Unexpected sadness

I haven't written for a long while. Recently I did a pregnancy test on a young woman, freshly out of college, who found out she was pregnant. She isn't sure what she wants to do. Part of my options counseling involved providing her with the names and numbers of local abortion clinics, which she requested. I didn't expect this, but it made me really sad. I'm a very strong advocate of woman's right to choice. But I still had to say a little prayer before I gave her the information.

Kazakhstan!

Here's portions of a letter that became a diary entry:

I am in Taraz, Kazakhstan now. I keep thinking of you because I keep seeing different birds and wishing that I had a bird book of central Asia with me. It’s quite wonderfully different here. We spent a few days in Almaty, which is the most cosmopolitan city here. There were two cities in Kazkahstan in which the USSR exiled intellectuals to and Almaty was one of them. Therefore it has a great intellectual academic class here. Because Janara and Daniel are very involved with the arts, we have learned all about the current artistic situation, gone to galleries with shows that were extended just for us, and had dinner with two of the country’s leading artists. (Their work, which we saw, is amazing). We also met with the Soros Cultural Institute artistic director and also learned from her about what is going on with the art community here. Because of oil money, Almaty is currently undergoing a construction boom. Prices have skyrocketed for apartments and while they are still not Boston prices, they are not far behind with one bedrooms going for the equivalent of $150,000. Everywhere we look there are new sky rise apartment buildings; of course most people cannot afford to live in them and it is said that a person is hired to turn the lights on and off inside to make them seem occupied.

Because there is no concept of tenants rights, people can be evicted without any notice if they decide to tear down the apartment for a new building. The gentrification process is excruciatingly painful here as it is anywhere else; the artistic community is being decimated, being turned out of their homes and studios and having to relocate to the outskirts of the city.

I’ve been astonished at the multicultural nature of the city. It’s Russian, Kazakh, Uzbek and Korean. Daniel sometimes gets stopped and they ask if he is Uzbek, there must be an illegal Uzbek immigration ‘problem’ according to authorities here. But when he says he is Mexican, they become very excited. He is probably the only Latin American person here.

The city is very green, with lush tree-lined boulevards and wide pedestrian pathways. All the green areas are thick and overgrown, creating a wild air in the city. Everywhere there is a mix of the old and the new. At the airport, there were automatic machines to pay the parking fee, but they were broken so you had to pay someone at the gate who would then open the lot for you. The residents are very fashionable, closer to downtown Boston or NYC style than to my style. Apartment buildings are either the nice, new modern ones or are old Soviet style cement monstrosities; I have some great pictures of them.The buildings were originally unfinished concrete on the outside; now the individual apartment owners are renovating them one by one. So the outside of a large building contains a mix of unfinished concrete, scattered siding, tiles, and other finishing materials. It makes an interesting melange. To travel from place to place we have taken buses, where they push you off if you don’t disembark quickly enough, to ‘taxis’- private cars that you flag down and they take you where you want to go for $2 - $3. It’s very safe. The price would be 3-4x as much if we didn’t have Zhanara to bargain for us.

The modernity of the city has certainly impressed me. Parts of it remind me of Japan. There was one mall we walked into that could have been any mall in the US with Benetton and Adidas stores charging $100-$200 for items.

We took a train to Taraz. It is a ten hour ride and we went in a sleeper car. It had 2 bunk beds, the top ones folded up. The train is one beneficial aspect of soviet times; it was fairly comfortable and very quaint. Mom was reminded of old British murder mystery novels set on sleeper cars. Evidently the police visited us and checked our passports because we are unique as Western tourists, but were friendly. They even sat down to chat. I slept through the whole thing. As a matter of fact, the rocking of the train served as a wonderful soporific for me. I slept 8 out of the 10 hours.

difficult days at work

I worked the last two days as a PCA at my job; it was really the last two days that I will work there because once a PCA has her RN license, she isn't allowed to work on the floor as a PCA anymore. I don't know why as other floors allow it, but my floor does not. I actually passed the boards in March, but because I enjoyed my job, needed the money, and didn't have time to look for or orient in a new job during school, I didn't tell any of the RNs, just the other PCAs.

While I had signed up to work the past two days, as a per diem employee, I don't know why they had me come in. Generally Sunday and Monday day are the quietest days, no surgeries and lots of discharges over the weekend; most of the surgery patients on Monday go initially to the ICU before coming to our unit. By Monday night, the floor starts filling up and by Friday it is a dance for rooms.The patient census wasn't high enough. I was working as a respiratory walker and there were only 5 or 6 stepdown-ICU patients; all the rest were regular floor patients and only a couple of them needed the thoracic walker or a companion to walk with (if we are worried about falls). So I spent a lot of time over the twenty hours trying to look busy.

Finally for the last hour I replaced another PCA who was sitting with a confused patient. This patient's case gave me the heebie-jeebies. She'd been at another elite hospital for more than a month, had gone home to die and had been home only a few short weeks before her family heard about the amazing surgeon here and decided that this surgeon would save the life of their beloved older family member. One family member even told me that he couldn't wait for the surgery. I knew at this point from Rounds that surgery was not an option. The cancer was too far advanced and the patient was too weak. A family meeting was called for more than 5 days later (time for all family members to arrive) where the news would be broken that surgery is not an option.

The patient, whose mental state was cloudy due to all the pain medication, has now been in the hospital for almost two months straight. Now, this is projection on my part, but if I were her, if my options were going to be palliative care or hospice, I'd want to know right away. I'd want to go home. I found it very difficult to sit there with her and not ask her if she wanted to go home or what she wanted. I get impatient with time lags. Hospitals are deadening places. I don't want to die in one unless it were the only way my symptoms could be controlled. Part of me does think that the way I want to die, if I have to die slowly, should be with a morphine and ativan drip. Morphine to control my pain and breathlessness. Ativan because, and I haven't seen this yet, but another nurse friend tells me, dying is anxiety producing and psychologically unpleasant. My ideal way to die would be with chronic renal failure when I am old enough to know that I don't want dialysis; then I will just drift off.

Temper Tantrum

First of all, sorry for not writing for a while. We had our pinning ceremony at school, my family came up to visit, and then to top it all off, I got really sick for two days. But I'm starting to feel better. As part of feeling better, I was puttering around my apartment and tidying it up. Now I live with 4 other roommates. We have a very large place. As I've been in school, I've felt the need to save money. Hence 4 roommates and I live in a very run down place.

But run down or not, there's no need to live in filth. Our kitchen today qualified as living in filth. There were so many dirty dishes in the sink that no one else could wash. There was mail scattered all over the place. The trash had been emptied, but no bag put in and someone had left two bags of groceries sitting out.

So I had a small kitchen temper tantrum. Groceries went in front of one roommates room. Any unidentifiable random crap, in the trash. All the plastic cups, tupperware, vases, beer and wine glasses that had been sitting there waiting to be washed for a month are now in the trash. Mail that has been out for a week is now in the trash. I washed anything that isconceivably mine or that I want to keep. I even tossed out some mugs that I don't particularly like and that have been sitting there for a month. It was disgusting. Absolutely disgusting. There's a pile of dishes left that belong to one particular roommate that are in one area. I felt like the parent who gets frustrated when the kids don't pick up and throws out the toys instead.

I am counting down the days until our gas gets turned off. We all contribute equally and each take a bill. For some reason, the gas bill keeps going in increasingly late and it hasn't been fully paid in three months. It's not my name on it, so I don't mind. I can't wait to get a job so that I can move. When I move, I am buying a cat. I can't wait. At least then I will be living in my own filth.

Homeless Volunteering

I had my first night volunteering with a group that does homeless youth (< 25 yrs) outreach. They have a medical van that goes out and actually serves people of any age, not just youth. The medical services provided are another draw for the kids to come by and for the outreach workers to connect with them. I really enjoyed myself.

It'll be an intense learning experience as I will have to start really relying on my own assessments and plans; I won't have another person to double check it with (Usually it's one medical person, RN, NP, MD or PA volunteering at a time). Tonight I was working with a NP. I think with what I saw today, I'll be ok. If it's a true emergency, we'll call 911, which they've had to do a few times in the past. One guy I would have been nervous with as he was on heroin and coke and he was really twitchy. But I think I'll get better at gauging it.

I've been surprised at how honest the patients were. One pt. told me in the same sentence about her daughter and her heroin addiction. This will be a good exercise in learning patience and acceptance. The knowledge of her daughter makes me even more uncomfortable with her addiction. But lectures of any kind will NOT work and are completely inappropriate. I did get her info about the community health center close to where she lives and she promised to make an appointment tomorrow (CA-MRSA with two abscesses). The more connected she gets to the community and the more resources she has to depend on, the better she will be. I tell myself and I believe that it is about building support for individuals and through engagement change can occur.

Current Favorite Music

I'm always looking for new music to listen to. Here is what I'm listening to now as I work on my pharm project. If you like any of these and think that I might like someone who you listen to, please let me know.

Richard Shindell: http://www.richardshindell.com/
Patty Larkin: http://pattylarkin.com/
Peter Mulvey: http://petermulvey.com/
Naomi Sommers: http://www.naomisommers.com/

Trauma

I still can't stop thinking about the kids at the residential crisis center I interviewed at. Most are aged 4 - 12, a few 3 year olds and a few 13 years olds with developmental disabilities; they are primarily foster care kids or former foster care kids (now adopted) who had been so severely physically or sexually abused that they are in need of a crisis placement out of a home to stabilize their behavior.

I haven't worked around kids in a long time. I had forgotten how young 12 is. When I read cases of horrific abuse and the young ages of the kids, I hadn't been able to make that translation to reality. I keep seeing the babies and cannot imagine the abuse that has been done. These kids are just babies is all I can think. They are so young, so small.

Confessions of A Mormon Boy

Last night, I went to see the play Confessions of a Mormon Boy. It is a one man show and the performer is also the author of the play; it is autobiographical. He describes his agonizing attempts for him to turn himself straight, the 'help' that he got from the Mormon Church, their referral to ex-gay therapists and help paying for them. He got married, having told his fiancee that he was struggling with homosexuality. Eventually his ability to 'remain straight' failed, he was excommunicated from the church, moved to NYC, became an escort (ie., prostitute), got involved with drugs, and eventually got clean of it all. The performance was phenomenal. Riveting the entire time. I think I can say that it was one of the best performances I've seen this year (I love student rush, when I have the time, I see as many plays as I can.)

I kept thinking the entire time about how much individual pain the Mormon Church and other conservative churches have caused. The amount of individual anguish that the belief that "homosexual acts are an abomination" has caused is overwhelming. When you are connected and have grown up within your church, synagogue, mosque, meeting, place of worship, and it is your entire life, having to reject it is heartbreaking. Thank God I grew up Quaker.

Another interview

This one is at a rehab hospital 20-40 minutes away from my house. No interview is set up yet, but I interviewed on the phone with human resources and she is getting some times and dates from the nurse manager. Cross your fingers. I'd really like the pediatric one I just wrote about, but they are hoping to find someone who can stay on fulltime. But there's a chance that they won't be able to, so then they would hire a few of us on part-time for the school year.

The rehab hospital sounds interesting. Three of their units I am interested in: cardiac rehab, spinal cord injury and brain injury. I think the SCI unit would be the toughest because the patients would be the youngest. This hospital pays $7-$9 differential for evenings, which is nice too. So cross your fingers that I get an interview before I leave for Kazakhstan.

Residential setting

Today I applied for a job at a residential crisis assessment, stabilization and treatment center for kids with serious emotional disturbances (ie., predominantly foster care and former foster care kids). The director, in my interview emphasized that the rewards are sometimes hard to see because the acuity level is so high and the kids are very disturbed from the physical, sexual and emotional abuse and neglect that they have undergone. She said that they have some children who are at the center whose parents were also treated here when they were children. Talk about a cycle that hasn't been broken.

Friendship dynamics

I had a friend who was a very good study buddy of mine. We dated briefly, it didn't work, and we returned to being friends. We were good study buddies and then the dynamics got weird. I found myself being uncomfortable in our conversations and get togethers, but I wouldn't be able to pinpoint why. I just knew that I was feeling uncomfortable about it. After a while, I realized that I was feeling bullied. Part of the problem is that it is lot of small interactions. If I think enough, I can pinpoint it, but when you talk about it, it often seems like trivial encounters.

For example, I was trying to figure out how I would work up an ALTE (acute life threatening event) in an infant. With an ALTE, an infant may while feeding or at some other time, suddenly turn blue, have trouble breathing, go limp, but with stimulation, promptly revives. In our conversation, he starts talking about what follow up he would do. I try to redirect to what we would do as our initial evaluation. But he keep talking about what we'd do as follow up. I get frustrated and say, can we talk about follow up after we've talked about the initial workup? He follows up with "I think you are just being too strict in your definition of follow up," rather than just saying "actually by follow up, I mean follow up to the ALTE not follow up after the initial visit."

It's those small types of interactions that make you feel silly if you pursue them. It's the overly intense reaction and adding in the attack, rather than just assuming that I wasn't following him, he assumes that I am being purposefully dense. It sounds so silly now as I try to write about it. But I do know that I am not comfortable around him now and I need to remember that and not make plans to get together and study. It's hard to accept that things are different.

Kudos

Talking to my psychiatrist today in a checkup on the strattera prescription, he told me that I shouldn't stop at an RN, but should become a nurse practitioner. I reminded him that that was my plan and he laughed, remembered, and asked if I was doing psych because he thought I'd be good at it. I told him no, I'm doing family and we talked a bit about it.

I'd thought a while about doing psych. For a time, I thought I might want to be a therapist. Finally I decided that I didn't because while I "get" a lot of things, I have trouble really getting some big issues that people come to therapy for. The judgemental side of me comes out and while listening about the troubles that a friend's roommate has with agoraphobia, I hear that little niggling whisper telling me that if she were to just try hard enough, just be with the anxiety when she went outside, it would get really bad and then start to decrease. If she just did that enough times, she'd "get over it."

This whisper knows that I know nothing about proper treatment of agoraphobia or its physiological basis. This whisper is also the same whisperer that that I hear when I think about cigarette addiction, drug abuse, alcoholism, etc. The judgemental side comes out. If I have personal knowledge of the struggle, I'm fine (no whisper). If I've observed really close friends struggling with it, then I'm fine. But without it, I judge and I hate it.

I don't know if I would judge if I were sitting in the room with someone. I don't think I would. In everyday life when I interact with people, I am almost not judgemental enough, too accepting.

There were a lot of other reasons why I chose not to become a psych np, I know I would have shut down the whisperer and been ok. But I'm glad I went with family.

Painful

But I still find myself hurt by it. As we've gotten closer and I've become interested, I do find myself hurt that it is not a real possibility. Please don't flirt with me if it's not, I need help to maintain appropriate friendship boundaries too.

I'm out, fully out

As Process pointed out, once you miss the chance to out yourself early in a relationship (platonic or romantic) with someone, it becomes more and more difficult to come out again. So with that in mind, I recently outed myself to M. We were talking about experiences having friends that we've had sexual chemistry with. I may lie by ommision, I won't lie by commision. So in my response, I acknowledged that the person I was talking about was a woman.

It was nice and we talked a bit about it. Later in the week we were out walking and I ended up mentioning the ADD (which I normally don't share with people who are or are potential work peers) and he asked me if I take meds for it, which I acknowledged I do. It's hard for me to be out to someone w/o ADD as an adult with it. Most of my friends have it; we do attract each other. But for those who don't, there is a serious lack of understanding. When I acknowledge that I take medication for it, I still feel some transient shame.

We keep spending large chunks of time together. I'm a little nervous because it is beginning to get the flavor of a potential relationship and I'm finding my feelings changing from brotherly/friendship to friendship/potential partner.

This isn't good for a couple different reasons. Reason #1: he's acknowledged having a pattern of sleeping with his female friends and having that mess up their friendship and of having a lot of unprotected sex in the past. To remedy this, he's cut back on his drinking a lot, started therapy (for reasons broader than this), and explicitly told me about this because he doesn't want to mess up our friendship.

Reason #2: He's two months post a breakup from a year long relationship. That one stands by itself.

Reason #3: He says that he has a habit of supporting a close friend or significant other emotionally for a long time and not getting his needs met and then he disappears suddenly and hurts them.

So he is not a good dating partner right now. But when there is that connection, I am so hesitant to let it go. There are so few guys who I really like and who are emotionally open. I am still averse to dating women right now (baggage) and now that I am becoming interested in him, I hate to lose it. All my friends are in relationships right now and it is really hard to be the only one that is not. Plus, we'd have really cute red headed children.

Pediatric vs Adult floors

Today I had an interview on a pediatric rehabilitation floor. The floor looks like a wonderful place to have kids. The floors are wood, the walls are painted. Their are stars on the ceiling, fish tanks and lots of color on the walls- a great mural that the kids have painted. All meals are eaten in a central dining room, all the kids together, and there are child life specialists whose job it is to make being a patient as a kid all a little easier.

My question is, why don't we do this on the adult floors? They are gloomy with white hard marble floors, white walls and beige or tan trim. All the rooms look alike, the flourescent ceiling lights make everybody look a little off and patients who are there on long stays are very isolated. I find it disorienting and I am young and healthy.

Now imagine that you are 68, in pain, on oxygen, trying to walk with a walker carrying your O2 tank and a chest tube. You generally wear glasses, but someone put them in the bedside table a few days ago and it seems like too much work to get them back. You've been in a room with three other patients for two days waiting to improve enough to move to a more private room. In the room you are in, their are 4 tvs going. Beeps every few minutes if an O2 monitor slips off a finger or if someone's heart rate is a little too high. Because of the noise, you haven't slept much and someone is taking your vital signs every couple hours anyway. A person you have never met before today is pushing your IV pole. You have walked in a circle between the four "pods" three times today to get your exercise; now you are circling back around in your pod to find your room. It's all white. You are confused, overwhelmed and you don't know where to go.

I've had patients only make it a few feet out of their room because the floor is so busy, so intense, and so disorienting.

Is a white wall any cleaner than a blue or purple or green wall? Can't there be pictures on the walls and non-flourescent lights? Can the hallways be wider? Can staff be alerted to codes via beepers rather than overhead announcements? Can their be a central dining room for patients without infectious diseases? What about a room with a few computers for adults to use? How come on the pediatric floor there is always room for a family member to sleep but not on the adult floor? Families are important for us too. Why is it that as adults we are expected to be immune to the physical environment? If I had a choice, I'd prefer to be on a pediatric floor. It's more humane.

Good news: ADD not NVLD

I got the final report back from the neuropsych testing. I found it pretty interesting. The results were substantially different from last time. They did find that I do still have ADD, that is consistent. But all the non-verbal test scores had gone way up. They explained that my abilities aren't as high as the test scores indicate although higher than the original scores indicated. My familiarity with testing made most of my scores go up. Also, I was moderately depressed at the time of the first testing. The areas that I was weakest in, the visuospatial abilities, became even weaker when I was depressed.

The components of the testing that indicated attentional difficulties however, I continued to have problems with. I knew that, one third of the way through the testing, Dr. B told me that she was almost positive that ADD would be a constant diagnosis. If I were NVLD, even with my testing experience and lack of current depression, I would still falter, same as I did with the attentional and planning components.

I am so happy to hear this. The research about "success" in adult life with NVLD is pretty bleak. I felt like I needed to know so that I could learn how to compensate for it.

The best advice I've gotten so far has been Dr. W's suggestion to go on Strattera rather than the stimulant medications. She says it is best for ADD without hyperactivity and also works very well in people who are weakest in non-verbal areas. I'm noticing consistently subtle changes every day. If I don't want to read anymore, if I don't want to lie in bed anymore, I can think about it, stop doing it and get up. It may sound weird, but I had immense difficulties doing so before. For 27 years, I would get into almost a trance state with books, tv, computer browsing and NOT be able to shake it even when I wanted to. It's something that I've even talked about in therapy because it was impairing my ability to manage my life and it isn't an obvious ADD sign. Lately though, I've been able to just stop, think about what I want to do and put down my book and do it. Phenomenal. I don't know why my psychiatrist had been so reluctant to try it. I'd brought it up a few times before; I really had to push it this time and emphasive the irritability that Adderal gave.

One more thing that Dr. W said was that my social skills difficulties as a kid were all ADD related. She said that because I've grown out of them in my twenties. In fact, and I want to do some research to see if this is true, Dr. W said that people with ADD mature about 30% slower than people without it. So in a lot of ways I'm like a 19 year old. Not in terms of my drinking or stupid decisions, but in terms of taking control of my life, figuring out what I want to do, social skillwise and personal empowerment. I don't really think of myself as a 19 year old, but in a lot of ways, I've only recently, in the past year or so, felt myself to be more like other people in terms of social abilities, knowing what I want to do and how to arrange my life the way I want.

I have an interview!!

I'm very excited. It's on the pediatric inpatient rehabilitation floor at one of the best rehabilitation hospitals in the country! I did research there, (not pediatric research), my senior year of college. Don't want to jinx it, but this would be an acceptable job.

I found out the nurse manager's name at a major teaching hospital nearby for the Acute Respiratory Disorders floor. There they do ventilator weaning and other work with patients with major respiratory disorders and sent her my resume directly. That would be an absolutely ideal job. I'd be willing to go to school part-time for that job.

Cross your fingers.

Verizon remains evil.

Evil is too strong of a word. Incompetent is a more accurate word.

After spending two hours tonight trying to upgrade my phone, after talking to multiple Verizon customer service reps online and being told that I have a bad credit card and finally talking to someone over the phone, and being told that their ordering service is still down, I have just ordered a new phone from T Mobile.

Multiple friends rave about T Mobile's customer service. I found a plan that works a little differently, but will give me about the same number of minutes for the same price.
The entire checkout process with T Mobile- 4 minutes.
The process with Verizon- multiple attempts over 2 weeks, been insulted by a rep, been told I have a suspended credit card, probably spent 5-6 hours total with them trying to remain a paying customer.

Here's a hint to all companies. If you are changing your ordering system, FIRST inform ALL employees. SECOND, make it clear on the website. THIRD, don't allow customers to spend an hour figuring out which phone and which service works for them and then let them get to checkout and give them repeat error messages regarding their credit card. This isn't rocket science folks.

Centering

Today I had trouble centering in church. None of it felt like worship to me. I think that I am still trying to determine how much church attenddance is right for me and how much is too much. Some of it may also be that I haven't had a real day off or chance to sleep in for weeks. I fell asleep last night at eleven, but still woke up reluctantly today around 9 and barely made it into the shower and out of the house in time for 10 am service.

I wish that there were a programmed Quaker meeting around here. Maybe I'll start attending Quaker meeting one day a month and the rest of the time UCC. That may give me the quiet worship that I need in small amounts.

How much information to share?

At work today, I was a 1:1 sitter. My patient had gone through a very invasive surgery and developed delerium afterwards. The delerium is likely due to combination of her age, the invasiveness of the surgery, and the narcotic pain medicine she was given. As soon as it developed, the medication was stopped, but her sensorium didn't clear immediately (nor would it be expected to).

Her family had been reassured that this was because of the medication and the surgery and would only be temporary. Likely it will be. However, in some older adults, delerium from medication, surgery, UTI or pneumonia, can spark the long slide into dementia. For some, it may worsen a pre-existing unrecognized dementia and for others, it may spark a dementia that would otherwise not develop for a few more years. This certainly doesn't happen in all cases, but in a larger percentage of cases than we like, it does happen. Almost as bad, often delerium following hospitalization is a sign of impending dementia. She might be all right in a few days, but in a few years, she will likely not be.

All day I wondered about the ethics of not telling her family that this is a possibility. At what point should that information be shared? Right up front when the delerium is recognized? If it doesn't clear within 24 hours? 48 hours? If she's still not cognitively intact at discharge or in rehab? How much information is too much and overwhelming? At what point are we "protecting" the family the same way we used to protect terminally ill patients by not talking about death? One of nurses' main jobs is to translate medical information from medicalese to language that the rest of us can understand and that is pertinent to every day life.

I'm uncomfortable when I need to decide what information at what point needs to be shared. The family wasn't even told that she had developed delerium. Rather, they were told that it was a "medication reaction." I disagree with that as it may prevent her from using the opiod medication in the future when it may be needed and, without the stress of surgery, it may not trigger delerium. A medication reaction is like haldol causing tardive dyskinesia. Even more, if a family member wants to find out more information about what happened later, they won't find it if they don't have the accurate name for what happened to them. The final trigger may have been the medication, but I can guarantee you that if she were 40 years younger and going through the exact same operation, she would not have become delerious.