Whee

The little ones are on Spring Break, which means I've had to adjust my sleeping schedule.  I now sleep in the evenings, go to work, then stay awake to do things with them.  It's been working out so far...its a nice change to stay up after work, and I'll admit that it's easier to fall asleep when it's starting to get darker out as opposed to brighter.  But this won't work when they're back in school, so in a couple of days, I need to return to my regular schedule.  I may shift back to this in the summer, we'll see.

I've been enjoying the last few days off.  I've caught up on sleep.  I'm spending time with the family.  I've turned down requests for work.  I'm just recharging the batteries, getting ready to once again tackle all of the Axis II that seems to have infiltrated the patient population.

The tough thing about personality disorders is that they are how a patient is wired, meaning that nothing is going to cure it.  Sometimes I do wish it was like psychosis, where a shot of Haldol will make the pink elephants go away...at least for a while.  Alas, it's not.  Medications may help them manage their symptoms, but the patients need some good old-fashioned therapy--usually CBT or DBT--to change how they think and respond.  But because they are wired this way, it's also incredibly hard to effect change.

All the Axis II can wear a nurse out after a while.

I'm debating if dealing with Axis II disorders is more exhausting than working with patients in mania.  Both can be challenging, frustrating, and have medications end up with little to no result.

But a manic patient with Axis II...now THAT'S a hurricane!

Happy 2017

New Year's Eve at work was calm.  We got to see the ball drop on television, and we all enjoyed our pot luck and complementary sparkling cider.  Then I had to go give multiple IMs to a patient who decided to get undressed and completely lose it...right after we had finally gotten all the manic patients to fall asleep.  Of course, that woke them up.

The following night, same unit, but much better.  Only one IM needed, and it was requested by the same patient before things got out of control.

It wouldn't be a holiday without some excitement, now would it?

A little break

After working a stretch on the psych-medical unit, it was a nice break to be floated to psych stepdown.  I spent the last several shifts wrestling with IV machines, suction and oxygen tubing.  Sometimes all with the same patient.  And all the call bells that go off when the bed alarms are triggered!  When there's a restless patient, it seems like their bell never stops ringing no matter how low we set the sensors to.

I have remembered that I dislike suctioning.  Phlegm is my kryptonite.

In an attempt to accelerate my getting up to med-surg snuff, I got a couple of med-surg reference books for my Kindle.  While I will always be a fan of paper books, the Kindle makes it possible for me to have all of my reference books with me while at work.   Plus I love the fact that I can order it and have it delivered within minutes.

I've also started looking at a few med-surg and LTAC CEUs.  I have to accumulate 150 of them by 2021 to renew my certification, and only 51% need to be in psych; the rest can be in whatever I choose.  So I'm going to kill two birds with one stone there.

Anyhow, back to stepdown.

Loads of manic patients.  The mania is very strong in the air as of late.

I generally tend to get along with patients in mania, though just watching and listening to them wears me out.   The rapid hyperverbal speech, the hyperactivity, the flight of ideas as they jump from topic to topic, the delusions of grandeur…it really is exhausting to keep up with them.  Still, it's a nice change from answering call bells.

It’s frustrating when PRNs don’t slow them down at all, especially when it’s the middle of the night and they’re waking other patients up.  I tell them repeatedly that as long as they can keep it quiet they don't have to return to bed (some of my peers do not agree with this strategy.  I am of the mindset that as long as they are behaving or not in danger of being hurt, I don't have the right to force them into their room).  The problem is that they’ll be calmer and quieter for a minute or two.  Then the voice and energy level naturally starts escalating again.  

At one of my previous jobs, we would utilize that energy for good and have manic patients fold towels or tidy up the common area.  Depending on the patient, they might get a broom and dustpan and be put on sweeping patrol.  Of course, this is if the patient is willing, which they usually were since they had all this energy to burn.

But it’s harder to manage at night.  During the evening, when everyone else is awake and active, having a manic patient or three is one thing.  At night, when the goal is to have all the patients sleeping…well, that’s another. Sometimes the PRNs need to be “strongly” encouraged.  While I hate pressuring patients into taking medications, it's better doing that than to have them wake the psychotic patients who would pose an even  bigger problem if THEY were awake.

For all the exhaustion working with manic patients can provide, one of my favorite things is to listen to two manic patients have a conversation.  They will be discussing two entirely different things at high speed and yet still understand each other perfectly.  It's amazing to watch.

But the manic patients are asleep tonight...for now, anyway.  It's the religiously preoccupied and delusional that are awake and roaming.  I've been lectured once already on how I'm going to hell, which is a nice change from just being told that I'm going to hell:  at least now I'm having the why-I'm-going-to-hell explained to me.  I'm apparently holding another patient hostage.  But at least the patients are being so polite and friendly about it with me.

My application status for the new specialty position remains unchanged.

Meanwhile, I've been rooting around my primary organization to see what opportunities they can offer me.  Truth be told, I'd rather not leave here...in fact, I'd like this to be my permanent home.  That is, if I can find a position that is financially feasible and professionally satisfying.  My second choice is to find a permanent position elsewhere that is 3 days a week, and then pick up 2 days as a per-diem here.

So here at my primary organization...

I'm being wooed to go permanent at the temporary position I'm working, or at least transfer to being a per-diem there.  I would, except that it's outpatient.  I really want to go back inpatient, plus I don't get shift differentials for outpatient so financially, it would be tight.  There's also no guarantee of 40 hours...mind you, I could probably pick up a few inpatient shifts here and there.   But I also don't really want to work 6 or even all 7 days a week.

I'm also being wooed to go evenings inpatient.  While I love evening shift, it's very hard to work them with a school-age little one.  Full-time evenings means I'd almost never see him during the week.  So while this isn't a top choice, it's a good safety net, especially since evening shift is the hardest of all to staff:  there's plenty of availability.

I started picking up several inpatient shifts at the medical hospital, mostly nights and the odd evening.  Of all the facilities my organization has, I like this one the best.  I'm patiently waiting for a night position to open up there.  Or an evening/night mix.

I've been offered the opportunity to orient as a liaison in the emergency department  I'll get to evaluate ED patients to see if they meet criteria for psychiatric holds and/or admission.  That starts in a couple of weeks, so I'm going to see what particular things I should brush up on.  My having taken that emergency nursing class will also be a help here, as I'll know more about whether they are medically stable enough for the psych unit.

Mania

I've had a rash of patients with bipolar disorder that are in mania.   I don't know if it's something in the water or the alignment of the planets or whatever.   Usually, I get them on the downside--they're depressed--so to see them dancing as fast as they can takes some getting used to.

Dealing with manic patients can wear anyone out.  They're talking a mile a minute, they're constantly fidgeting and restless, they're impulsive and unpredictable, they bounce from topic to topic as they follow their flight of ideas, and they're so distractable that they need constant redirection.  Then it gets even more fun if they're delusional on top of that--the grandiosity, the ideas of reference...

I feel like I've run a marathon after admitting such a patient.  I ran a lot of marathons lately.

Most want help stabilizing their mood.  The occasional one prefers their mania and would rather stay in that state.  I don't judge, I just make sure they stay safe and out of trouble.

Of course, it's always entertaining when two patients in mania meet.  They can keep each other entertained rather well because they can keep up with each other.  I'll have them hang out near me and let the two of  them have at it.  I just have to make sure that neither one (or both) are hypersexual, lest I have to go break up a romance or worse.  But anyhow, the conversations they have can be fascinating, though a little exhausting to listen to, especially if they try to pull me in.

Or I'll have them help me on the floor.  They're great at folding laundry...heck, they're happy to have something to do to burn up all that energy.  Occasionally I'll ask if they can tidy up the unit, which they're happy to.

Hopefully when I return to work, things will have calmed down.  I'm savoring this weekend off because I'm not going to have a lot of weekends off for a while.  Thanks to having to balance the scheduling demands of Jobs 1 and 3, I am working at least one day of the weekend every weekend for the next several weeks.  I did manage to save Mother's Day weekend for myself though.

Antisocial Personality Disorder

Those with antisocial personality disorders are all about themselves.  They do not have any remorse for their actions, nor do they feel empathy towards other people.  They will lie, cheat, steal, calculate manipulate, violate, disregard, act recklessly and basically do whatever they want for their own purposes.  They don't want to be caught but if they are, they're not sorry for what they did and they don't care what the consequences are.  All the patient with antisocial personality disorder cares about is whether their horse will win the race.

These are the ones who abuse animals either directly or indirectly, such as setting a cat loose in a full birdcage.  They may abuse other humans the same way, either directly or indirectly.  Instead of stopping a child from touching a hot stove, they may just sit back and watch the child burn themselves without intervening.  They lack compassion--the suffering of others may be an amusement to them or merely something about which they don't give a flying...anyhow.

It is said that a majority of prisoners have antisocial personality disorder...I'm not surprised.  Most people with antisocial personality disorder are male, but females can be diagnosed with it.  It shows up in dual diagnosis frequently, appearing in the company of a chemical or other addiction.

Like all other personality disorders, antisocial personality disorder is a bitch to treat because it's how the patient is hard-wired.  You can never cure them, just help them work with it.  But the problem is that by the nature of the disorder itself, those with antisocial personality disorder don't want to work with it because it's not what THEY want.  These patients are very resistant to treatment.

Someone once told me that patients with antisocial personality disorder are lost causes.  Some days, I agree with that sentiment.

They're not my favorite patient population to work with, and it takes a lot of self-assessment and self-control for me to do my job properly and provide then with the best care that I can.  It's hard not to appear or be judgmental and to treat them with the same level of dignity, compassion and respect that I'd give any other patient, especially after I hear what they've done.  These are one of the patient populations that take a lot out of me.  I find working with patients with other personality disorders, even those with borderline personality disorder, far easier.

Christmas party at work this week.  We played parlor games...and it's rather entertaining to watch psych staff play "guess the celebrity."  Most were identified by their psych issues.   Don't ask any of us what their latest movie is or who they're married to, but tell us their personality disorder or CD issue, and we're all over it.

Interesting fact:  Anakin Skywalker/Darth Vader meets most criteria for a borderline personality disorder diagnosis.  Vader's my favorite Star Wars character, so I found this intriguing.  This meant nothing to the men in the family other than it made them want to watch the Star Wars movies...again...

Sometimes my family just doesn't appreciate psych.

Senioritis:  2, Meriwhen:  0.  For history class, I have a test and a last entry to finish up in the next 8 hours, and I'm waffling on both.

Attack of Cluster B

In terns of personality disorders, Cluster B leads the pack as being the most prevalent.  Of Cluster B, borderline personality disorder is the most common, followed by antisocial personality disorder.  Yet lately, I am coming across more patients with narcissistic personality disorder.  It's getting to the point that they are keeping pace with the top 2.  Cluster B is common in dual/addictions as well as in eating disorders.

I haven't seen (yet) a patient with two cluster B diagnoses.  I've seen those with Cluster B and Cluster C (usually obsessive-compulsive, sometimes dependent, never avoidant) but not often.  Never seen Cluster B with Cluster A...which is understandable in a way:  I can't really picture a borderline schizoaffective patient or a histrionic paranoid patient.  A and B just do not seem to mesh.

So anyway, the Cluster Bs have been coming fast and furious in both of the programs I'm working in.  I decided to treat myself to an early birthday/Christmas gift and get "The Personality Disorders Treatment Planner" in order to stay on top of things.  It's a great book for those who have to deal with personality disorders on a regular basis, or even the curious who'd like to go beyond the stereotypical presentations of personality disorders.  Because there really is far more to personality disorders than the image of angsty teenage girls cutting themselves while railing against the world.

Happy Thanksgiving if you celebrate it, Happy Thursday if you don't.

Cinco De Mayo

Y'all know the history of this day isn't based on a party but on a battle, right?  Anyhow, enjoy it and be safe.

I was on the trolley the other day.  Not far away was a man, maybe in his 50s, repeatedly making the Sign of the Cross and touching his forehead.  Before becoming a psych nurse, I would have mentally classified this man as "a wacko" and moved further away.  But after three years, I recognize a compulsion when I see it, so while I didn't exactly sidle up next to him, I didn't feel unsafe enough to move.  In fact, I tried to see if the book he was carrying was a Bible (it was).  OCD plus religious preoccupation...interesting combo.

I watched as covertly as possible to see if there was a pattern to his compulsions.  No pattern.  Sometimes he'd stop after 3, sometimes after 7, sometimes after I lost count.  When he wasn't crossing himself he'd look around...but no one else was fazed either.  I guess he was a regular and they were used to it...and besides, crossing yourself repeatedly isn't too bad as far as compulsions go.  He wasn't directly bothering anyone.

I have two papers, two discussion question responses and a quiz due by Monday at 0600.  I hadn't thought of this when I signed up to work Sunday day shift at the ER.  Oh well.  I made good inroads into paper #1 last night; today I'll work on paper #2 and the responses.  Sunday I'll finish off and clean both up, and take that quiz.  

I've got this.  I hope.