Tag: psychiatry

The Broken Hearts of Nurses
Mental Health Stigma Suicide

The Broken Hearts of Nurses

lesbehonest2017Leave a comment

Sometimes when I write my patient notes I actually have to pause in between them. On busy days when I do three intakes I likely still have three intake notes to finish late at night after the boys go to bed and it’s just me and the laptop. Intakes can range from easy to me curled up in a ball on my bed watching The Office trying to forget the horror I heard today.

I remember working in the emergency department and documenting abuse cases. I tried to write as little as possible, as I didn’t want there to be any conflictual information between my notes and the MD’s notes. And good lord I didn’t want to be subpoena’d.

I’ve had my charts subpoena’d now. It happens eventually in healthcare. I’ve been called on the phone by judges who just found my chart in the middle of a trial who demand to speak with me about a patient I saw four years ago and asking about a note I wrote and did I think they would actually harm some one.

I’ve spoken to district attorneys and defense attorneys and divorce attorneys and DCF workers. Inpatient I spoke with the Secret Service, the Federal Marshal’s Office, the FBI, and several police departments.

Working outpatient mental health now I generally can avoid the Secret Service and the FBI so that’s a plus.

But sometimes the hardest cases and the toughest stories are the ones who never were reported to law enforcement. Because I know and they know that they suffered and that no one stepped up and protected them. No one made the call for them.

Now here they are all those years later telling me their story. All I can do is listen, document it, and support them now in that moment. I’ve learned a hollow “I’m sorry” doesn’t cut it. They’ve heard that before.

My general response is a poker expression, so they keep talking, and/or if they are looking for some verbal confirmation that I’m listening, “That’s fucked up.” or “That’s horrible.” I’m sorry isn’t enough. But when you acknowledge that it was fucked up with a straight face that looks like maybe you would fuck a person up for this client for what they’ve been through. That had I been there all those years ago I would have called the police for you or DCF or both…that’s when they make eye contact and really see you.

They can really see that your heart breaks for them.

I always see articles about nursing being the most trusted profession. Then commentary on why it’s nurses and not MDs. I’m always thinking why would it be MDs? Why not nurses? Do people even know what nurses do every day?

I’ve had a long week. Hard week. I’m also approaching my first birthday without my Dad. That’s been weighing on me in the background.

But this week in between being yelled at, threatened, etc. by patients and former patients, I’ve had parents call and tell me “They wanted to fire you and I told them oh hell no because she’s the only one who gives a shit about you and your medications. She’s the only one that’s done a damn thing for you. So she was what? Brutally brutally honest with you?! Good. You freaking deserve to hear the truth and she’s too real to not tell it you. They are coming back to see you. Because I don’t trust any one else to see them.”

Some times I need to hear that.

There’s a Frasier episode when he starts private practice. His first day of course is a disaster. He starts by trying to welcome’s each client. By the end he says just come in a sit down. That’s how I felt by 3 PM Friday. Just get in here and sit down and let’s get through this.

But you can’t do that. I can’t do that. I had to be there. Present and accounted for. I did a lot of intakes this week. I kept thinking about how to welcome them into my practice. I find though that I’m an acquired taste.

I had a few clients disagree with me this week. What’s great is that they keep coming back. I teach through modeling that it’s okay to disagree. That I disagree without judging their opinion. That we can disagree about certain aspects to their diagnosis or treatment and still work together often by reaching a compromise and often by me working hard to understand and validate their point of view.

Psychiatry is hard. Nursing is hard. Because at the end of a week like this week I don’t want to spend time with my kids. I don’t want to be a wife. I want to curl up and watch The Office. Space out. Forget and not feel. But if I do that. If I numb out I don’t feel my heart aching for some of my clients. That would defeat the reason I became a nurse.

Instead of numbing out with tv or alcohol or anything else. I am writing my notes. Charting. In between my notes I’m writing this blog post. To feel. To process. To know it’s okay for my eyes to well up when I think of the experiences some people have lived through. It’s okay for me to feel something for my work for my people. Because if I didn’t feel that. If I lost my empathy then I’d be useless at my job.

That’s why nursing is the most trusted profession. We allow ourselves to be vulnerable with patients. We feel their pain we work ourselves to exhaustion trying to help people. It’s also why we have incredibly high burnout rates but…that’s a different blogpost.

Tonight my heart aches for people who were never helped by anyone but themselves.

Tonight my cheeks may be wet with tears as I chart notes from this week.

Yes tonight my heart breaks with the pain that I bear witness to each day in my office.

I don’t regret my job I don’t even hate it. I love it. Which I suppose makes me a bit of a masochist. But all the notes don’t make me cry. Just a few. There are many more that report “significant improvement in symptoms” and a call from a parent who had to tell me they would never trust anyone else with their child.

Why This Nurse Cares.
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Why This Nurse Cares.

lesbehonest2017Leave a comment

In my time as a psychiatric nurse practitioner I’ve had people react to me in many different ways. I often say people either love me or hate me. There’s not much of an in between. But that’s wrong; I am learning the in between exists.

There’s a gray area where some people live where they just don’t understand me and are scared to hope that I might be real.

It’s taken me some time to recognize this particular response to me as it presents as hate some times. Often times. I’ve had clients scream at me, “BUT WHY ARE YOU BEING SO NICE?! I FUCKED UP!” I’ve had clients say, “BUT WHY DO YOU CARE?! YOU AREN’T MY RELATIVE SO WHY DO YOU FUCKING CARE?”

It surprised me the first couple times. Why would I not care? Why would I be in the profession I’m in if I didn’t give a shit?

I’ve reflected a lot about this particular reaction to me.

Clients that stick with me; who have been with me through divorces, marriages, bearing children, gender changes, sexual orientation changes, sobriety and relapses, and any other major life event you can think of…these clients know that I’ve got their back. They may hate me sometimes. When I’m not doing what they want me to do and I may push them in ways they don’t want to be pushed. But I’m there for them through it all.

I tell clients I don’t get mad at them, I just try and understand where they are struggling and why and work through it with them. And it’s really true. It takes too much energy and would require taking things very personally if I was to get upset with clients and sort of counterproductive to my role.

A client who recently questioned why I cared about them with skepticism said it must be because I have to care because it’s my job because I have to care about everyone who walks through the door. I immediately shook my head no. I do not keep every one who walks through my door. I do not take on everyone who calls. And certainly not everyone keeps me.

It has to be a good fit on both sides. We don’t necessarily have to like each other but we have to have respect for one another and we have to feel safe with one another. I’ve discharged people who threatened me or who were too acute for a private practice. And people have discharged themselves when they don’t get what they want or need from me.

But my peeps, my clients and my patients, yes I care about them. I don’t know any other way to be. I don’t know how to sit with some one and hear their story and try and partner with them to move forward and not feel something toward them. Empathy. Compassion. Because it is from those clients who I learn the most. The clients who take steps forward when the world pushes them back; they are the people who inspire me. They are the stars to see, to feel, to experience, and to be witness to that brings me joy like nothing else.

I saw a client recently and we got in really deep about something and they teared up, and we had this moment, and I’m like you just got therapized. But it’s not just them it’s me who learns from them. Me who learns that it took almost two years to get a tear from them to watch them progress toward feeling the hard mushy feelings.

I care about people because I couldn’t sit in the chair I sit in and not care.

I trained with an APRN who was amazing. She taught me tremendous amounts about everything but mostly she taught me how to see patients as people. She said she did half hour follow-ups instead of the standard fifteen minutes a psychiatrist does because, “Ya know. I like to talk to my people.” I agree with her. I like talking to my people. I like to know them, and although caring about each and every one makes me vulnerable it’s also what makes me good.

It makes people trust me because they know I am prescribing to them in a way that I would prescribe and treat my own family member.

To wonder why some one would care hurts me. Because it means that person has been wounded. Deeply.

Why the fuck do you care?

My answer is because I can. Because I do. Because I see you and you are worthy of being cared about. My question back would be why are you scared of being cared about?

Stop the stigma.

Psychostimulants…the Good the Bad and the Ugly.
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Psychostimulants…the Good the Bad and the Ugly.

lesbehonest2017Leave a comment

Stimulants first arrived on the market back in the 1950’s. Prior to that they were given to soldiers in World War II in order to keep them awake and focused. There’s a great novel- ADHD Nation- that outlines the history of stimulants so I will not go into that here. What I do want to talk about is my clinical experience in prescribing stimulants.

I have a lot of thoughts about ADHD as outlined here. For this blog post I’m going to try and stay off my soap box and stick to clinical experience only.

The Good. 

I don’t prescribe Adderall. I will limit my discussion to Ritalin LA, Ritalin (methylphenidate), Focalin XR, Focalin, Vyvanse, and Concerta. There are short acting stimulants (Methylphenidate and Focalin are the ones I prescribe most, however I have also prescribed Dexedrine) and long acting stimulants (Concerta, Vyvanse, Focalin XR, Ritalin LA). There is also a patch called Daytrana- I have never prescribed it. I know prescribers who have and they report mixed results. The good about Concerta is that it’s cheap and usually covered by insurance. The good about Vyvanse is it is less addicting and has a slower onset as well as less of a crash. Focalin XR I’ve had mixed results with, it doesn’t last as long as Vyvanse or Concerta but when it works it does really work for people. Some people who couldn’t tolerate Vyvanse or Concerta were able to tolerate Focalin XR. Ritalin LA same results, doesn’t last as long but generally well tolerated when it works. The benefits of stimulants for teenagers with ADHD can be quite astounding. They report feeling like they can focus better, having improved short term memory, improved organizational skills, and many of my clients report feeling better and more confident socially. To be clear, these are all subjective reports from my clients and what I have observed in my practice. None of the above should be substituted for your own practitioner’s recommendations and clinical experience.

The Bad.

They all reduce appetite and I’ve had to stop them or not even be able to start them in teenagers who are already underweight. There often is a crash of some sort. People report feeling very tired when it wears off or having onset of significant headaches. Some people just don’t tolerate long acting stimulants in general and feel crappy and in a fog when they take any of them. They can cause hypertension, and yes I’ve seen that happen in multiple cases hence why I check blood pressure. They can cause increase in irritability and anger. They can interfere with sleep. The worst is when a teenager is taking a stimulant and doing much better in school, and then they start to not be able to sleep. They come in for a medication visit with their parent and they both ask for a sleep aide. This is something I don’t do. I’m not going to prescribe an “upper” during the day and a “downer” at night to mitigate the side effects of the “upper”. If there are adverse effects such as poor sleep then we need to take a break from the stimulant. Many people do not like this answer.

The Ugly. 

Stimulants (and non-stimulant Strattera) can cause auditory and tactile hallucinations. I have seen this in clinical practice and it’s very scary for the client and their family. Stimulants can stunt growth. I’ve had clients on stimulants throughout their adolescence who grow to be over six feet. I’ve also had clients in their adolescence who stop growing and who need to be off stimulants and obtain growth hormone injections in order to reverse these effects. The growth stunting is very rare, but I’ve only been prescribing for four years and I’ve seen it happen. There is no predicting who will be in which category. Stimulants are absolutely addictive and they have a street value and you can snort them. I’ve even had clients who injected them.

The ugliest part of stimulants to me as a prescriber are instances when they are sought for the wrong reasons. I’ve done intakes on kids who are absolutely brilliant. They are referred by teachers for being “too fidgety” or “off in space” but they are getting straight A’s. These kids are bored. They need more challenging work at school, but in a class of 25-30 kids the teacher teaches to the average or below average so the kid only has to pay attention for the first five minutes to understand the lesson. I don’t prescribe to these kids, but their parents can easily take them to some one who will. Or the kids who are angry all the time and acting out at home so they must have ADHD. Then you talk to the kid and find out about a trauma history. These kids don’t need stimulants they need trauma therapy. The worst are the drug addicts who seek them to abuse or to sell or both. The addiction to psychostimulants is rampant and it’s something that no one talks about because drug companies are making billions of dollars.

Fun fact- the volume of Adderall that can be produced in a single year is regulated by congress. Guess who endorses the continued increase in the volume of Adderall that can be produced yearly? Our representatives and senators in congress. In one breath our politicians are speaking out against opiate addiction while in the next they are advocating for increase in production of stimulants. As a prescriber who sees the abuse of these medications daily I feel this is a problem.

My take home message is there can be vast benefits for people who truly suffer from ADHD and for who it is impairing their functioning socially and academically. But there are also adverse effects, long term effects, and addiction which all need to be considered carefully before writing out a prescription.

The Challenges of Treating ADHD as a Prescriber
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The Challenges of Treating ADHD as a Prescriber

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I receive around two or three calls weekly for evaluation of ADHD in children and adults. Generally people have done some sort of questionnaire online and self diagnosed after answering six general questions. Or they have been receiving stimulants from their pediatrician, PCP, or other psychiatrist or APRN who is now requesting they transition care to psychiatry for whatever reason. They could have been on stimulants for years, having only completed a basic questionnaire at the time of the first prescription.

Diagnosing ADHD is hard. There are a lot of false positives because our brains and bodies are not supposed to sit for eight hours a day listening to lectures or working on a computer. So kids in high school and college who find lectures challenging often come to me stating they can’t pay attention to a three hour lecture. I’m thinking yeah but who can?

Depression is pretty straightforward. For a true severe depressive episode there is weight loss/gain, poor ability to function in daily life (decrease in showering, poorly groomed, missing work etc.), sleep increase or decrease, irritability…the list goes on. I’ve sat with enough depressed people on the spectrum from mild to severe with psychotic features that it in general fits a picture and there is overt evidence of impairment in functioning of the individual.

ADHD, especially in adults, is more subjective. Sometimes it takes a few sessions for me to see the full disorganization of their thought process. These are people who could be getting a 3.5 GPA telling me they can’t focus and can’t organize themselves. It’s hard for me to believe that when they are doing well academically. There’s also a lot to rule out. Anxiety disorders often present with difficulty focusing as do depressive disorders. Bipolar disorder has a high co-morbidity with ADHD and many times when bipolar patients are treated with mood stabilizers their focus improves. Trauma/abuse in children presents often as behavioral difficulties and difficulty focusing. I can’t tell you the number of kids I’ve assessed who have been diagnosed with ADHD but no one asked them about being sexually assaulted and how that is on their mind all the time making it impossible to focus.

I have adults who come to see me who are working two or three jobs, raising kids, getting maybe four hours of sleep per night telling me they have trouble concentrating and completing tasks. Chronic sleep deprivation can cause cognitive impairments. In other words without enough sleep you can’t think straight. Taking a stimulant would enhance anyone who is chronically tired. Taking a stimulant honestly would enhance anyone in general too.

What I look for in an assessment is thorough testing of some sort. Neuropsychiatric evaluation, or at the most basic a Conners Behavioral Rating Scale. Anything beyond a Vanderbilt really. Then I need to figure out how functioning is impaired. It needs to be impaired for me to offer medication. In the midst of all of this I have to assess for those who are drug seeking: those who would potentially sell their medications to others, and any other co-morbid substance abuse issues.

Then if I get through all of that and decide this person could benefit from some sort of medication for ADHD I have to warn about all the adverse effects. Because they exist. For real. I’ve seen stimulants make kids psychotic (visual hallucinations), more angry, irritable, lose weight due to decrease in appetite, stunt growth (yes I measure height and weight at every visit and rarely kids have needed Growth Hormone injections), and yes I’ve seen people who are addicted to stimulants. It’s a real thing.

Then we have to pick the stimulant to trial. There’s a bunch. I point blank don’t prescribe Adderall- it has a high, then a crash, and a wicked withdrawal, it also had a major street value and is the “most addicting”. Yet Adderall is the cheapest and the one all insurance companies want me to prescribe first. So for every stimulant prescription I write that’s a new prescription, new medication, I have to do a prior authorization. It’s a pain in the ass.

This is a side note. Adderall is supposedly the “cheapest” available. But Ritalin has been out on the market since 1952. So I’m confused as to why it is still wicked expensive. It’s generic now, yet pharmaceutical companies keep the price of stimulants jacked up. Read ADHD Nation. It’s a good book.

So, I do a thorough assessment, I provide drug education for my patient and/or their parents, I potentially send a urine toxicology screen, I fight the insurance company to cover the stimulant I feel is safest to prescribe. I call the pharmacy and the patient to tell them they can now pick up the stimulant. They try it. We do a follow-up. They don’t like it. “I just don’t feel like me.” “It makes me too tired.” “I have no appetite.” “It makes me angry.” “It makes me cloudy.” “My friends notice something’s not right.” The list goes on.

Round 2. We try another one. I have to do another prior authorization. I have to do more education. If it’s a college kid I have to make sure they get the old stimulant out of their dorm room and off the college campus to a place that destroys old medication.

Potential success with second medication trial. Or we go onto the third.

In my experience it can take 1-3 tries to find the right ADHD medication. I do prescribe non-stimulants as well.

We find the right medication. Then we have to taper to the right dose. Then it’s only lasting 6 hours they want it to last 8 or 10 or 16.

Then we have to have the discussion- my goals are to medicate someone to last a school day. My goal is not to have a person’s brain on a stimulant for sixteen hours a day. That’s not healthy. Then we may have to have the discussion of why they are running out of their medication early- because they are doubling their dose, or taking an added afternoon or evening dose to get through work or night classes. Then we have to revisit goals of treatment, misuse of medication….it goes on.

I don’t want people to think I don’t love treating ADHD. Because I do. When a thirteen or fourteen year old comes to me and is suffering and being made fun of at school and says the one thing they want to fix with medication “is to give me friends” well that just about breaks me and when I see them respond to ADHD medication and therapy and a year or two down the line they are functioning beautiful teenagers with friends and a social life and good grades, well that’s just about the best feeling in the world.

I’ve been in outpatient practice now for three and a half years. Some of the patient’s have been with me since day one. I started treating them as gangly and awkward thirteen year olds and they are now applying for college and asking me advice about sex and if they can smoke pot with their medications. It’s frightening watching these babies turn into men and women but it’s also amazing forging relationships with them and being a safe space for them to ask any question about anything. It’s also heart-melting to see them now have friends when a few years ago they felt like the most lonely kid in the world.

Those are my success stories and those are the reasons I still treat clients with ADHD. But there have been a lot of problems along the way too. I’ve seen clients who became irate and verbally aggressive because I wouldn’t prescribe them stimulants, specifically their Adderall. I now screen clients over the phone for intakes and am clear that I don’t prescribe that particular medication to weed out those issues.

Prescribing psychiatric medication is hard. Diagnosing psychiatric illness is hard. I take that responsibility very seriously and I try and be exceptionally thorough. Because for those suffering with ADHD I do want to help. But it can be exhausting and it is one of the few fields where patients come often thinking they know more than their healthcare provider about their diagnosis and course of treatment because of the tests they’ve taken online and subsequent research (many pharmaceutical companies are tricky and link ADHD questionnaires with websites about stimulants- you have a problem? Here’s the answer!).

For those truly suffering from ADHD I’m not trying to invalidate your experience. Because like I said, there are clients I treat with true ADHD who improve with therapy and medication and allowing me to be part of their journey is an honor. But to everyone else, you may not have ADHD- don’t jump to conclusions and please ask for a thorough evaluation before agreeing to the diagnosis. Also note that behavioral and cognitive therapy does help ADHD in addition to medication. Naturopath doctors also are around who treat ADHD if you are looking for an alternative approach.

Read legitimate sources and articles. ADHD Nation is great, the American Journal of Psychiatry has excellent articles about ADHD. Don’t depend on WebMD and pharmaceutical company websites. Be truly informed and don’t get mad when your healthcare provider recommends a thorough evaluation before jumping to a stimulant. Instead be thankful.

 

What I consider a hard day as a nurse.
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What I consider a hard day as a nurse.

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This day occurred two or three years ago.

I walked in at 7:30 AM to the inpatient psychiatric unit. I found out quickly I was the only provider for twenty-six patients. We were already short one, then one call out and one psychiatrist working in the interventional suite. I had a team of three residents and two medical students, and myself, so we all just buckled down and started seeing patients.

It was kind of wild in general on the unit that day. We had a run of manic/psychotic patients who were loud, up generally all day and night, refusing medication, and one out of all of them who was particularly rude and verbally aggressive in their unmedicated state.

The other part of the culture on that unit was there was a very anti-nurse practitioner view by patients. They always wanted to see the doctor. But that day they didn’t have a choice because there were no Attending physicians to be had. It was nice always having a resident with me because I could at least say there was a doctor with me, but I ultimately was the one making decisions. So, there were a lot of irrational unmedicated patients. Some were angry about being involuntarily hospitalized and they really had no time for me because they wanted to see the Doctor.

I was in the middle of a particularly trying interview with a patient who was becoming verbally threatening around not being discharged when I saw a nurse run out of a patient room. He looked frazzled. On impulse I got up and went out of the interview room mid-sentence and stopped the nurse who told me a patient was seizing.

I was now in charge of a medical emergency. We called for transport to the emergency department. I started an IV and we gave Lorazepam (an anti-seizure medication). The patient was large, and it was hard, and we were doing this all in a psychiatric room which is not at all equipped or set up for medical emergencies. I was literally holding the oxygen mask on the patient after just pushing in the IV Lorazepam when some one tapped on my shoulder. “What?” I asked with somewhat of an attitude, as I was clearly busy.

“Um, you need to come out to the front.” I heard the voice of a tech.

“Kinda busy here,” I replied irritated.

“Um, the Secret Service is here.”

I sort of stopped and turned my head.

“You’ve got to be fucking kidding me?” I said. But I knew they weren’t. Because at that point I worked there for a few years, and we had been visited by federal marshals, sheriff’s, and the FBI, so really all that was left was the Secret Service. Psychiatry is nuts.

The ambulance stretcher rolled in. Thank God for paramedics. I gladly gave over my patient and walked out the door to go talk to the goddamn Secret Service.

My day didn’t get better from there.

After all of that we still had to write twenty-six notes. We discharged four patients, and admitted four patients. We reviewed labwork, EKG’s, medication doses, changes, etc. etc. etc.

We had to do all the normal shit healthcare providers do on top of rescue a seizing patient and deal with the Secret Service while working with one provider on a unit where there was supposed to be four. We did all this while one of the patients yelled racial and religious slurs at all of us. All day.

It was a Friday.

I vividly remember this day. I remember thinking I don’t get paid enough to keep my brain sharp enough to deal with this shit. I remember thinking NFL players get paid way too much to get their brains turned to shit. I remember feeling thankful I had my colleagues: the nursing staff, the residents, the social workers, everyone was a team. That’s the benefit to working in a hospital setting. I remember feeling burnt out; physically and emotionally exhausted, and also gross because the seizing patient puked and I felt like I had flecks of vomit on me all day. I hope to God I didn’t. But it was a possibility.

I remember mostly though that whole day no one cared or thought to ask about my sexuality. It didn’t matter that I am a lesbian when I threw the IV into that patient’s arm and pushed the anti-seizure medication. The families I met with to review discharge plans for their family members, the patients who screamed and swore at me for not discharging them, and all the staff. No one could have given two shits that I was married to a woman. Because I was competent and I got the job done. I’d like to think I got it done well.

The religious right says the homosexual agenda is to “normalize” homosexuality. Well duh. Because my identity as a lesbian has nothing to do with the ability to perform my job as a nurse practitioner. It has nothing to do with my ability to be a wife or mother or daughter. Being homosexual is normal. For me. I am a normal person who happens to be gay. If that was your relative seizing, and I was the one running the response, would it really matter to you if I am a lesbian or not?

Would you want me to step back and let a straight person who might have less skills as a nurse step in because they are straight? Gotta be honest even if that’s what you want I wouldn’t let it happen. Because my duty as a nurse and a human being would not allow me to let someone potentially die because of some one else’s ignorance. I’d tell you to shut the hell up and get out of my way most likely.

My ability to function and to be a contributing member of society has nothing to do with my sexuality. And this debate over whether people have the right to refuse services to others based on sexual orientation or gender identity infuriates me.

Illness eventually touches everyone. Illness does not discriminate. Remember that every single person will at some point be in a hospital. Think long and hard about whether you want to give your nurse, doctor, tech, surgeon, anesthesiologist, the right to discriminate.