Psych Moments

So I've just recently started my psych rotation on a floor that specializes in patients with schizophrenia, bipolar disorder and shizoaffective disorder. I've been out of psych for long enough that I miss it. Random moments and exchanges with patients that you won't ever experience anywhere else happen on these floors. Here are a couple:

First day getting adjusted--I am suddenly distracted from a conversation with a biploar patient due to a loud noise. I ask the patient to repeat what she just said. She responds, "Look, I know I have a short attention span, but I'm bipolar. What's your excuse?"

Second day, talking to a patient with schizoaffective disorder. I attempt to assess his ability at abstract thinking by asking him to interpret the saying 'A rolling stone gathers no moss'. Our exchange:
Patient: Stones don't gather moths. Besides moths couldn't lift stones either.
Me: No, moss.
Patient: Oh, that changes everything. That rock is a loser. The moss is the winner.
Me: Why is that?
Patient: The rock couldn't gather any moss so the moss must have gathered all the stones!
[I still don't know how to interpret that one]

Third day, walking up to patient who is rolling their eyes in every direction, " I can't even see my eyes!"

Another patient, when asked if she was Catholic, said, "I'm on the cusp."

“There’s a boy in here”

This is me venturing out of my personal narratives and into an op-ed style...

While doing an observation at a pre-school for my Pediatric Nursing course, a four-year-old girl entered the classroom and, curious to identify the strangers in her classroom, asked her teacher, “Who are the new people?” Her teacher responded plainly by stating that we were nursing students. The little girl’s face quickly changed from an innocent and curious expression to being conflicted and confused. She took a long pause and then looked up at her teacher and said, “But there’s a boy in here.”

Indeed there is a boy in here—right smack-dab in the middle of many people’s privately held stereotype of what a nurse looks like. The little girl, of course, is certainly not without adult company. On more than one occasion I have been asked, “So you’re going to be a male nurse?” as if I was still in the process of choosing my sex as well as my profession.

Yes indeed! I’m a “murse”. Or, more accurately, a “mursing” student. And to be perfectly honest, I’m never offended by people’s surprise at a man becoming a nurse; not only do I revel in throwing people for a loop, I understand that some part of their stereotype is not without basis. According to the 2002 U.S. Department of Health and Human Services’ National Sample Survey of Registered Nurses, only 5.4 percent of RNs in the United States are men. Given the fact that registered nurses constitute the largest health care occupation, with 2.5 million jobs, the chances of interacting with a female nurse are pretty likely.

What does trouble me, however, is the all-too-frequent follow up question, “Why didn’t you go to medical school?” Given that 72.2 percent of physicians are male, I suppose I should probably expect this question, too. And yet, I am simultaneously fascinated and deeply concerned by how infrequently the flip side of this question, “Why didn’t you go to nursing school?” isn’t being asked of medical students. Clearly, nursing is not on equal footing with medicine.

I believe that the reason that this question isn’t asked points to a different, very misguided part of the nursing stereotype that is seldom discussed openly: that nursing is some sort of a lesser, sloppy-second alternative to medicine—particularly for a boy. I take serious issue with this aspect of the stereotype not only because is it categorically untrue, but also because this belief is extremely dangerous due to its roots in the long-standing power struggle between men and women. Historically, women have been professionally subjugated to men due to the inaccurate and sexist perception that men are smarter than women.

The reason that this hushed stereotype still exists is rooted in socially constructed and learned behavior. As exemplified by the four year-old at the pre-school, from a very young age we learn gender rules on a variety of subjects that range from toys and clothes to behavior and jobs. Consequently, I believe that the average Joe and Josephine on the street quietly subscribes to the idea that nursing, being female dominated, is also associated with the female personality attributes of caring and empathy while medicine, being male-dominated, is associated with the male personality attribute of scientific objectivity. Or, put more simply, RNs are sensitive girls and doctors are scientific boys. Furthermore, this translates to why Joe and Josephine view medical science, being more quantifiable than the ever-ambiguous emotion, as being equated with intelligence, while they view nursing as less intelligent.

It is absolutely time to smash these perceptions. Easy. Although it is true that nursing fosters a slightly more nurturing perspective than medicine, nursing is an incredibly dynamic field that includes nursing research on subjects not traditionally associated with nurses. For example, a colleague of mine, Monica R. McLemore, a Ph.D. Candidate and American Cancer Society Fellow at the University of California, San Francisco School of Nursing, recently described her research to me, “Simply put, I study the isoforms of CA125, which is a tumor marker of ovarian cancer. I also attempt to correlate these isoforms (using kilodalton size as a proxy for the true amino acid sequence, since I'm not THAT well funded) to serum concentration.” How about them apples?

As a man within a traditionally female-dominated profession, I am acutely aware of the fact that my presence in this profession is still perceived with some discomfort due to the fact that the socially constructed stereotypes of yesteryear still govern many people’s perception of the field. My message to you is this: let’s evolve people. It is absolutely time that we embrace a more enlightened perspective in order to truly understand the incredibly dynamic and diverse field of nursing.

I got a job!

I got the phone call today that I got a job on the cardiothoraic floor where I did my Med-Surg rotation. Wow! I feel so incredibly fortunate to have found a job so early in the year that is so in line with what I want to do. I accepted and then called my wife and then my parents. I will bask in the glory of this moment today, but tomorrow, I move on to the next thing to worry about...the NCLEX!

Nurses As Scientists

A classmate and colleague of mine, Elizabeth Goldstein, recently created and published a self-made podcast that explores the notion of "Nurses as Scientists". She is interested in demonstrating how nurses use science in our everyday actions, though it might not always appear so...take a listen.

How job interview anxiety and this program has caused me to talk to myself...

Reflecting on: Job search anxiety that manifested itself as apocalyptic self-doubt...

I am a little tired. Okay. A lot tired and want a break. My anxiety has been getting the best of me lately. I re-rehearse things that I certainly already know for tests, and for interviews. Thank god spring break is almost here. I have pushed myself and learned an amazing amount in one year. I have sufficiently squished and jammed my brain so full of knowledge that occasionally I don’t remember what’s going on around me. My brain aches like it does after a really hard test. All the time.

I’m complaining but am not going to change because this kind of ache is hugely beneficial to me. Knowledge allows me to better understand my patients and facilitate desired outcomes for them. From time to time, however, I need my rug pulled out from underneath me. I also need a little balance; a few purposeless conversations that aren’t always guided by overarching school goals might do me some good.

The long and the short of it is that I'm starting to talk to myself (loudly) in public. Most concerning...

Tomorrow I have a job/scholarship interview on the cardiovascular-thoracic floor at the hospital where I have been doing my clinical rotations. That is certainly freaking me out. No doubt. I made the plunge a year ago and was committed to an academic and profession. But this is the job. This isn’t school. This is the work! This is the work that I want to do. These patients—this is why I am in this program. Holy. Freaking. Cow.

The advanced practice degree, though meaningful and eventually useful, is not exactly my focus right now. Understanding the exactness of nursing procedure and working with patients is. Each patient is a lesson. There is no way of knowing what might happen in a day, except to monitor them and pay attention through assessments.

So I am committed to this work—as I am committed to working on this floor. Initially, I was concerned that working on a cardiac floor was not necessarily consistent with my career goals because it is not strictly a critical care environment such as the emergency department or ICU. When I really examine what I have learned this year and what I want to learn, I realize that working on this floor is perfect for me. My primary goal is to help patients that are critically ill and better understand them. While the ED certainly provides this opportunity, I do not believe that the patient care perspective that I will develop in the ED will be as complete as I need. Having volunteered in the ED for almost two years, I realize that nurses mostly get little snap-shots of different patients before stabilizing them and then discharging or admitting them.

While I feel that I am capable of doing these important tasks and still want to work in the ED, the cardiovascular-thoracic floor affords me the opportunity to cast my net a little wider, and better understand the history of the disease/illness that has brought the individual to the hospital. Thus, when eventually I decide to work in the ED, I will have insight into the exact "snap-shot" that I am seeing. Given the fact that heart disease kills more Americans than any other disease, the skills that I will learn on the cardiac floor are particularly relevant to emergency and intensive care nursing. Furthermore, the variety of patients and pathologies is particularly appealing to me, not to mention the fact there are codes almost weekly on this floor, thereby allowing me to be surrounded by and participate in critical care as well as acute and even preventative care.

God I hope I get this job.

Heart Attack and Angioplasty...

The heart is becoming my favorite nursing preoccupation. I could write pages about the pathophysiology of a heart attack (myocardial infarction/MI), or you could just watch this really good video. In a heart attack, the heart essentially essentially chokes itself to death.

To correct for the "choking", the coronary arteries must be widened, which can be done by placing a Stent, or artificial tube, in the coronary arteries to widen it. An excellent explanation:

Here is the actual video of someone's angiogram where they are injecting the dye in order to see various parts of this guy's vasculature.

Stress and Tachycardic, Psychedelic Dreams

Reflecting on: Nursing, stress, and psychedelic dreams…

Lately, I’ve come to the conclusion that MEPN, for me, is like running a race where the finish line is gradually being pulled further away from me. Sometimes I feel like I’m gaining ground—most of the time, really—but then there are the times where my legs are cycling in a sick, nightmarish pantomime that approximates running, but gets me exactly nowhere—as if I’m stuck on a quicksandish treadmill and the finish line disappears into the horizon.

I’ve actually had this dream before and it sucks every time.

The key to overcoming such nightmares, I’ve found out, is to become self-aware while still in the dream. It doesn’t happen as much as I would like.

In the nightmare, I spin my legs so fast and become so agitated and over-rot with emotion that I actually wake myself up—heart beating as though I actually were running an endless mile. I can hear the blood pounding in my ears…I take a moment to soak up the relief that I am not actually stuck—that I am in my bed with my ridiculous cat and beautiful wife and that everything will be alright. My wife snorts and shifts her pillow. The cat rouses and looks at me as if I were crazy. Possibly. But not so far gone that I’m afraid to go back to sleep. I look around and slow my breathing. I close my eyes…

…I fall back asleep and drift off into the same dream.

Given a second chance, I become self-aware—“lucid dreaming” I think professionals call it. The sensation of lucid dreaming is akin to the same relief that I had when I woke, but quickly transitions into being exceedingly tickled that I can laugh at the ground I was once stuck on. Chuckling to myself, solid matter blurs into sky and I fly off through clouds and over towns I vaguely I recognize. Total exhilaration of the dream fuzz flies past my face. I feel victorious that I have overcome physical boundaries. But then, while flying, I sometimes am bothered by the notion that “this isn’t real” and will falter—even fall. Gravity regains its hold on me and I plummet. As I rush towards the earth, I am reminded that I am still dreaming, and go into my best dive formation. Hurdling towards the ground, there is no impact because I dive into the earth’s crust and through the center of the earth. I am now in an entirely new dimension.

I want to do it again. And again…

Sometimes my dreams mean something and sometimes they don’t.
Sometimes I don’t wanna know (seriously).

This one, however, has some pretty obvious symbols.

Clearly, I’m racing my ass off to be the best damn nurse I can be in one year. It’s kind of ridiculous when I say it out loud, but since that is what I am, in fact, doing, it’s better to be clear about my intentions. The overall experience is a lovely mélange of being completely overwhelmed but, now faced with a challenge, exhilarated that I am alive and in the middle of something meaningful and stimulating.

Baptism by fire.

The finish line is nonsense though; it is nothing more than a self-imposed limit that I created because this accelerated RN experience is done in one year. Time to laugh and become self-aware: I am built for this. I love doing this. So why would I ever stop? Why would I even want a finish line? I think I’d rather keep on running, jump in a limo, get out, and, I don’t know, do the freaking running man or something. I mean, let’s evolve, right?

Right.

The endless, never ending run that doesn’t allow me to move anywhere: that’s my battle with perfectionism—a huge limitation. I am operating under the incredibly unrealistic notion that I have to be perfect in 6 weeks. Ridiculous. More ridiculous than my cat. So what do I do? Let’s challenge those expectations…let’s laugh at them—or rather, laugh with them! Maybe I’ll fly. Maybe I’ll forget…more than likely I’ll do both…but whatever…let’s breakdown and build up and get back to basics. Let’s evolve. I said that already. How about relative perfectionism instead? How about I be as good as I can be in 6 weeks without losing my mind and making my quicksand treadmill a reality? How about a little reminder that I can continue to reform and dive into the challenges that present themselves to me…

It’s a beautiful thing to be stressed and overworked and running with your pants around your ankles because although it makes me crazy, it forces me to think and learn: it is here that I am reminded that I can fly and that I will fly again.

Just one non-nursey thing...

Pretty much the most calming song and video I've ever seen. I'm trying to remember to take it easy--this seems to do the trick somehow.

One!

Laparoscopic Nephrectomies for dummies...

Today I got observe a laparoscopic nephrectomy (kidney removal). Just amazing. Very similar to this one, except it wasn't "hand"-assisted; laparoscopic clamps were used instead @ much smaller ports, thereby reducing the size of the incisions and scaring of the patient. It took me a while to get my bearings, because although I know my anatomy pretty well, knowing it inside-out and backwards takes some doing. I got the hang of it by the second operation.

It did confirm one thing though: I don't have much of an interest in working in the OR as a nurse due to the lack of face-time with the patient (unless of course one counts time watching the vital signs of someone who is under general anesthesia). OR nursing is valuable, no doubt, but I just don't think it would be the right fit.

Check out a nephrectomy (pretty bizarre that a nephrectomy is on youtube). Simple as 1-2-3:

1. Dissect away the connective tissue from the bowels and kidney.
2. Clamp of the major arteries/veins feeding/running off the kidney.
3. Cut out the kidney with a cauterizing clamp.

Check it out:

Feathers, Harpoons, Livers, & Transplants

REFLECTING ON: Ethical issues of transplanting a new liver into a "recovered" alcoholic. Martha's name is real and written with her permission.

In post-conference on Friday, a fellow MEPN ruffled my feathers. You see, in our clinical rotations, we were discussing the hospital policy to transplant new livers into “recovered” alcoholics and the ethical issues contained therein. When somebody informed me that the hospital's policy required a transplantee to be sober for a mere 3 months, I stated aloud, “That just doesn’t sit right with me.” There were some murmurings of agreement and some quiet dissent.

The feather ruffler, Martha, then coolly dealt her reply, “Oh those alcoholics, they don’t deserve livers, do they?”

Ire now raised, I took the bait, “That’s exactly what I’m saying.”

With what I perceived to be silent judgment, Martha looked me coolly, and said, “I know.”

Discussion ensued amongst the other students, but my mind was fixated on Martha’s words; they had jarred me. I was mad at the implication that my judgment of alcoholics was inappropriate or unfounded. I remained silent though. You see, one of the few things that I’ve learned in my thirty years is that when I am full of emotion, I try to keep my cards to myself for fear of revealing a bad hand. I don’t enjoy becoming overheated; it’s a sure-fire recipe for saying ridiculous things and becoming illogical.

As the discussion continued, Martha solidified her seat in court, “And those queers, should we give them livers too?”

Fine Martha. I see your point. Where do we draw the ethical line regarding who is eligible for a transplant and who is not? A fair point: we need to maintain objectivity or else slip down that slope of judgment that can ultimately lead to prejudice and discrimination. And although I concede this point, it was presented with the delicacy of a harpoon thrower. Of course, perhaps I need a harpoon now and then so that I can re-examine issues like these. So, in all honesty, thank you for the harpoon, and for the record, I do believe that gay people do deserve livers.

Alcoholics though? I just don’t know.

Where I take issue with most alcoholics is theirs is an affliction of the mind. While the non-addicted brain maintains its status as an efficient conductor of the organ systems that supply and maintain life, the addict’s mind will gladly sell the piano that it feebly pounds out chopsticks on in order to continue its own selfish, self-annihilation. Replacing the liver is a like putting a tiny band-aid on a huge gash that will continue to expand, ooze, and bleed until the actual cause is effectively managed and treated. The perpetrator of this deep cut is not the liver; it is the mind, and all of the complex and ever evolving layers and patterns that it alternates influencing and being influenced by. I maintain, as in triage, the most serious and life-threatening problems should be treated first. Since the origins of an alcoholic’s liver failure are routed in their addiction, a mental illness, the mind should therefore be prioritized for treatment. And although I am open to it, I have never witnessed a recovery from addiction in just 3 short months.

I ask, what is the point of extending a person’s life that is hell-bent on drinking him or herself to death? Unless that individual shows sincere and real progress towards treating their addiction, their true disease, fixing a diseased liver merely buys them time in the off-chance that they have an epiphany—and what is the likelihood that a person will suddenly shift to a pattern of making healthy decisions after a lifetime of making it’s bad ones? It’s like waiting for lightening to strike.

And in the meantime, while we’re waiting for lightening to strike, what do we actually witness? In my experience working at a group home for emotionally disturbed boys, most of whom were the products of parents that were abusive addicts, I watched how alcoholism continually disappoints, hurts, and self-destructs. One child, Steven, comes to mind. At 14, Steven appeared as if he was in early grade school. His physical and mental stature had been severely retarded by his mother’s drinking. His face and head revealed all the classic physical manifestations of Fetal Alcohol Syndrome: small head, low, misshapen ears, an unnaturally flat face, almost no jaw, thin lips, and incredibly small eyes. Steven read at maybe a 2nd grade level on a good day but cursed like a sailor when he was angry, which was almost all the time. When he got mad, he would often run away in a manner that resembled what a second grader would do: run three or four blocks, and then return home. Until he began to express suicidal ideation, the staff at the facility where I worked would let him run, knowing full well that he would soon return. One day, after Brent Steven expressed committing suicide, I was chasing him during one of his efforts at going AWOL. When I caught up with him, I just stood beside him. I had learned early on that grabbing someone that wants to leave is a sure way of making them dislike you. So I just stood, and then walked beside him, away from the group home. Steven was clearly frustrated—his brow was furrowed and he walked with fists at his sides. Then he stopped and looked up at me. I looked down and asked the kind of question that you only ask after you’ve chased a kid a hundred times, “Why don’t you ever just go for it? Why do you always stop?” Steven turned around and began returning home. We walked side-by-side. He walked silently for a bit, and then answered my question, “If I only just had a piece of paper, that I could draw a map on, then maybe I could draw a map and figure out how to get out of here.”

Now Steven had been in cars and even hikes that lead him off the facility’s premises a thousand times. It was only in that moment that I became acutely aware of how damaging the alcohol had been to his brain: he couldn’t keep his surrounding or even where he was in his mind for long enough to leave. He wanted to draw a map, one that he could keep in his mind, so that he could escape. In his distorted thinking, he hadn’t thought to consult an already existing map.

So there it is: why I resent and am so unforgiving of alcoholics. How can 3 months of drying out correct for Steven's lifetime of depression and frustration? It can’t. And it’s not fair. It’s not fair to Steven and it’s not fair to someone on the transplant list who, in all honesty, shows a hell of a lot more promise than a 3-month “recovered” alcoholic. Does Steven's mother deserve a new liver? I think not. And though it may sound harsh, I’m fine with that. Why? Because both within my personal and professional life, I’ve seen and felt the wake of mayhem and hurt left behind by alcoholics.

I realize that Steven is a dramatic illustration of the consequences of someone’s addiction. But it is real, and although most that are affected by alcoholism do not bare Steven's physical abnormalities, they are nonetheless affected in a manner that is similar to Steven; they bare internal scars and pain that they will carry with them for the rest of their lives. Call it what you will: a bias, a stereotype, or even prejudice. Judgment based on experience is what I prefer to call wisdom. Oh Jesus Christ I sound like a televangelist. Sorry. Just let me have my televangelist moment though and I will go back to trying to be well adjusted.

Here’s where it starts and ends for me: I’m absolutely willing to give the next recovering alcoholic a fair shake—just not after three months. How can an individual consider himself or herself cured when they’ve spent a much longer period of time slowly poisoning themselves? They’ve proved time and time again that they are not competent to make healthy choices, so why would we prolong that process? I don’t have time in my life to wait for the lightening to strike. Someone who deserves a new liver, in my mind, would be hit by that lightening, bottle it up, and bring it to the god damn hospital and show everyone that they deserve a new liver. That’s just me though.

I’m sure I sound like a pessimist right now. Rest assured, I’m not. I’m a horribly sensitive, bleeding heart optimist. You know how I know? Because despite my animosity towards alcoholics that have caused pain everywhere, I will still do my best, as a student and nurse-to-be, to provide quality nursing care to that alcoholic--even to Steven's mother. Why? Part of me is still invested in the hope that a person can change, even though the odds are against it. Pragmatic optimism? I don’t know what to call it. Most of me, however, just knows it’s the right thing to do.