Tuesday, February 1, 2011

haldol, np: the reason for the season

And finally, a contribution from one of our psychiatric brethren, Haldol NP. I'm especially appreciative of this, because I've been played by some of psych's frequent flyers before. Still a little bitter about that. Thanks, Haldol!

19 year old Patient began her relationship with me by missing her scheduled appointment. She decided to instead drop-in unannounced later in the day to be fit into the schedule. She flopped down at my desk and shoved a piece of paper in front of me.

"Can you sign this?" Patient asked. "This" appeared to be paperwork from the state that proved that she was actively engaged in mental health treatment. I explained to her that I couldn't sign it because this was the first time I'd met her and that treatment had yet to begin. "Whatever," replied the young lady. Emphasis on "lady."

She was actually pretty good at talking and snapping gum loudly, if one considers this a talent.

As the psychiatric evaluation opens, Patient's chief complaint seemed to be anxiety. "I need Valium, I need Klonopin...this is what makes me anxious, talking to you." Patient's cell phone started blaring tacky hip hop; of course, she answered it.
I waited until she was off the phone.
Tacky hip hop again.
I requested that she silence the ringer.
Patient informed me that I was mean.
I insisted I was not mean, but rather straightforward and trying to do my job.
In response, Patient immediately began texting on her cell phone.

She followed up this singular act of respect with knocking on the window of my office to get the attention of a young man in an extemely puffy white coat with dog fur trim. She was trying to guide him to the office. I told her that I consider texting on a phone the same as talking on a phone. The delicate young creature exploded. "I don't understand why you can't just give me Valium. This is why I hate doctors!"

I tried to get across that the point of a psychiatric  evaluation is to collect a history and get to know the patient in order to guide diagnosis and treatment options. I shared with this sweet, sweet girl that I hadn't gotten an opportunity to know anything about her, as she has been otherwise focused.

Patient, the darling turnip blossom that she was, jumped from her chair and stormed out the door. She screamed: "I'LL JUST GO TALK TO MY THERAPIST! AT LEAST SHE HELPS ME, YOU FUCKING BITCH!"
I called back after her: "Happy Holidays."

Monday, January 31, 2011

the virgin mollie: how to get saved!

"I'm a little high on NyQuil and Tramadol as I write, so feel free to edit," the Virgin Mollie starts her submission. We won't hold it against you, Mollie. 
You know how we're supposed to have scripted bits we use to talk with patients? I want to know why we haven't received this as a script, because I'm fucking using it. Thanks, VM!
This is a story about coming to Jesus.
I started my career as a floor nurse. There, on Satan's Li'l Tele Unit, I learned what is probably my most valuable nursing skill: the Come to Jesus Meeting. This is a one-sided conversation, during which I lay out for my patients why we're going to do things my way.  It's a sort of behavioral modification tool, where we---Patient and I---come to an understanding. Usually it is used for those who:
  • ride their call lights incessantly with the mistaken idea that their nurse = their bitch
  • have unreasonable expectations (only ordering chocolate cake on a diabetic diet, refusing to walk until done watching the Maury Povich rerun marathon)
  • have family members who believe, after careful research on Wikipedia, Facebook polls, and Ask.com, that they know MORE about disease/pharmaceuticals/avoiding death than our staff.
Patient was typical of our clientele. He was angry at us for his illness, as if we "gave" him coronary artery disease ("Here's a lollipop for you, and here's coronary artery disease for you"). Since surgery, this patient had been a terror---he'd been on the unit nearly a week. He was the sort of patient that, during global report, was not referred to as "pleasant", "confused", or "cute" (code word for "batshit crazy". Bulldog, the weekend charge nurse, understands "cute" differently than most). I forget the exact terminology Bulldog did use, but it boiled down to "unpleasant".

Usually report and nursing assignments go quickly. "Good" patients are divvied up accordingly and the less intense ones are paired with a sicker patient. There was absolute silence this Saturday morning. No one wanted this guy. Finally, I spoke up: "I'll take him." A collective sigh of relief. 
Off I went to get report. I'd been working in the CVU for only three months, so I wasn't trusted with very sick patients at this point. Background on Patient: male, in his late 50s/early 60s; angry; smoker; drinker; had major heart surgery. Secondary complications of renal failure and constipation, and did I mention he was angry? Meanest motherfucker ever, by report. The offgoing RN gave me the rundown. He shared that Patient was a "one-shifter", meaning "after one shift of having him, you will want to kill him and possibly yourself to eliminate every possibility you might end up with him again".
Patient hit the call light. Ding, ding, ding, ding, ding. He was also loudly calling out, using a string of obscenities, for his nurse. Night RN finished his report and asked, "Do you want to go look at him (which, in our unit, means 'so I can show you anything abnormal/ interesting/etc' about him)?" He was a recent graduate; he just wanted to go home. 
"No, I got this," I said.
Patient's call light continued to ding. 

As soon as he saw me, Patient immediately launched into a tirade about his call light going off for more than 30 seconds, which was how soon he expected "the help" (me) to arrive. He then began to curse me at the top of his lungs and tell me everything that was wrong with me. I stepped inside his room, calmly shut the sliding door to his room, and drew the curtain.
"I only have to come in here once an hour," I informed him. 
"I am not your maid. I control the pain medications, the nausea medications, the benzodiazepines. Also, the stool softeners. You are at my mercy and I will be directing your care today. I will be polite to you and I expect you to be polite back. You will NOT be hateful to me, or to other nurses."
"HOLY SHIT," said his face. And he was saved. Jesus 1, Patient 0.
It was mentioned in report for several mornings that someone had done something to him and now he was actually being pleasant. Nah. I'm only an instrument of the Lord.

o-dubs: on the other hand...

I've been really lucky to get such positive feedback from readers, and even luckier to get contributions from some of them. o-dubs wrote this in response to "my empire of dirt". Lightly edited. Thanks, o-dubs!

Patient had already completed round one of chemotherapy, with no discernible progress; she was admitted for respiratory distress. She and her incredibly supportive family were trying to decipher all of the information presented to them by the pulmonary team, the oncology team, the nephrologists, the medical ICU team. She was pleading with me through her tired eyes as I replaced the biPAP mask that she had worn for the last three days; this was the only way for her avoid intubation. I would explain to her again and again why it was necessary for her lungs at this point; she would just politely say, "Do what you need to do, sweetheart. You all know best."

I brought the attending into her room following rounds. He made direct eye contact with each of the expectant faces looking toward him and said this: "Look, here's where we're at. Right now, you are alert, you are aware of what's happening around you, you are able to talk to your family and enjoy the company that they bring. At any moment, all of that may change. Our medical technology will not be able to cure your condition. Yes, we will be able to keep you alive---possibly longer than if we stop aggressive treatment at this point---but your mental status will decline, you will be supported by machines, and some of those machines require sedation that would dull what capacity you have left. If it is more important to maintain the quality that you have right now, to be able to see and speak to your family and enjoy them...get the hell out. Now. Today. Don't stay here one hour longer than you have to. You don't have much time left either way, but right now you have the opportunity to choose to spend that time in a comfortable place, surrounded by these people who love you, not worrying about any more tests, procedures, or results. If that's what you want, now is the time to get out of here. We can help you do that, too."

I don't have any words to describe the relief, the happiness on Patient's face. Her cheeks had color for the first time in the three days I'd taken care of her. She smiled. As her family looked shocked and dismayed at this "failure" of medicine, this woman emanated a peace that was almost palpable. the family discussed this "new development" in the room for quite some time, but the woman's ultimate decision was delivered as a quiet, "Yes, please."

I removed her biPAP mask and traded it for a simple face mask. She was able to speak again. I could finally give her ice chips to moisten her dry, cracked mouth. No more lab draws. No more consults. Later that day, I sent her off to spend the rest of her life in a hospice house surrounded by gardens and art and a family who now had the freedom to focus on enjoying this woman as a mother, a wife, a sister, a grandma. A person.

Not a patient.