4/28/24

Really, really proud of my team today. Beyond excellent response to a potential disaster scenario this morning.

Turns out overnight we got an admission to our unit who was just banned from, apparently, every other hospital in the area. At an outside hospital we occasionally accept patients from, he assaulted 3+ staff members; multiple new assault charges against him. They didn't want him anymore, so they sent him to us in 4 point restraints. He was knocked out from a sedative the night before, currently sleeping in his room.

Always fun to hear someone say "Yeah they just seriously attacked like four or five other people. Alright Gomdy, it's your turn!" As soon as report was over, I updated the security guard on the situation, called the security department to be aware of the pending need for backup, and very, very politely informed the doctor on call of the very, very important need for his prn injection to be strong enough. We were not taking any chances.

Guy wakes up an hour after report is over, walks into the hall, asks me where he is. I calmly answer his question, he shouts "FUCK!" and goes back into his room. Security and I are already watching each other closely, and he calls for back up just in case.

For the next twenty five minutes, the guy is just asleep in his room. I hear him cough and hock a loogie, so I walk in and talk to him a bit. Denies knowing why he's in any hospital to begin with, says the police kidnapped him. He agrees to breakfast. I bring it to him in his room. I am not fucking around with "No, you need to eat out here with everyone else." Not today, not like this. Someone who gets special privileges on the acute psych unit is someone who is not doing well.

While all this is going down, I'm constantly, constantly keeping everyone in the loop. Resident doctor? Let him rest, come back when he's ready for her. House Sup? Meets us in person to discuss the security risk. The security officer present at the time is the same guy who was hurt several months ago with one of my other patients, so he deserved to see that I was doing everything I could to make sure there wasn't going to be an event, and if there was, that it would be quick and decisive.

After I bring the patient his tray, what, fifteen minutes pass? And i hear a clatter. I go in there and find his food half eaten and spread lying against the wall, a few feet from him, clearly thrown. I ask him what happened, he says "I dropped the tray." Yeah okay. I ask him "Will you help me clean it up so I can get it out of here?"

The thing some people may not realize is, that's a valid assessment question, and his answer was "yeah." He immediately started helping me pick the food up off the floor and put back onto the tray so I can take it to the dirty food cart thing. I ask him if there's anything I can help him with; he wants to speak with "whoever's in charge." I tell him I'll contact the doctors, etc.

That was the moment I started suspecting it; that "emotional outburst" syndrome, or whatever its called. Where someone has a brief episode of losing their shit completely, and then regains control again soon after. That comes before the probable meth addiction. As far as I'm concerned, if he didn't have the former, he wouldn't have the latter.

But that's getting away from myself. Someone calls, and it's his mom. She asks me if we have a patient with his exact name and description; I put her on hold, and check if he knows the lady; He does. I quickly and quietly ask him to file the form that says she's allowed to know who he is and why he's here, and what does he do? He complies! Perfectly cooperative, he rights himself, takes my pen, signs the form, plops back down in bed.

I go back and tell his mom "Yeah he's here." She's quieting down a cat in her house, then asking me for details. "Assaulted a bunch of staff members." That gets an "oh, oh, ohhhh oh dear," from her, the kind only a little old lady can give. She's gotta be his enabler, I think to myself.

This whole morning, he's got that standard affect I've come to find in men with severe anxiety disorders and drug addictions; brief, one word answers, feigned lack of knowledge of a subject, guarded/masked disclosures, and desperation to discharge. All his interactions with me, when they're cooperative, are filled with desperate and practiced self control. One that doesn't come with a deeper feeling of inner peace, but instead from having learned "if I lose my cool now, I will be worse off for it."

The resident and the head physician come by, and as soon as they're on the unit I make sure the security guard calls for back up. Once the two doctors are ready to go talk to the guy I tell them, "Hold on, I've been building a rapport with him. Let me go in there first, and let me introduce you two."

And they do it. We go in, and he's talking with them from his hospital bed. All the standard questions anyone wants to know when they're an involuntary admission. "What's going on? Why am I here?" The doctors start asking him what he remembers, and he reveals he of course knows a little bit more than he let on. He remembers feeling "parasites" all over his skin, and telling his mom he wants to die. He fully well remembers all of it, I'm sure. Just doesn't want to admit it, out of fear of being punished. And at one point he asks "And my cat! Where is my cat?" That was when I interrupted the doctors. "I spoke with your mom briefly on the phone this morning, and she was quieting down a cat who was mewing loudly. Does that sound like your cat?" Immediately, the guy's face relaxes. My god, I think to myself, that was a really fucking lucky phonecall.

"When can I leave?" That last one is the one that tests everyone, and I don't envy them for being asked it. They tell him "Not today," and "we'll see how you respond to treatment," or something like that. Guy's already clearly desperately controlling himself. Asks for permission to go use the patient phone on the unit. They tell him "yes," and he gets up to go use the phone.

At this point, I've been watching him closely enough to go "Okay, yeah, that phone call is not going to go well." I take the opportunity to warn another nurse, who's already watching, what I'm sure is about to happen, and then go pull meds from the med room. While I'm in there, I hear an unmistakable banging sound; Guy's smashing the phone against the receiver. Yup, needs something to calm down before he attacks.

I thought that morning when I called the doctor to ask for a stronger dose I got one, but the head doctor on the unit who saw him stopped me and told me "No, up the haldol dose. Make it stronger." Kinda surprised me, but in a good way. They understood exactly what I was trying to avoid. I had to go back and get more haldol in a syringe, but whatever works.

I had two syringes of sedatives ready pretty quickly all things considered, but we still waited for more security to arrive before doing anything. The patient had already gone back to his room after getting whatever bad news he heard on the phone, it turns out, so we were just preparing for the worst before doing anything.

It ended up being a party of, what, eight people? Three nurses, a technician, and four security guards to go into this guy's room. Each of the guards agree on what limb they would grab if it came to that. But I stopped them up front and said "Hey, before anything happens, let me do the talking. I'm gonna go in there, introduce myself and explain what we're here for, and we'll go from there."

So, when we went in there, I politely explained "I see you want to calm down, we have some medication to help you with that." And what does he do? He willfully complies! Just rolls over onto one side and exposes his shoulder for me. I give the injection pretty quick, apply my bandaid, and allow the other nurse to get his other shoulder. The guy was clearly forcing himself to manage his anxiety in the moment, but he wasn't attacking anyone or screaming. Nobody even needed to lay a hand on him.

And he just slept like that for the rest of the shift! Not totally sleeping, mind. I'd leave lunch and dinner trays in his room, and come back an hour or two later to find them half eaten. He knew food was there, he knew we were letting him rest, and he wasn't fighting us on it. No violent outbursts, no nothing. Just some angry phone treatment and food to clean up off the floor.

This event could have so easily been another security guard out on leave, or a nurse out, or what. But it wasn't, because everyone communicated and worked together. Completely avoided any events entirely. I don't want to pretend we did better than that other hospital did, because I'm pretty sure we were on the latter half of withdrawal, but I won't deny we displayed some true skill in our interventions this morning. I know it's going to happen eventually, but so far I've never been assaulted on this job.

I don't want to write all this without talking about the patient, though. I think the root issue with guys with his presentation is basically, the anxiety. They don't have an internal locus of control, beyond "Shut up and calm down." They can't examine themselves effectively; it's either not part of their thought process or its too painful. So when they've got a thought, or a feeling, or a situation, causing them so much pain and fear, they can only tell themselves "I can't lose my shit right now" to get through it. Nobody can survive on "just keep it together" forever.

Without any understanding or guidance, they're just going to stay in a bad situation as it gets worse. Eventually turning to drugs like meth to try to make the pain go away, which of course only makes everything exponentially worse. Eventually they snap, in whatever form that takes. But when they regain control, they don't experience that release of tension, or fear. They just go back to keeping that internal storm barely under control.

My heart goes out to this population. I don't know how to help them, beyond my job. And my job is really only to help him through the withdrawal and get him out of the crisis state of wanting to kill himself or hurt anyone else. After he leaves here, If the social worker can't help him effectively, he goes right back to whatever resources he has available to him. And he's in this situation because those have already failed him. Lots of people say "patients in these situations don't get better until they accept that they need to get better." But how does someone like him reach that point?

Hey, but that security guard has come to appreciate me a lot though. He frequently tells me he likes working with me, because I'm so "By the book." Well damn dude, I'm so thankful you're here to let me do my job safely! Can't believe administration tried to tell us we didn't need a full time security presence on this unit. Buncha fuckin chumps.

4/27/24

Very uneventful day today.

Most notable thing that happened was, one of my patients pulled me aside and asked me if I wanted to hear a song he wrote. He busted out a two or three minute long love song about a girl he knew. I was kind of surprised; seemed like he was going for kind of an ed sheeran thing? Not like he was trying to be the guy, but just the whole "soulful lyrics about wanting to love someone" and a guitar. Didn't have a guitar, sadly. I told him our music therapist might, might provide him with one while he's here so long as he can make everyone believe it will be safe with him while it's on the unit.

That's one of those things I'm sad we can't give to patients more. Like books, for example. Same patient asked me for a book. We have less than 5 on the whole unit right now. I went to the subacute unit to look for books but I couldn't find anything he wanted; he likes young adult fiction, and most other people do too. So those books end up going home with people, which is nice, but then we run out of all the books everyone likes pretty quick.

He wasn't my patient, so I don't know his details or his backstory. I just know that he seems like if we just gave him books and a guitar so he could have a creative outlet, he'd be doing more than fine. He basically just wants to do the same things I do on my days off. Maybe I'll see if I can get him transferred to the subacute unit tomorrow.

4/26/24

Tasky as hell, today. Not busy, just tasky. One of my patients was an older lady. Had some pretty uncontrolled Borderline personality disorder, as well as some particularly nasty trauma. Pacing in the halls, raising her voice, hostility towards staff, needed a therapeutic hold for a sedative. Classic presentation for trauma behavior, someone who knows they need to be here but doesn't know how to feel safe while they're here.

Doctor actually placed an order for her to discharge not long after she got that injection. I was a little surprised by that. Sometimes doctors just figure out "This milieu is not what's going to help this patient, and she'll be better off somewhere else." I gave the patient the heads up, "hey here's the plan," which was essentially "you're going to leave the hospital via taxi." She was thankful and cooperative, and I went off to lunch.

15 minutes later I'm back on the unit because I knew I couldn't spend a full half hour, and something was going to go down while I was away. Sure enough, the same patient is pacing and shouting in the halls again. Refusing to cooperate with staff, even though what we're asking her to cooperate with is the very discharge she wanted. I even handed her her clothes, and instead of putting them on, she just held them in her hands and refused.

We ended up putting her in a wheelchair and rolling her out in her paper scrubs. What else could we do? Discharge orders were in, the patient refused to do it, and we needed the bed for a new admission. Patient kept accusing staff and shouting about this and that the whole time, right past the front desk and out the front door. Most patients, when they leave, I tell them "If you need to come back here, please do." This was the rare exception, where instead someone is kind of forced to say "Please do not come back through this door, that constitutes trespassing."

Once she was outside, she started to walk off with her belongings. Two of the security guards were savvy enough to follow her; She did, in fact, try to reenter the hospital through a few different doors, in which she was informed multiples times "No, that's trespassing. If you want to come back to the hospital you have to do it through the ER." I only found that out about 20 minutes later, though.

I won't deny, I've been thinking about it since then. We have a new employee on our unit who's never worked in psych before, so I was explaining to her what was going on with this patient. "This is one of those patients who isn't going to cooperate with us today, and maybe not tomorrow, because she doesn't feel safe here and doesn't know how to feel safe." The kind of patient who you just medicate and leave alone in their room while they slowly yet surely realize they're being given three hots and a cot, and medications to calm them down. Usually they slowly calm down and start to at least talk to staff about how they're feeling or what happened that they were brought here.

I dunno, maybe the doctor saw something in the chart or the patient's history that made them think otherwise. But that immediate trying to reenter the hospital after how much she hated being in the hospital is such a clear example of "I don't know where I'm safe, I don't know what to do." I might have to ask my nurse educator more about why this patient was discharged like that.

Anyways. Now I'm finally going to eat that lunch I bought eight hours ago and never ate.

4/21/24

Today was my first day back, after going out of town, coming back, and then getting really, really sick. Probably picked something up at the airport.

I had to put a 19 year old in restraints today. Young guy, paranoid, refuses to speak more than a word to anyone at a time. Walks around the unit slowly and tries to ignore staff when they ask him to follow unit guidelines I.E: not checking every emergency exit door to see if it's unlocked all the time.

Guy ended up getting a few PRN's for that. Pretty light stuff, to be fair; he wasn't being violent, he wasn't throwing punches or trying to hurt himself. But he kept trying to leave. Despite all our attempts to explain, "Hey, you leave a lot faster if you talk with us about what's going on," no dice.

I respect it. I was the same way when I was his age. He's afraid of us, and what all this means for him. I can't say what specifically is his fear, but he's pretty clearly masking it. Nobody could get him to just explain what he was worried about.

In the last hour of my shift, he saw a nurse's station door left open and dashed through it. Through himself on the fire alarm and yanked it down like his life depended on it. I think he expected a bunch of alarms to go off and doors to unlock, or something. All that really happened was, apparently, a fire truck showed up outside out building. I was a little surprised by that too, actually. I expected lights and alarms or something.

Once we pulled him away from the station and back onto his side of the unit, he went straight back into his calm and non-interactive behavior. I had to follow him to his room and tell him, "Listen. You've been refusing to talk to us all day. Now I need you to tell me what all that was about. If you can talk me out of it, I won't put you in the restraint chair." Still wouldn't speak a word to me. But, when I asked him to, he transferred peacefully into the chair and let us strap him in. That's the second time in my career I've been able to talk someone into getting into the chair.

I explained to him a few times, "Release criteria is you talk to us about what's going on." Not with that kind of brevity; I explain everything in detail to my patients. But I made sure he fully well understood exactly why he was in the chair, and how he was going to get out.

And then my shift ended and I traded him to the nurse who also had him last night. I popped my head in his room and told him one last time, "please just talk to us, we want to help you leave," and left. And now I'm writing this and just realized how hungry I am.

I just found your blog and I'm happy to see someone on here talking about nursing - do you know any other (active) nurse blogs?

Regretfully, i don't. Not sure how many nurses i know are also the demographic of people who regularly use tumblr. I remember seeing one or two physician blogs on here that inspired my own blog, that's about it for medical professionals with blogs on this platform. If you find any good ones let me know!

You've mentioned 'stage three' suicidal ideation. What are the stages and how does one know where a patient is at? I'm curious both as a nurse-in-training and a mentally ill person. I'm from a different country and haven't heard of it.

Excellent question! So, the way it was taught in school (at least to me) was, there's three stages to suicidal ideation. Just, as a simple way of understanding suicidal thoughts, and severity.

The first, and lowest stage, is passive suicidal ideation. That is, having this constant thought in the back of your mind, of "I feel like I would be better off dead. I don't agree with that thought, it doesn't help me at all, but I can't make it go away." If this person is otherwise safe, and can do things like explain their safety plan, they don't really need involuntary psychiatric commitment. Usually a counselor, or just a solution to whatever it is that's making them suicidal to begin with, is all it takes to help them. But that's a different topic.

The second stage is "weighing the pros and cons." That is, spending time seriously considering the risks and rewards of suicide. "Well, I'd stop being in constant pain and I wouldn't have to inflect my worthless failure self upon the world anymore, but what happens to my dog? Or my brother?" etc.

- As an aside, in this example I just made up, the brother and the dog are what we would call "deterrents to suicide." The person who wants to die is held back from making an attempt by these two.

The third stage is the preparatory stage. "Alright, that's it. I'm going to do it. I don't love it, but I'm out of options." This is someone who's making suicide notes. They're saying "goodbye" without saying goodbye to loved ones, by doing things like paying back old debts. They have a plan.

There's also a stage that I treat as the "alarm stage." That is, someone who's been morosely depressed for months or years, who suddenly comes up to you one day and says "Everything will be okay." And they can't explain how or why it will, they just know that it will. Completely at peace with themselves. Usually that's someone who isn't just ready to commit suicide, but they're happy about it.

I just want to say, that's how I was taught about it in school. But it seems like But as I sit here looking up "stages to suicidal ideation," I see different scales that all sort of vary in the steps as listed.

As I was looking for different infographics to explain my post, I found one that had two other stages listed before stage one:

Yoinked this one off google. See how the first two are "no suicidal thoughts" and "intrusive thoughts here?" Whenever I see infographics that list extra stages like this, I think they're usually made by someone who's passionate about the subject enough to consider expanding our clinical understanding of it in practice.

Though, I'm critical of this particular graphic. I have my doubts that intrusive thoughts should count as suicidal ideation. That, to me, is sort of like saying having an intrusive thought like "I should yeet this baby" or "I should crash this car" are things that will naturally progress into acts of violence, if left unexamined. I just don't think that's true. But as I say that, I think I'm crossing the line from being a nurse to being a counselor, and I'm not a counselor.

After writing this out, I think I might reach out to my old teacher and ask her for the source she used to teach us about the stages, actually. I know I've read about the "stages" beyond what I'm just reading here, but it's hard to find a decent infographic for some reason.

Does this answer your question? I had to cull a lot of information to answer this lol. Please ask me more specific questions if you don't understand what I'm saying!

What does "prn" mean? I've seen it on a few blogs now and thought you'd be good to ask about it

Excellent question! "PRN" really just means it's prescribed by a doctor, or nurse practitioner, or someone with prescriptive powers, but it isn't set to be given on a specific schedule. Your standard meds will be prescribed as, say, "Take once a day in the morning, before breakfast" or something. A PRN med will still have restrictions on when it can be given. For example, a healthy adult can't receive more than 1000mg tylenol inside of 6 hours, for example. But you can take the tylenol whenever you want throughout the day. You could take 1000mg at 1pm and be fine, then again at 7pm and still be fine. Any more frequent than that, though, and you start to damage your liver.

But that's tylenol, which is an over the counter medication that doesn't really need to be prescribed. You might find a PRN medication prescription in something like, for my patient population, hydroxyzine. Actually, I spoke briefly with a patient today about how weird it was that hydroxyzine is only available via prescription, but benadryl is available over the counter. I might have to ask a pharmacist about that at work some day.

This blog is called "prn anxiety" because, uh, I go to work and do things that sometimes cause anxiety, but uh, only because I choose to do them. I could choose not to care about my job, and then I wouldn't have anxiety. But. I, uh. Do that. So it makes me anxious, but in a way that I do to myself deliberately. Or something. Also just about all my patients have anxiety disorders in some manner, as well as genuinely the majority of my coworkers. I think there's other reason that are artsy and deep, but I forget what they are.

Also, my singular friend who knows I run this blog pointed out that "PRN Anxiety, a nursing daily diary" has a cadence that fits that old musical song "modern major general," which is fun.

4/7/24

So, I supposed I didn't technically write anything about yesterday, beyond my thoughts on this blog.

I can sum it up pretty simple. Yesterday, 4/6/24, my patient who I was really worried about was still agitated. He made some angry phone calls in the afternoon to his family and friends, telling them he had no intention of staying on pills for the rest of his life. Normally I jump straight into "lets talk about meds," but in this moment, I kinda figured the guy wasn't ready to start talking about how mood stabilizers actually work. So instead I grabbed a tangent in conversation and went with that. "Hey man, what's that about plumbing?" We ended up talking for half an hour about all his interests, jobs he's had, what he does in his free time, etc.

Just a whole conversation independent of his delusions and mania. When he finished talking with me, he was out of his agitated state, and ended up calling some family and friends back and apologizing. "I don't actually want to kill myself," he said. Just doesn't want to be on pills for life. Apparently, whatever he was doing outside the hospital, the family and friends don't want him around unless he's on stabilizers.

It's a classic presentation of suicide. "I can't do anything to change anything, life is horrible and painful, it can never get better, god has abandoned me and I give up. It's time." And then you calm down, and start to rethink the decision. I'm glad it worked, with him.

There wasn't much else to talk about yesterday, outside of a different patient who was excited about wrestlemania; ended up talking my ear off about wrestling facts. The guy seems to know the entire family Dwayne "The Rock" Johnson belongs to, and can talk about each member on the fly, with wikipedia to back him up. He's sad we don't have any channels on the unit that stream wrestlemania, so he's been asking me to read articles online to him about what happens.

I kind of loved doing it actually. I don't know anything about wrestling, so he's been teaching me all about it. Turns out the wrestlers aren't always 100% performing, but sometimes they actually deliberately try to hurt each other in the attempt to fix their own careers. "Now no one can stand against me as wrestling champion," or whatever. I figured they'd all just go back stage and shake hands and congratulate each other on another show well done.

So that brings us to today, 4/7/24. Which was a thankfully uneventful day, but only by luck. One of the patients on my acute unit started the day off really, really agitated. He was making aggressive gestures and comments in his room. When I asked him "Hey man, what's up?" He went straight into "Why the hell is it always you?! Why are you always the one always asking me if I'm being aggressive?" I started trying to explain why we're always checking on patients to make sure they're not about to throw hands with anyone, but he wasn't having it. My supervisor was thankfully right there in the hall, and she intervened and took over.

Later, that same patient was angry that I was staring at him, but I wasn't, I was watching how much he (and everyone else) was eating, as part of my job as a nurse. Between his shadowboxing in front of everyone and his paranoia, he was so, so close to attacking someone. So the other nurses ended up asking me to just hang out on the other side of the hall, and let them handle this side for the day.

I always hate that. Not because its the wrong decision or something, but because it hurts my pride. I do this job every day because I want to do it right! I want to help people! Being told "You are inherently the problem for no reason that you can possibly solve and the only solution is for you to leave it" hurts me! So being on the other side of the hall just kinda made me stare at that side of the hall and wonder if everything was okay, all day. Which is actually a fault of mine. I should really have more faith in my coworkers, those other people who were there today are good at what they do.

The day was otherwise uneventful, but I want to mention one of my schizoaffective bipolar patients. He tends to like me, says a lot of good things about me as a nurse. He started challenging me last night about schizophrenia, saying "it's actually a super power, but I know you don't agree with me." Which is true, I don't. But I'm also aware of the population of people who think I'm willing to participate in a system that goes out and actively searches for people with schizophrenia and plucks them from their homes and alters their minds forever, for the crime of being different.

I do not participate in that system. Nobody here does. Since starting this job, I've learned to answer this fear with, "If your voices aren't telling you to hurt yourself or anyone else, I will never meet you." Which is true, as far as I'm concerned; I have to face the facts that there's people out there who hear voices all the time, and who never hurt anyone, or themselves. So why the hell would they ever show up in my ER?

The only people I meet are the people like one of my patients in the most secure part of the unit, who self reported here because he was hearing voices that were commanding him to have sex with animals. And I do this because I'm certain he doesn't want do that, and I want to help him.

But maybe that sounds contradictory to the first guy I mentioned, who doesn't want to be on pills for the rest of his life. I dunno. I'm not gonna be at work this week because I'll be out of town, maybe I'll write about instead or something.

As an aside, that guy was actually pretty calm all day. No agitation, mostly slept in his room but still sociable with peers. Between yesterday and today I'm pretty sure I was wrong about my stage 3 suicidal ideation fears.

I’ve read a few of your diary entries now and I love this blog. You’re doing gods work by being an inpatient nurse. This isn’t necessarily a question but more of giving praise. A lot of my friends and I have all been in and out of psych for years and we all really appreciate how kind the nurses and staff are there. Y’all are the first people we meet on the inside and the guide that serves as a means for us to get better. So thank you :)

This is the easiest ask to answer though. Messages like this are worth more than every daisy award combined! Thank you for sending it! <3

Stop sharing the intimite details of other peoples fucking lives on tumblr cunt.

4/6/24

Now, this ask has been hard for me to answer. This is a problem that's been on my mind for a while now. Is there a right way to share details about a case and a patient

I personally started this blog because I saw too many things for myself and the patients with these struggles to benefit from; I'm surrounded every day by people who think my patients are to be locked up and forgotten about. It's one thing to meet someone who doesn't give a shit about psych patients in a super market, I'm just about numb to that nowadays. It's another thing entirely to have someone who doesn't care, who's your god damned nurse coworker.

Somebody who you know for a fact is trained in psych. Somebody who has had to study the same subjects and pass the same tests as you, and Somebody who is expected to be an expert in care for a patient's psychiatric background, in order to save that patient's life. That somebody still looks at the psych patients on your medical unit and wants them gone. Looking at someone homeless, psychotic, paranoid, and desperate, who's been assaulted every which way, still trying to hold on to a reason to live, and wanting them gone? Because their psychosis is inconvenient? Because you don't like knowing that psychosis can happen to anyone? Because they have an addiction?

It's an attitude I have never respected, yet continuously ran into in the medical side of hospitals. The thing is, nurses who think stuff like that go to the same lectures and continuing education credits I do, and have to learn the same stuff about psych I do. They keep passing the competencies and retaining their licenses, and they keep treating psych patients like they're wastes of space and time. So as far as I'm concerned, just being another face saying "Here's a study that says treating people like people makes treating them easier, even if they're severely mentally ill," isn't going to change any minds.

I figured coming home from work every shift and writing honest posts about things I saw that I loved or hated, or what challenged me that day, would at least give the same subject a different angle; "Hey look at how this person was, today." Something to sort of aggressively hammer home the point that "No, goddammit, they're not wastes of space."

But damn, I'm not really telling the patients I'm doing it either, am I? I can sit here and change details all I want until someone is someone else entirely. "A guy who survived a suicide attempt talked about basketball with me today" and tell myself "that can hardly identify anyone." But I'm still talking about these same patients themselves, without their awareness or consent. Even when my posts are short, even when my posts are "just like any other reddit or twitter post any other doctor or nurse makes every day." That hasn't been sitting well with me for a few months now.

There's an article about this on the American Medical Association's Journal of Ethics website that tackles this issue with physician memoirs. I'm not a physician, but its the same issue, as far as I'm concerned; A Doctor cares about their patients. They write a book about a patient population they care deeply for and a case that has long since stayed with them. The book gets published. The doctor makes money. Did the doctor exploit the patients?

The article makes the point that this kind of thing is "Creative nonfiction in medicine," and discusses some excellent pros and cons to it.

In this context we’ve developed two main approaches to dealing with patient stories in medical memoir. One is informed consent; the other is de-identification [2, 3]. Each of these, however, creates new problems. For example, de-identification, i.e., changing the narrative to make the patient unrecognizable, decreases the factual accuracy of the account, raising the question, “Where does nonfiction end and fiction begin?” Alternatively, what about the patient who refuses consent? Must we never publish stories about angry, withdrawn, or paranoid patients who, like Melville’s Bartleby the scrivener, repeatedly tell us, 'I prefer not to'”' when asked for permission?"

I personally don't sweat the first question too terribly hard; I'd rather everyone who reads this identify with they thing they have in common with the patient than focus on what sport the guy I mentioned likes (it wasn't hockey). I might lose some people who like the real sport we talked about, but I'd gain anyone willing to find the humanity in the guy. The second question is what I'm more worried about.

Let me envision two scenarios for Dr. Cushman as he prepared to publish Picking up the Pieces. In the first case, he has taken the paternalistic attitude that his patients are, after all, poorly educated and lack the sophistication necessary to understand his project. He also felt that authorial license permitted him to alter patient stories at will and to invent situations and conversations in the service of a “larger truth.” Consequently, he neither informed his patients about his use of their narratives, nor obtained their consent—but neither did he alert his readers to his practice of altering or inventing patient narratives. Given this scenario, I would have to conclude that, despite his good intentions, Dr. Cushman should see his book as ethically flawed. Let me make another point about de-identification in creative nonfiction. By definition, “nonfiction” requires factual accuracy. The “creative” element is supposed to be confined to literary style and technique. Nonetheless, authors of memoirs often reconstruct characters, events, and conversations from memory, perhaps with little or no documentary support. Moreover, the memoirist packages his or her experience to present a coherent narrative. In this process, the author might delete, merge, or alter material in the pursuit of “truth.” Although perhaps appropriate, this can constitute a breach of contract with readers, unless the author lets them in on the secret. Readers of books like the one whose publicity blurb I mentioned above rightfully expect an unvarnished firsthand account of actual patients, just as advertised. The remedy for Dr. Cushman would be to explain the criteria and process he used in de-identifying or re-imagining the narratives included in his book.

The article does a great job summing up the perfect, ethical scenario for a medical memoir, or published journal; Obtain the patient's permission, preserve crucial details, change everything else, then publish. Man, I have no idea how to ask my patients if I can write about them like that. After all, I might feel pressured to only write positive and uplifting stories, when being brutally honest about someone's misery or hate would be a more honest representation of psychiatry, in the way laypeople like to pretend isn't real. "Hey, patient who just tried to sexually assault other patient, thanks for getting into the restraint chair for us. Can I write about you on my blog tonight? I promise not to identify you, I just want to talk about how fucked up your upbringing was, and ask the reader 'did they ever really have a chance?'"

I dunno. Maybe I do need to do that.

If I ever suddenly stop posting on this blog without saying goodbye, it's because I decided that was probably the best route to take. Always wanting to do right by my patients and all. Not gonna stop writing about my patients though, that's too helpful for me. And I'm also not gonna stop trying to figure out how the fuck to get more people to care about this field.

People use the mental illness tags because they want community not a judgemental nurse complaining about how hard their job is

Guarantee I'm not complaining. If anything, I do this because I want to shed light on what I do every day. I love my job!

Youre a hypocrite for pretending to support mentally ill people while being a direct pillar of a coersive and abusive system.

I disagree. Between my own psych history, my friends with psych issues, and working in this field, I've learned that it isn't the field of psychiatry that's coersive and abusive, not inherently. That comes from anyone involved who doesn't care, and isn't invested in the best interest of the patient. And, that isn't something unique to psychiatry.

4/5/24

Rough situation today.

Don't get me wrong, it wasn't a dangerous day or anything. We only had three nurses and no techs for the whole acute unit, which meant I didn't have time to sit and review charts safely, but all the patients were, for the most part, fine. One of my patients was having what I and the other nurses suspected were behaviors to imitate psychosis, on the grounds that the symptoms would routinely stop as soon as he noticed nobody was paying him the level of attention he wanted.

But there was a specific rough situation, and it was with one of my patients. The guy's been here since last week. Bipolar type one, came in for mania. Delusions are (almost completely) fixed and don't recede with treatment. The mood stabilizers are controlling the mania; he's definitely way calmer than he was a week ago. Though, he's still pretty anxious.

Which is hard not to understand why, because he knew today he was going to a court hearing for his right to make his own medical decisions. It's the same thing that happens at the end of every brief hold a doctor initiates where they decide "Yeah, this patient needs care that will last several more weeks," and essentially, petition a judge for permission to do that.

All morning before the case, the patient was irritated and anxious. Didn't want to talk to staff or engage with anyone. But the thing is, the hearing came, and he finally spoke his peace. Told the judge about how he didn't have bipolar one, it was just the doctor's opinion, he was actually fine and he just wanted to leave. The judge was calm and showed he was listening respectfully to the patient. So, after that, the patient was noticeably way calmer. Still frustrated, but willing to engage with staff more. In fact, he was frequently seen in the day room talking with other patients and socializing, after that.

I personally thought he was just, up until that point, anticipating the big important event and worried about how it was going to go. But when the doctors came back a few hours later and told him "the extension on your stay has been granted," he stayed calm and sociable. Started asking me questions about mood stabilizers and blood draws, and what conditions he had to satisfy so he could hurry up and leave.

I was pretty happy about that, to start talking to him about medications and levels and what he needed to know about managing his diagnosis. Here I was, thinking everything was going to be cool tomorrow, when I came in with a technician this time, and would have time for patient education. But then he pulls me aside, ten minutes before the end of the shift, and asks me "What states do they do assisted suicide in?"

I start asking him to elaborate. He's mentioned to nursing staff in the past, "Look, I know I don't got much time left on earth." He usually mentions it in the same vein as saving and protecting the omniverse, or that he's a KGB agent. We're of course never happy to hear him talking about feeling like he's going to die so soon, but I don't know how seriously all of us took it. But here he is, going on about physician assisted suicide. Do they have it in canada?

I know PAS was something being hotly debated when I was in nursing school, and I wrote a few papers on it, expecting to one day be confronted with it in the field and knowing I need to know my position on the subject by then. I've mentioned in past posts its the one time I'm comfortable with someone committing suicide, because its usually when someone's on hospice, has months left to live, all quality of life is gone, and they want to go out with a smile. And without the legal consequences and ramifications of having committed suicide, of course.

So I started to explain, plainly (and without a tone), that usually it takes a few doctor's visits to see a patient and the doctor has to determine the patient's prognosis is otherwise poor, and that other treatments aren't likely to help the patient. Just kind of gently moving into "I don't think a doctor is going to tell you its better for you to die than have Bipolar Disorder."

But I didn't even get that far, before the patient cut me off. "I am not spending the rest of my life on pills." His family doesn't want him around them unless he accepts he has an illness and takes the meds, but he knows he doesn't have the illness and hates the meds. He just wants to get the hell out and travel the country, maybe go somewhere PAS is legal, and end it all. "I don't want to kill myself, I just want to remove myself from the equation." His words, not mine.

He ended our conversation before I could dive any deeper. "Just keep this to yourself, alright?" He said to me. So of course I immediately wrote a nurse's note about it in his chart, and told the oncoming night shift about the exchange. It's not something I could really keep to myself anyways, since one of the other nurse's on my shift also very clearly heard him.

With all that smiling, and engagement with his peers? I doubted it at first, but I doubt it a little less now; I'm worried this guy is at suicidal ideation stage 3. The very rarest stage to ever see, in the hospital setting. I think he wants to do it, and he's made peace with it.

Lack of insight is the real killer, in all mental illnesses. If no one accepts the problem is the problem, nobody addresses it. My schizophrenic patients and bipolar patients who know they're paranoid are so eager to get treatment, my heart goes out to them when they come back as a result of something dumb happening in the community that stopped them from continuing care. But this? It's anosognasia. The meds can control his mood disorder, but they can't make him recognize it. He thinks he's an otherworldly being and that he's going to protect infinite versions of the multiverse, and that his soul is going to be just fine after he kills himself.

Man. This case is going to occupy me in the morning. One of my most challenging yet, I think.

3/31/24

Today was a long, looong day.

Not for any particularly exhausting reason; we just had two patients on the unit, in the back hall, with bipolar mania. No insight in either of them, both delusional, and both can't stop themselves from talking.

They're both also really anxious people and sociable with each other, which means they feed off each other pretty hard. They would sit in the day room and talk, and no matter what it would always be about discharge. One in particular I almost think was truly perseverating on the subject, as opposed to simple rumination. No matter what I'd do to try to explain to him the conditions of his admission, or whatever phone calls I'd make, whatever information I'd show him in the chart or notes I'd write with him watching over my shoulder, he couldn't stop talking about, or thinking about, discharge. Nothing I say to him about the importance of staying on mood stabilizers when he leaves the hospital sticks. He's someone we're going to see again.

But yeah, that kind of constant "I can't believe they've got me here," six times a minute, minute after minute, hour after hour, has a way of wearing away at someone. All of us were pretty exhausted by the end of this shift. On the flip side of the hall though, my two BPD patients were getting along with each other again. The older guy who I mentioned in my previous two posts was just spending time talking with the younger one and getting to know her. I was kind of worried for a while that maybe he'd be inappropriate with her, but he genuinely just seemed like he wanted to be nice to a young lady who's struggling with the same condition he's got.

He ended up talking with me some more this evening, before shift change. Just ended up rambling a lot about his life. Friends who're dead, family who're dead or he's finally burnt his bridges with, sexual behavior he hates himself for (cheating/promiscuity), attempts he's made in the past to try to control himself and manage his behavior. Talking about how he's aware that he only sees people as either all good or all bad, with no in between. He's committed to staying on Seroquel, now. Hasn't been able to stay on it in the past, but he wants to stay on it, now. Something about this stay was the stay, for him. I don't know if that's true or not, but he was talking tonight like this is the last time he's coming somewhere like this, in a positive, moving forward kind of way. I'm rooting for my boy.

Oh and uh. One of my patients came out of his room completely agitated and making verbal threats. I walked him back to his room and talked with him a bit about what's going on. When he was ranting to me about what amounted to fears of being a victim of violence, he was glaring pretty angrily at myself and other things in the room, and I noticed his retinas were unequal. I definitely did a double take at that; That kind of retinal mismatch is something you only ever see in cartoons, really. I told the doctor about it immediately after I got done with the guy and she clarified for me he's got a history of retinal detachment and likely wasn't suffering any new onset CNS damage. I likely hadn't noticed it because I hadn't seen his one functioning pupil constrict r/t agitation like that. Definitely caught me off guard.

3/30/24

My patient from yesterday, who had the questions about psych and institutional abuse, started talking to me about it again today. We talked briefly about the troubled teen industry and how horrifying it is. He mentioned to me something from a book written by Peter Breggins, and I mentioned that I was critical of that author. He actually looked at me pretty shocked, didn't expect me to know who that was.

I talked a bit about how people who are huge into antipsychiatry often times care about this demographic just as much as I do, they just have different ideas about how to be good to them. I've already emphasized to him several times that he's not being punished for being here, but I think it's starting to sink in a bit, exactly how much I mean that.

So he ends up taking some of the playing cards he was playing solitaire with, and he spread them out in front of him. Like, 52 pick up style. Not paying attention to their pattern or anything, just spreading them out. Then he calls me over and asks me to pick a card, any card.

I pick one. He starts going on "yeah, it's the four of hearts." I haven't seen the card yet, but I thought to myself, okay, so the back of the cards are marked. But then he says "Your next two cards will be the seven of clubs and the queen of hearts." So I grab two cards. Just, two fuckin cards. He flips them for me. It's the four of hearts, the seven of clubs, and the queen of hearts.

What the fuck? I ask him to do it again, this time watching more intently as he shuffles the deck. He spreads it all out in front of him again. He tells me, "Okay, pick a card." I literally just pick a fucking card. "Jack of spades. Next will be the three of clubs and the two of diamonds."

And they fucking were. They were exactly those cards! I start asking him "How the hell are you doing that??" He said "Oh I'm not doing anything, you're the magic one!" Ohhhh, oh the bastard. Oh he drove me nuts in that moment. I keep trying to figure out how the hell this trick worked!

Later that shift he heard me talking to a young patient, gen z, someone I made fun of (laughed with) for having among us installed on her phone. Found out she had borderline personality disorder, just like he does. Both of them are just here while they wait to find placement for themselves outside the hospital. He ended up spending time getting to know her, playing cards and scrabble.

Good guy, all told. Just needs help managing his anxiety, and his emotions.

3/29/24

One of my patients today has some kind of history of anxiety or delusional thinking, that I didn't really get to spend a lot of time going into today. But when dinner rolled around and I was watching the patients eat, he started asking me questions about myself as a nurse and nursing practice.

It was lots of the same questions and concerns people have about psych units to begin with. Just the same standard "Hey, are these meds FDA approved?" and "Are patients here incognito? Do you tell anyone patients are here when they're here?" He clarified as in, family and friends. It wasn't the kind of delusional paranoia fear, it was the "this is what I've heard about these units" fear. As in, someone is going to be sequestered away and given mind altering drugs that permanently make them into a zombie.

He was pretty educated on it. He was aware of the risperidone nation wide class action lawsuit that started 14 years ago, for example. "Pharmaceutical companies lie for money." Mostly his fear was "what if you, the nurse, are doing something to somebody, that you think is the right thing to do, but ultimately its based on evidence that has been doctored with a profit motive by a pharmaceutical company?"

I just kind of answered his questions as best and as honestly as I could. The thing about that last one is, that can really be applied to anything in life. "Is someone manipulating me? Am I being taken advantage of right now?" With out any further information, that question is really just a litmus test for whether or not someone is an optimist or a pessimist. But I emphasized to him, I fully respect pharmaceutical watch dog groups and whistle blowers completely and entirely.

I told the oncoming nurse "I didn't have time to look into it, so for me it's a differential between 'is this delusional' and 'is this just anxiety?' To be frank, I'm leaning towards anxiety. Guy just wants to make sure his hospital staff cares about what they do and isn't screwing him over.

3/24/24

Work was null today. Lots of calm patients who got along with each other. Knowing the patients we've had on this unit, and that a few of them are repeat admissions who can be difficult personalities, these are the days I swear up and down "psych nursing is only easy if you care about doing it right." Happy, calm, cooperative patients are three thousand times easier to deal with!

One of the hypersexual patients keeps calling all the men on the unit her husband(s). It's rough because she gets all smiley with me, seems like she's oriented to reality, then starts telling me she loved me in all the movies I've been in. Earlier today, I watched a small handful of security guards walk onto the unit and make small talk with the nursing staff during their change of shift. The patient started trying to smile with them and talk to them, and they just kind of gave her a side "how do you do" kind of deal before getting back to their conversation.

I saw her go from clearly wanting to stand and talk with everyone to just, turning away, ignoring all of it, flipping back to talking about something delusional while watching TV. It just hurt my heart to watch. Poor lady's lonely, just wants to hang out with people and talk. But when we try to talk to her, she gets hypersexual and inappropriate, can't turn it off.

When she was in the ED, she wandered into a patient's room who was in 4 point restraints (sedated, as I understand it) and started kissing him. Apparently the ER nurses were monitoring the situation from a camera instead of being directly at bedside for their 1:1. When she gets manic like this she just can't stop herself.