Monday, August 27, 2012

Those Less Fortunate

In psych, most of our patients are homeless.  They were removed from the street for overly bizarre behavior, criminal behavior, or for medical reasons- unresponsive, bleeding, vomiting, and the like.  When they arrive, they are filthy, usually have some external parasites, and a bunch of abrasions and infections in the wounds and on other surfaces.  We won't even mention the internal problems in this posting.

They have only the clothes on their backs.  Literally.  They have a few shirts, usually two coats, ill-fitting pants with holes, no socks, no underwear, and shoes with holes in the soles.  These garments are filthy because the homeless do not have access to washers and dryers.

Taking the last item that a person owns in this world is a very difficult thing to do.  They will battle you to keep their coats, even though it is summertime.  They need their coats for the cold weather.  The streets are below freezing most nights in the winter here, with temperatures sometimes in the single digits.

So most of the staff gives up and doesn't offer them new clothes.  We have new clothes.  They are not beautiful or stylish, but they are clean and functional.  I think we get the irregulars from low-end manufacturers who can't unload the stuff anywhere and "donate" it to the facility for a tax write-off.

A lot of the staff is deeply religious, which strikes me as rather odd, given their behavior.  A lot carry around bibles and read them on the floor (along with their phones).

I tried to use a passage from the Bible to explain why they should help these patients.  This is Matthew 25:34-40 from The Sheep and the Goats.

34 Then the King will say to those on his right, “Come, you who are blessed by my Father; take your inheritance, the kingdom prepared for you since the creation of the world. 35 For I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in, 36 I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me.”

37 Then the righteous will answer him, “Lord, when did we see you hungry and feed you, or thirsty and give you something to drink? 38 When did we see you a stranger and invite you in, or needing clothes and clothe you? 39 When did we see you sick or in prison and go to visit you?”

40 The King will reply, “Truly I tell you, whatever you did for one of the least of these brothers and sisters of mine, you did for me.”

I read this passage to them from one of their own Bibles. I explained that when you clothe, feed, and care for a patient in need, you are doing this for God. The patients were sent to us so that we may demonstrate how we would care for the Lord.

There were oohs and aahs. Has their behavior changed? No.

Saturday, August 25, 2012

Psych Hospital Tidbit: Plastic Utensils Only

And I carry my own real fork with me.

Only plastic utensils are permitted on the ward- and they must be accounted for after the meal is over!  Like counting instruments in the Operating Room before closing up the patient, yes?

Friday, August 24, 2012

Empty Black Hole Instead of a Brain

The striking features of most of my patients is their lack of impulse control and their overwhelming sense of entitlement.  "I want juice.  Give me juice.  Oh my God.  I just asked her for some juice and she is still sitting there, when she should have been getting my juice."

Because of the incessant demands, we are not permitted to give patients anything outside their schedule:  pills, meals, afternoon and evening snacks.  No extra food.  No pens, books, notebooks, music, hair pins, combs, lotion, towels, and on and on.  They don't stop with a laundry list of demands.  If you give in and give them what they have been repeatedly asking for, they are satisfied at most for five seconds.  Then they start the barrage of demands for the next random item on their list.  "Can I use the phone?  I want to call my mother.  I don't know her number.  Can you look it up?  Is it in my chart?  Can you just call my sister instead and tell her to bring me Burger King to eat.  No.  Make that McDonald's.  And tell her that I want my X Box here.  I can have that here.  My doctor at the other hospital said that you would let me play X Box, but so far, you have not given me an X Box, so you have to call my sister to get me one."  They then follow me around, demanding to know why I have not called the sister yet.

It doesn't stop.  They don't sleep.  They might cat-nap every now and then.  They bounce off the walls, draining the energy from everyone around them and using it for themselves to keep going and going.

People who don't work with these non-stop demands all day will flag me down with the same fervor as the ignored patient to say, "He just wants his mother's phone number from the chart.  That's not hard."

That's not the point.  Most of the desired tasks are easy.  The point is that I am not their Fairy Godmother, here to grant their minute-by-minute whims.  I have work to do.  One of their reasons that their lives are such a mess is that they don't stop harassing the life out of everyone.  Family members often don't pick up their phones when the hospitalized member calls because they are enjoying the peace and quiet while their Energizer Bunny is away.

An attendant who knows better kept coming to me with a patient's requests for juice, cups, napkins, paper, information, and so forth.  Each time I turned her down.  Finally she pointed out to me that the patient was becoming upset because he want HIS NURSE [read: Fairy Godmother] to be doing all of this for him.  [Do I get to stroll into a business and bark out one demand after another and choose an employee who has to do it all?  NO.]

I told the attendant that the patient was a "bottomless pit of need."  She nodded her head, as if she understood.  She did not.

"So you want to throw him in a pit?" was her reply, half scared, half confused.

"No.  He is LIKE a bottomless pit."  She couldn't be that stupid, or could she?

"He is already in the pit?  He is not," she tried to respond.

"How much can you put into a bottomless pit?" I proceeded, trying to make something click in her dense head.

"Everything," she answered, as if she knew something.

"The patient is LIKE a bottomless pit because no matter how much you give him, he always wants more."  I waited for the wheels to turn.  They didn't.

"So that is why you want to put him in a pit?" she continued again.

She didn't get it.  Nobody I work with gets it.  They understand very little of what I say and the rest they interpret as an insult or threat.

Thursday, August 23, 2012

A Reminder to Me

My coworkers do not get this.

"So you should remind him sooner?" was one of the hesitant questions asked.

This highlights to me that they do not get me.  The expressions of speech.  References to pop culture, current event, past events.  They have no clue.

Not only do they not understand, they conclude that what I said was negative.

I can't say much around them.

Wednesday, August 22, 2012


I was trying to write a simple nursing note on a patient.

Quality Assurance Manager walks in.  He is not a nurse.

Asks me for a chart on a specific patient.

The desired chart is sitting on a shelf in front of his face.  With all of the other charts.

His interruption causes me to write the wrong word.

"The chart is somewhere on the shelf.  Go ahead and look," I say calmly and return to my writing.

He stands there silently and then says, "I don't see it."

I start to write the wrong word.  Again.  This is in ink.  I have to cross off, date and initial.

"Keep looking," I try to sound encouraging yet firm.  He is 100% capable of locating a chart all by himself and I am the nurse, not the file retrieval girl.

He finds it.  He opens it and starts talking again.  "I'm investigating an error," he says, as if this is enticing information that will draw me in.  Little does he know that I cover up more errors in a day than he'll see in a year.  He also does not know that his constant interruptions have caused me to err in writing a third time.

In the background are ringing phones that nobody else can answer because they didn't go to nursing school.  (You answer phones and don't have a nursing degree?  You are quite talented!)  Patients screaming, "Nurse!"  Alarms beeping.

"You want to know the number one cause of all of those errors you examine?" I ask him.  He looks intrigued.  "Interruptions.  You interrupt the nurse and she loses focus on what she was doing."  He didn't seem to understand.  I pointed to the paper I was writing my note upon.  "You see these three cross-outs?"  He nodded his head.  "They were the three times that you interrupted me."  Recognition flashed into his eyes.  "Nursing requires focus and concentration to deliver quality care.  You cannot pay attention and properly complete a task when you are incessantly interrupted, which is the norm around here."

"I didn't realize this," he stammered.

"Now you just saw how your seemingly innocent interruptions caused errors in documentation.  Keep that in mind as you look for the causes of omissions and errors."

I walked away.  Idiot.

Tuesday, August 21, 2012

Psych Hospital Tidbit

Glass is forbidden in psychiatric hospitals.  The mirrors are shiny metal.
You cannot see details in the reflection.
Patients who have been there for a very long time do not know what they really look like or that their face has aged.

Monday, August 20, 2012

Mirror Mirror

New patient spent the entire shift staring at his reflection in a glass window.




Better than harassing me or the patients.

Friday, August 17, 2012

Passive Aggressive

I think I may have a better grasp of passive aggressive behavior.

I ask the attendants which lunch they would like.  Some have a preference; others do not.

One attendant stated, "I don't care.  Whatever you give me as fine."

I scheduled everyone's activities and breaks and put out the sheet for the day.  The same attendant who did not care suddenly did care.

"You gave me the first lunch?  No!  Who gives the first lunch?  Nobody!  That's who!"

I tried reminding the attendant that she had said that she did not care which lunch slot she received.

"That doesn't mean I wanted first lunch!  Everyone knows that means second lunch!" came the shouted reply.

I did not revamp the assignments because of her.

The passive part:  Stating that she did not have a preference.

The aggressive part:  Exploding when her actual preference was not met.

Friday, August 10, 2012

Must this be such a weighty issue?

Excessive water intake is a common problem among my patients.  This results in fluid and electrolyte imbalance, which can be deadly.  A quick and painless assessment is to measure the patient's weight daily.  A difference in more than a few pounds from day to day can indicate excessive water intake.

I worked with an attendant I don't usually work with.  I don't know why it is that I work with certain people all the time, even when we are all floated to strange and unknowing wards, yet I hardly ever see other people.  Anyway, this woman is stupid and nasty about it.  She loves to challenge me and then ask someone who is not a nurse to support her position.  She starts with, "We never had to do this in all these years.  Now all of a sudden, you show up today, and it's supposed to be done a different way.  Have you ever even heard of this?"

It's different this time round because I'm different:  I know exactly what she's going to say it and the way she's going to say it.  I asked her to weigh a patient.

Her brows furrowed and a look of mixed shock and disgust flooded her her face, as if she were twelve years old and her mother just asked her to remove her socks from the living room coffee table.  "He doesn't get weighed.  We never weigh him.  You don't work here.  You don't know anything.  All of a sudden, you walk in the door, and this patient needs to be weighed?  NO."

"I need the patient weighed before breakfast."  I stood my ground.  Next would be her appeal to an irrelevant party.

"So now he not only has to be weighed, but you get to decide that it's before breakfast?  Did you ever hear about this in all your time here?" she asked the clerk.  Clerk shook her head no, as if the clerk knows more about monitoring input and output than the nurse does.  "Go do something else and I'll weigh only the people who need to be weighed and not all these people that you're just making up."

"Ms Smith," I remained firm, "The doctor is on his way over here to review the labs from last evening in light of the weight you are about to report to me.  Are you telling me that you know how to handle polydipsia and the resulting hyponatremia better than the doctor?"

"I don't even know what you're talking about," she quipped back, as if that was supposed to be an insult to me.

"I wouldn't expect you to, Ms Smith, as you have no medical training.  Your role here is quite narrow; simply weigh the patient.  We are waiting."  I stood there, not budging.  Not nice.  Condescending?  Perhaps.  She did the same to me.  Nice doesn't work with her.

She huffed off with the patient.  This particular patient is ambulatory and cooperative (though he doesn't cooperative with refraining from drinking gallons of water).  The scale is digital.  This was not a laborious task.  They were gone a long time.  Finally Ms Smith emerged from the treatment room, looking purposely past me.  "John," she called to an attendant down the hall, "How do you work this scale?"

She couldn't even perform the simple task.  How has she been getting by all these years?  Arguing with nurses until they backed down?  The nerve!  Yelled at me in front of others, like I was an idiot for wanting a weight on a patient, when all along she was trying to cover up that she was the idiot because she couldn't work the scale.

A nearby patient volunteered to show the attendant how to work the scale.  Most patients know how to weigh themselves:  Step on; read weight; step off.

Now if I could just train the staff on how to use the scale.

It is so ironic that so many smart, diligent people can't find work while a person like this nit-wit, who cannot perform simple tasks and is nasty about it, has a full-time job with benefits.

Thursday, August 9, 2012

Defense Tactic

People are talking about the strangling incident.

"The best way to keep the patients from attacking you," explained one of the older attendants, "Is to make them think that you are just a little bit crazier than they are.  Then they are afraid to mess with you.  Look at this counter," he commanded and pointed to cracks and missing pieces in the hard plastic.  "That could have been my head, but I made the patient think I was crazy, so he attacked the counter top and not me."

Wednesday, August 8, 2012

Patient Attacked Staff

Physical altercations are commonplace where I work.  Most are mild incidents with no long-term damage, but still make for an unstable and hostile work environment.  This week, I was present for a bad fight when a patient attacked a staff member and strangled him into unconsciousness.

This particular patient is too dangerous.  His attacks have been escalating.  There are facilities for long-term treatment of very dangerous psych patients.  The problem is that they are at capacity.  All over the country, psychiatric care facilities are closing.  The milder cases are pushed to the street while the worst fill the beds.  The facility where I work was not designed and is not equipped to handle very dangerous people, but with no beds available at a more appropriate facility, the truly dangerous now call this low-security psych treatment facility "home."  They call the staff whatever they wish and they punch whomever they want.  The response from management is to transfer the staff member's assignment to a different area of the building, as if this was a peculiar personal conflict that won't repeat.

I don't foresee more funding and additional facilities appearing by tomorrow, so the next best step may be for the facility to change some policies and allow more aggressive medication and restraint of these dangerous patients.

Tuesday, August 7, 2012

Is anyone in charge?

This cartoon gave me a chuckle.

We cannot medicate crazy against their will.  That is the policy where I work.

One of the hallmarks of schizophrenia is medication non-compliance, which results in relapses that worsen with each occurrence.

Nevermind that crazy is not logical or reasonable and that appropriate medication will help the person become less anxious and paranoid and help the thought process become clearer.

Patients can refuse medication and not be forced and must be left alone to be as manic, psychotic, and paranoid as they possibly can be- even if the refusal is based on paranoia, such as being poisoned, or based on an illogical thought, such as women should only take pink pills.  This is their "right."  As if someone would want to spend life barricaded in their room using tin foil to shield themselves from the beams that the FBI is aiming at them to zap thoughts into their brain.  Yet this is what some of the patients are back to doing.  I say "back" because this is the behavior that got them brought to a hospital in the first place.  I also say "back" because this is how people had to live before drugs like Lithium were invented.

"Just reason with them," is the response from management.  Now if people were so reasonable during a psychotic break, we would not need hospitals in the first place.

This is getting really out of control.

Monday, August 6, 2012

Red did not do well in these disasters

Highly recommended crazy night nurse worked with me on the day shift once.

We had five codes that day, which was a record, for the record.

Crazy wore red high heel shoes.  Highly inappropriate for so many reasons, yet not unusual in this place.  By the third code, she threw the shoes and got down to work.  When the action had cleared, she went looking for her shoes and could not find them!  One of the patients must have swiped them!

She walked around in her stocking feet for the rest of the shift.  She literally slid into the fourth code and fell.  She sat out the fifth code.

Let's find her a new job.

Sunday, August 5, 2012

I highly recommend . . .

A night nurse asked me for a letter of recommendation for a job she's applying for.

Problem is, she's not very good.

On second thought, why is this a problem for me?  If she wants to quit, or in other words, get out of my hair, I should be happy that I have a legitimate way to help her [get] out.

Unbeknownst to me, she asked another nurse for a recommendation as well.  I happened to see the letter on a desk.  I was quite impressed that this other nurse had found some good, though non-specific things, to write.  I scanned through it for some ideas.

The other nurse saw me.  I complemented the letter.  "Well, I had to leave out some things, you know, like about how crazy she is," the other nurse explained.

How true.  There are patients who are more stable than this nurse.

I can write this letter.

Friday, August 3, 2012

Giving a shower to a cat

A patient clawed me.  On my arm.  Could have been worse, like on my face or in my eyes.

It will heal.

Management's response:  "You shouldn't go near the patients."

Bedside care has officially ended?  Now can I telecommute?

The other response:  "Why don't you keep her nails short?"

See above response- I should not go near the patients.  Manic, violent patients don't take well to having manicures or any personal hygiene performed on them.  Have you ever tried to give a shower to a cat?  Same idea.  Also, this patient is violently out of control because she does not take her medication and you can't force a patient to take medication if they refuse.  Same rule applies to the nail cutting, so that is why she can run around with dagger nails, clawing people.