Saturday, January 24, 2015

Pregnancy and the Bipolar Patient

Well, whoever made this sign misspelled monotherapy and arrythmia.

Prologue or perhaps I should call this a disclaimer - Let’s just say this is a fictional account and the writer makes no claims on it being based on a real people. Any similarities real or imagined are merely coincidental.

A woman shows up at the Emergency Department and is admitted to the Psych Unit. Almost a month later she is still in the hospital without any signs of improvement. Thus the difficulty of treating a pregnant woman with Bipolar Disorder. The foremost issue is to protect the baby, then treat the mental illness. Medications must be chosen which do not affect the pregnancy and at lower doses and sometimes like in the case of this woman, it has not worked. The psych ward had a similar situation before but with good fortune, even at her worst the woman was still verbally redirectable and she reconstituted quite quickly.

Just a week or so ago, it took four very patient nurses taking turns in keeping the patient and baby safe because she was wandering all over the unit and jumping on and off beds. The mental health worker (MHW) had never witnessed such patience and compassion before from staff in all his/her years working in psych units.

Then the MHW had his/her own opportunity to take care of this patient since she had to be sent to the semi-medical unit for rehydration, i.e. she had to have I.V. fluids infused. Since she was the type who could not stay still for even a short amount of time, the MHW was tasked on pulling the I.V. pole along with her wherever she went, while at the same time trying to keep her steady. Well, even though the MHW had gained more patience in recent years, part of him/her wanted to quit within the first 2 hours of trying to take care of this woman. If not for the possibility of being charged with abandonment of duties, he/she may have seriously considered walking out. There were other things at play though. They were supposed to have an extra worker take care of the patient but that worker was moved to another unit. The hospital did the same thing to the MHW the previous week when they provided an extra worker then pulling him out after 3 hours. Guess what happened after that? The patients started acting out!

Going back to the pregnant bipolar/manic patient, she ran the MHW ragged, thus his/her thought about quitting. What do you do when medications don’t work and the patient doesn’t listen to redirection? You do the best you can but it’s mentally tiring. She wasn’t the type who slept well at night and that’s the reason why 4 different nurses had to deal with her. The MHW was dreading having to chase her around for the 12 hours of his/her shift. Then, as luck would have it, the meds kicked in and the patient fell asleep close to midnight. The MHW was thankful that the patient as well as he/she was getting some rest. Knowing this patient, the MHW was aware that she never sleeps all night and is usually awake by 2 or 3 a.m. and the chase starts all over again. But one can always hope for miracles like for example if she doesn’t wake up until after the MHW leaves at 7:30 a.m., or if she does sleep well (which she hadn’t for the several weeks she had been in the psych ward), maybe by the time she woke up, her mind would be finally clear. But that would be asking for too much, wouldn’t it? She woke up at about 6 a.m. and she and the MHW started a new trek up and down the hallway with the IV pole.

Mind you, the MHW had to rely on his/her past as a lapsed marathoner and dig deep into his/her muscle memory to keep up with this patient. At least the MHW thought he/she could outwalk the patient if need be. When daylight came, the supervisor who happens to be a runner too, came up to help the MHW, which was really good timing because the patient started dropping herself to the floor and it took two people help her up. The minutes ticked by slowly until the day shift took over. The IV fluids were supposed to run for another three hours before the patient was to be sent back to her previous unit. Knowing that made the MHW feel a little better about coming back the next night. But…

When the MHW returned for his/her shift the next night, the patient remained on the same unit with plans to return downstairs soon after change of shift. Once again, the MHW was supposed to stay with her, but at least this time she was no longer attached to the IV pole which made it much easier to walk up and down the hallway. However, her behavior remained unpredictable. The doctor saw her and made a change in her medication. Another nurse soon joined the MHW from downstairs so he/she could help take care of the three other patients on the unit. At least now he/she didn’t have to concern himself/herself with them but rather focus on just one patient. The supervisor informed the staff that the nurse’s aide from the registry never showed up so they were short staffed again. To add to that, they were keeping Mrs. Manic  for another night. At about midnight, another MHW came to the rescue and relieved the other MHW of his/her duties for a couple of hours. Why just a couple? Well Mrs. Manic woke up at 2 a.m. and began screaming and when the first MHW came in the room with other workers, the patient called him/her a child molester and a one minute man/woman among other things. The two female nurses tried to calm her down to no avail. With great relief, the first MHW was able to break away for his/her half hour lunch. When he/she returned, they had taken the patient to the TV room where she was pacing around but also trying to toss magazines and papers from the bookshelf. So the first MHW took her out to the hallway and they started another 10K walkathon. When the patient finally said she was tired, the MHW escorted her back to bed along with the second MHW who needed to be present as a witness in case the patient claimed the first MHW did something inappropriate. She was restless in bed and would drift off for a few seconds before awakening again. It was like a startle response. The MHW talked to her softly and gently trying his/her best to emulate the horse whisperer. It didn’t work too well because she never went to sleep. After two hours of this, the first MHW had to cut himself/herself loose and let the other MHW take over so the first one could check on the other patients. The other MHW gave the patient a shower and changed her clothes before the first MHW did another 10K up and down the hallway until it was time for the night shift to go home. The MHW was glad to have the next two nights off.

Epilogue – What can the whole treatment team do better to make this patient functional again while protecting her unborn child? Perhaps they can consult with the family on what their expectations are so they can make decisions about the care of their loved one. They need to provide some input about what to do next since the present treatment is not working and thus not making the patient any better. It’s a big dilemma trying to save the sanity of the patient and trying to save the life of the baby too.

Well, that’s the writer’s fictional account of what happened one weekend in the Psych Ward where dull moments are sometimes few and far between.

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