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.

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.

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.

I closeted myself tonight.

I've become friends with someone in my grad program who is a year ahead of me in the program. We actually met in church, he started attending a few weeks after me and we saw each other across the aisle. He has very similar hair and skin coloring and when I looked at him initially, he reminded me of my father when he was younger. Walking past us on the street, I think many people might think that we were related, brother and sister because of our coloring. A lot of what he says, reminds me of myself. He talks about not being able to be alone and do activities by himself; I used to frequently wish that I were more independent. He is very easy to get along with (I love male nurses; I love men who talk about emotional intimacy and palliative care) and we've been getting to know each other.

Earlier this week in class I was talking about a friend and her girlfriend, and he asked me if I had any straight friends. It was half in jest, but half real. Most of my friends are queer. Tonight we were talking about college and he asked me why I made the decision to attend an all-women's college. This would have been the perfect time for me to say that I chose it because I felt so comfortable there and the reason I felt so comfortable there was that they had a very visible queer group on campus. Then I could have launched into the explanation about how I date both women and men yadda yadda yadda...

But I didn't. I talked about all the other reasons I chose it. I talked about being a feminist and how wonderful it is to be in an arena where strong smart intellectual women are the norm and how you don't need to compete in class to be called on, to be listened to. How wonderful it was to be able to do the experiments in science class without having to force my lab partner to let me do some of it. All of it true, but not why I chose it. I chose it because I wanted to date women, to surround myself with women, and to explore this part of myself. But I didn't want him to know that. I wanted him to keep me in the "normal" category because I admire him. While I'm not particularly attracted to him, part of me wishes that I were.

Because I've felt out of sync with the rest of the world for a long time, part of me wants to be closeted and just step with everybody else. That, and lately I have been only minimally attracted to woman, I've been wanting to get away from my queerness. Or, to have it not be an issue at all. I enjoy the dynamic I have with him. I like the friendly flirtation we do. I don't want to change it. I also don't want an additional person in my life to try to define who I am attracted to. I've had too many friends tell me, "You can't be bi, you're even gayer than me." Or from people I don't know well, "I could never imagine you with a boy. You're so clearly oriented to women." And, occasionally from random people, "but you don't look gay."

But guess what, I am bi. I am attracted to men. I am attracted to women. At different times, I may be attracted to them with different intensity, but that does not preclude the fact that I have been intensely attracted to both men and women. So why didn't I tell him? I didn't want to open the conversation, I didn't want to be different, and I didn't want another person scrutinizing me for evidence of which way I "truly" lean. But, I'm still uncomfortable with my reticence and now, as I get to know him better and better, it will only be harder for me to open up that conversation.

Nursing Home Education

Today, at the nursing home I am at for the semester, I watched one resident try very determinedly to teach another resident how to "walk" across the floor in his wheelchair. He was crawling along at about one inch an hour. So she tried explaining, repeatedly, how if you move your feet as if you were walking, but stayed seated, you'd move quickly. Unfortunately, every time she said the word "walk," he'd try to stand up to walk. Then she'd yell at him to sit down, which he would. The process would then start all over again. After about fifteen minutes, she gave up, but boy was it amusing.

I love the signs of life in the home. Many of the residents are so impaired that they cannot socialize, but the ones who do are active. The romances, hurt feelings and roommate quarrels aren't obvious at first, but now that I have been there three months, that world is becoming more transparent to me. I love this population.

Boundaries

When I went a week or so ago to be retested for ADD/NVLD, the neuropsychologist who tested me introduced herself as Dr. X. It felt very strange. The one who had tested me in college I also called Dr. W, but that didn't feel weird. Some of it I think is the age difference. Dr. W is 20+ years older than me; I met her when I was younger and she is an expert in her field. Dr. X is my age, could be a little older or a little younger.

I've spent several years doing psychology research since I graduated college and didn't call anybody except for two particular individuals by their title "Dr." and even then we'd often go by first names. It made me feel uncomfortable. I felt as if she were demarkating the differences between us with the title. Part of it is I am not comfortable in the patient role; I want to feel a working partnership between equals and my expertise to be respected. At the same time, I acknowledge that she is more of an expert in this area than I am. I just felt as if the title made the relationship hierarchical rather than, hmm, I'm not sure what the word is. Rather than non-hierarchical? Rather than a relationship between equals I guess. I felt as if we were unequal partners.

How much of this is guided by physical appearances I don't know. Dr. W inspires confidence. She has visible markings that separate her from me. We're not peers in any sense. Her "bedside," I guess "chairside" manner is better. She's a little warmer, D. X was a little more New Englandy. As part of it, I think that some of it is Dr. W's greater experience and knowledge allows her to focus more on her interactions with her patients and less on what she is doing. Dr. X is still more task oriented.

I'm going to keep a lot of this in mind when I have patients independently. I'm not sure how I'll use it, but I know it will be important.

An unusual presentation

At a birthday party on Saturday, one of my friends left early because she didn't feel well. I asked her what was wrong, and she said she didn't know, she was exhausted and had been fainting a lot lately. Although my friend has a tendency to be rather melodramatic (going to the ED because the back of her throat looked funny; she didn't feel ill) and she also faints every time she sees blood or has blood taken, this sounded a little strange even for her.

My wise nursing skills came into play and I strongly encouraged her to go see a provider or at least call a doctor. She kept asking me what could be causing it and why I was worried. However, as I was at a party, I didn't feel like playing let's list and explain the differentials. My strong nursing and NCLEX pass skills came into play and my first thought and reason for going to her provider was "safety." Regardless of the cause, it is dangerous to be randomly losing consciousness. You can hit your head, crash your car, etc.

Leaving the restaurant, my friend evidently fainted again outside her car. Finally she went to the ED either that night or Sunday. What was her diagnosis? Pneumonia. I never would have guessed. Her only other sign was "not feeling right." She had no fever, chills, cough, shortness of breath or chest pain. Today, she wasn't able to keep down her antibiotics and started coughing up bloody mucus, so she went back. I'm still waiting to hear if anything has changed.

Great reminder that diseases often don't present classically and that it is much more likely to be an uncommon presentation of a common illness than a common presentation of an uncommon illness.

Rules for Patients

Say you are in the hospital and recovering from surgery. Here are some general rules that will make everybody much happier if you follow them.

1. Don't flirt with the nurses and patient care assistants unless you are exactly our age, the attraction is reciprocated (and let me tell you, you don't smell too good and there's nothing attractive about a Foley) and we start it. Or you can be severely demented and then we don't mind. Otherwise, the last thing we want to do in hour 10 of a 12 hour shift is to have to start setting real clear boundaries. See your idea of flirtation, is our idea of not fun cause we still have to deal with you. And it's best if we just don't go there.

2. Your nurse is not your maid. If you brought six bags to the hospital, no I will not pack and repack and find things for you. Your family and friends can and I will look for occasional items as necessary, but that's all I can do, I'm sorry. What should you bring to the hospital?

Reading material and music if you like it. Pen and paper if you want to write. Your wallet, cell phone.

You probably don't want to wear your clothes in bed. 90% of the time, they will get bloodied, shit stained, sweated through, urine soaked, or some other nastiness on them. There's a reason you are here. If you are not doing any of the above, you are probably almost ready to go home. If you want to wear it, go for it, but don't say I didn't warn you. And your clothes can't go in our laundry, so whatever it is dirty with, it is going to fester.

Your own robe is a wonderful idea for walks. And yes we do have robes here so you don't need to worry about showing the world your backside and if you are really lucky, we even have pajama pants. Bring underwear for once some of the tubes come out; we have some disposable mesh ones, but really, it's quite funny looking. Otherwise, a change of clothes for going home. That's it. We have soap and toothpaste and toothbrushes and socks and shampoo.

3. We are not your waiter or waitress. If you didn't get enough sugar with your meal, then that does not mean that you should start calling at me for more sugar while I am trying to take your roommate for a walk. Ring your call bell. Call the PCA and he/she will get it when they are done with vital signs. See when I work as a walker, like today, I have 22 step-down ICU patients to walk with; each needs at least three walks a day to prevent pneumonia with the types of surgery we do. While I am trying to disentangle the wires and tubes, the last thing you want me to do is to be distracted by your calling me frantically and for me to trip and break your roommate's arterial line. Then I will be so busy that you will NEVER get that sugar.