I have the flu. I spent the most god-awful day at work, periodically dashing to the bathroom to vomit as I vainly tried to have a heart-felt therapeutic interaction with a young woman the morning after her failed suicide attempt. It was beyond ridiculous. I walked in to work, sat down for report and waves of nausea washed over me. The day went downhill from there. I was so chilled, I had on 3 layers. I finally got to leave early -- at 4pm instead of 7. Yeah baby. (and yes, of course I got a flu shot.)
From the couch, I got to watch Lance talk to Oprah. I'm aware that I defended him in one of my previous posts -- I always liked the guy, guess I bought into the myth he created and of course there's LiveStrong (which I still salute him for). Can you hear the "but" coming? I was intensely turned off by his act on Oprah. Yes, it seemed an act to me. He's a fame whore and a narcissist. And I'm mad at Oprah too. He bizarrely said about a teammate's wife that testified he was doping, "I called her a crazy bitch but I never said FAT crazy bitch.". She gave him an awfully strange look but she should have said WHAT IS WRONG WITH YOU?
Last semester has commenced. Things seem good, but it's early. And the job hunt is on too. I have a meeting next week to start some discussions with a potential employer. It's nice to be a nurse, even nicer to be an NP.
I had a terribly interesting therapy experience recently -- and it was actually both terrible and interesting. It was my first session with a client, and I had this feeling of repugnance afterwards. At first it felt like anger, but then I figured out that I was convinced he was lying to me, and I mean big, juicy lies. Critical information left out, bizarre answers to questions (no, he wasn't psychotic, believe me, I know psychosis). But since I'm new at this, it was good - I learned a lot. And I certainly will handle things differently next time. For one thing, I've been practicing this: "I think you're leaving something out." But I keep thinking about this: why would you pay someone to listen to your lies? Guess that's a topic for my next supervision session.
I enjoyed working so much over the break. Found I could still give emergency injections with flair. I realized that because I've worked in an acute psych hospital this long, I've seen a lot. I mean, reading in a chart that a patient killed his brother and just got out of prison is not eyebrow-raising. Some of my patients on almost every shift either came from jail or recently got out, or have that in their history. The worst is when you read about someone in the paper, show up to work, and there he is. Another thing that I've noticed is how pissed off the nurses get at these young women that try to kill themselves over some loser boyfriend that either left them or is cheating. It's an almost uniform reaction, I've noticed, and I try to remind myself to keep my own reactions to myself. Many patients are really good at driving others away. Let me give an example. I was assigned a patient with long-standing borderline personality disorder. I bring her morning meds to her with breakfast and she immediately complains that I'm rushing her. She apparently needs extra time to swallow her pills, which actually is fine with me, I am not aware that I'm rushing. I sit across from her and ask how she slept, how she feels (might as well collect some data), but instead of replying she notes what an ugly color my nails are. Later, she comes to the desk, says she can't remember my name ("it was something weird") and then harangues me because my badge is clipped to my waist and she can't see it right then. OK. I feel my reaction but I don't display it. At lunch, I bring her another pill and then she gushes about what a great nurse I am and wants to talk like old girlfriends. Really? What's sad is that she's done this exact sequence to the close people in her life and driven them away. Now she's old and alone, in poor health and suicidal. Yet a characteristic of borderlines is they don't want to change. I'm attending a workshop in late February on working with them, boy do I need it.
One of the standard frustrations at work is dealing with the prescription narcotic addicts, which is an epidemic in the United States. Did you know more people die from prescription drug overdose than from illegal drugs? Addicts are skilled at feigning both pain and psychiatric illness to obtain more drugs. Where it gets squirrely is when someone starts with legitimate pain but has become an addict. How can we help them? They need a detox, treatment facility and we're not that. But they don't want that. Most of them are so deeply self-deceived, it is comic. One of the docs told me that the United States writes 95 percent of the world's narcotic prescriptions. And we are only 7 percent of the world population. So why don't other advanced societies do this? Like Europe, Scandinavia? Ah, because of socialized medicine. The public isn't willing to pay for it. I haven't fact-checked these stats by the way. Something to think about.
Friday, January 18, 2013
Sunday, December 30, 2012
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.
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.
Friday, December 14, 2012
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
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
Thursday, October 18, 2012
The Naked Eye
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.
Friday, September 28, 2012
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.)
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.)
Friday, September 7, 2012
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
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.
http://www.thedailybeast.com/newsweek/2012/08/26/ira-glass-on-rescuing-a-pit-bull-dog-with-a-ridiculous-diet.html
Wednesday, August 22, 2012
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.
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.
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