband, the shy boy that they used to be and now constrains them so much socially, the perceived shortcomings they possess. We all have these from time to time. Did I really screw up my charting? No, I'm actually coming along with that pretty well. But I couldn't stop obsessing over it. It's like if I get an unusual stimulus big enough that day, it really screws up sleep. It takes a while to come down. And I think patients experience the same thing. (by the way, details changed/obscured to protect confidentiality above)

So I tweeted something today: Good news! Texas gives Nurse Practitioners full practice authority, and joins16 other progressives states. #hell #AprilFool
And of course, the followup: Reality is that Texas is among the 13 most-restrictive states where we are squarely under a doctor's thumb. #changeiscoming
We will see how long that takes, of course. I wrote a big check to CNAP (Coalition for Nurses in Advanced Practice) this year to help move it forward. It's interesting, I am already starting to have some ... constraints ... with my supervising physician. Who in general is one of the good guys, helpful, respectful, smart and not in my face at all. However, he lacks experience and knowledge in eating disorders, which is exactly my area of specialty and that I obviously expected to bring with me to this practice. I have about 3 ED clients right now, and recently he asked me to limit it to just that. I about fell out of my chair. Apparently, he believes that they pose an extra risk (I don't agree) and he lacks experience with them. We talked and agreed on a plan to get him informed but he expects that to take a couple of months. And I'm not happy about that. I wish now that I'd thought to bring it up before we signed our contract -- I didn't. But all of a sudden, I see the allure of those 16 states. Beyond the financial boost (yes, the physician takes a cut of what we earn), there's a freedom to use your skills and experience as a professional. Here's a map of those states if you're interested. Map for NP Restrictions

Nile and I are back at the Animal Shelter. We go every other Sunday evening for 3 hours. It's good for both of us, and it's really fun to be so surrounded by the cats. Bonus: it's not kitten season yet! Because of the prolonged "winter" here, the feral cats bred less. And maybe all that spaying and neutering is paying off. Fix your pets!

I gave a lecture to my old psych NP class at UT, along with the former COO from my previous job. We talked about eating disorders, of course, for about an hour. It was nice to be back, but strangely didn't even felt like I left. I guess it's been a little less than a year. I am amazed at how much I have learned in this short time. The human brain is such a great thing. And it was fun to dress up like a professional - I used to wear my yoga clothes to class as I was always trying to squeeze in a class either before or after being at school. Here's a pic of the retail therapy that provided the cute new dress that I got to wear from Anthro - a definite perk to not being a student any more - making a little (very little right now) money. And hey - I got the word yesterday that one of the insurance plans accepted me! This is the one that initially said they won't accept anyone - even physicians - without 3 years experience. Our savvy office manager then sent in a letter outlining what they should make an exception for me, and they DID. Way cool.