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.

T’was The Night Before Christmas in the Psych Ward

T’was the night before Christmas and all through the psych ward not a creature was stirring except for an occasional loonie who was med seeking. The patients were doped up on their meds with care, with hope that a few more patients like Nick or Claus soon would be there.

The patients were nestled all snug in their beds, while visual hallucinations danced in their heads. The computer screens made the  nurse’s faces glow, and work on the ward had begun to slow. A potluck dinner was had by the staff, and all of us gained at least two pounds and a half.

   

When out from the parking lot arose such a clatter. The ambulances had arrived and the doorbell was rung. The staff’s ears perked up to listen to what was the matter. Davonna had arrived with a patient in tow, with three more coming, all in a row.

No Dasher, no Dancer, no Prancer, nor Vixen. No Comet, No cupid, no Donder, nor Blitzen. Instead through the door in came the EMT’s. Along with patients named Dander, and Blunder, and Fix'em (names changed to protect the insane), none dressed to a tee.

We started work and had patients sign admission papers. While the nurses took care of medical matters. The patients brought clothes and all sorts of things in our presence. Alas, St. Nick they were not and the staff got no presents. We sent the patients off to their beds, all taken cared of, thanks to their meds.

As dawn approached with no sight of St. Nick, we’d done those admissions, I’d say pretty quick. But the intake office called out of the blue, saying five more patients were all in a queue. Without a full moon in sight yet we were getting patients all night, we couldn’t wait till 7:30 to bid the psychos Merry Christmas to all and to all a good night.

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Back To Basics - A Uniform and Group Therapy Mandate

          Starting June 1st, our hospital has mandated the mental health unit staff to start wearing nursing garb, i.e. scrubs. We’ve always had to option to wear those instead of the civvies that has been standard wear for psych units for decades. One of the reasons why out administration decided to do this was because they wanted to eliminate the wearing of hoodie sweatshirts. I guess they finally got a clue that people wear hoodies so that the cameras that surround the hospital hallways cannot identify them. As I post this, I would have been wearing my uniform the previous night.
Another thing our bosses wanted us to do was group therapy on the night shift. That would be difficult to squeeze in between the time we report to work at 7 p.m. and 10 p.m. when the patients go to bed. I commented facetiously during a staff meeting that maybe I could conduct group therapy while passing snacks at 8 p.m. Pass the patient a snack and ask him/her how the day went and if he/she met her goals for the day. If not, what he/she could have done better to achieve those goals. In the meantime, the rest of the hungry masses (and they are always hungry) wait in line for their turn. Then a group riot ensues… Just stating the worst case scenario.
In reality, this is how the night shift schedule works out: at 7 p.m. we report for duty and until 7:30, we listen to report from the day shift. At 7:30, we do our rounds, check on how our assigned patients are doing (first we have to make sure that they haven’t run away, and are still alive). The mental health workers do this while the RN’s talk to their patients. It is also in this span of time that patients get visits from family and friends until 8 p.m. The LVN’s on the other hand are getting the medications ready for the evening. At 8 p.m. we serve snacks to all the patients. They line up in the dining room and we pass out whatever the dietary department left for snacks: sandwiches, or fruit cups, or yogurt, plus juice and milk. This can be quite chaotic since everyone wants their share plus more. Some patients want a second helping even when the others haven’t had their first helping yet. Also at 8 o’clock, we offer free phone calls on the hospital phone and there is another queue in the hallway for that. Some patients do their phone calls first, then come to the dining room to get their snack or vice versa. Did I mention that we also check the patient’s vital signs at that time? There is another line in the hallway for that and we have to do orthostatic blood pressures and pulses which take time especially that we almost always have 30 to 36 patients. This takes about an hour and a half to finish.
So there is a constant flow between the hallway and the dining room. How are you supposed to conduct group therapy that way? By 8:30, the medication nurses are ready to pass medications and that requires a separate line in the dayroom area where the medication room window is. So there are actually 4 activities going on at the span of time between 8 to 9 p.m. After that, at 9:15, we conduct the last smoke break of the day, which lasts till 9:30, and finish off the remaining vital signs. Most of the patients go to bed after that and a lingering few watch TV until 10 p.m. after which we close the TV room so that the housekeepers can clean it up before they leave for the night. As you can see by now, the schedule is tightly packed between 7 and 10 p.m. and squeezing a group therapy session in there would be an exercise in futility. Of course the bosses who told us we should do group therapy has never worked the night shift or even observed what goes on in the evenings. Go figure.

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Work Matters – Where Have All Our Patients Gone?

The number of patients being admitted to the psych units of our hospital has deteriorated in the past year. Usually, during winter time the units are always full because we get a lot of homeless people with mental problems who want or have to get out of the cold. Lately it hasn’t been that way and I can’t figure out the reason why. Did the government finally catch up with the abuses of some of these patients? It is common knowledge in this field that there are some people who abuse the system. They claim to be mentally disabled, get free medical insurance and social security benefits from the government. After that, they don’t have to work a day in their lives any more. When they run out of money, they check themselves in the hospital until their next check arrives. These are the people whom we usually rely on to fill our units. However their numbers have dwindled lately and that doesn’t bode well for our job security. We are getting sent to other units more often now, or sent home early, or cancelled from work. Still, that’s better than not having a job.

On another note regarding work - I don’t mind end of the shift admissions most of the time except when the patient brings his or her house except the kitchen sink. Inventorying belongings takes most of the time when doing admissions. That is what happened to me last week. As soon as I saw the name of the patient on our roster board, I knew right away that she would be bringing a lot of belongings. When she arrived, I told her jokingly that I didn’t expect any less from her. Since it was 6 a.m. and she had been in the emergency room all night, she was tired and didn’t really grasp what I was saying. Fortunately my coworkers did the vital signs of my other assigned patients for me while I was inventorying this woman’s clothes and accessories. Thank you very much for your help Saganda!

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Checking Blood Pressures At Work

The behavioral health unit in our hospital was inspected by the Department of Mental Health a couple of weeks ago and one of the things they wanted corrected was covering the electrical outlets in the patient rooms. Although there have not been any incidents regarding those outlets in the hospital, there must have been some in other mental institutions. I know for sure that patients sometimes insert graphite from pencils in the outlets to create a spark so they can light smuggled cigarettes. So since the DMH ordered all outlets covered, the staff could no longer check patient’s vital signs in the rooms. The blood pressure machines do come with rechargeable batteries but the machines we have run out of power pretty quickly if they even recharge at all. Now we have to rouse the patients as early as 5:30 in the morning to come out of their rooms and into the hallway where we can plug in the blood pressure machines. It really hampers the staff by making them unable to finish their tasks if the patients don’t want to get up so early. The best we can do is just mark it as a refusal by the patient to have their vital signs checked since we cannot force them to do it. One solution would be that the hospital provide the workers with better equipment. Given the tough economy, that is not forthcoming. I for one do not like waking patients up very early since that makes them cranky especially when they have nothing to do that early to occupy them. Smoke break doesn’t come until 6:45 and breakfast is at 8 o’clock. Of course there is the option of checking blood pressures with the old fashioned sphygmomanometer and stethoscope.

Taking initiative, I bought my own battery operated wrist blood pressure machine from Harbor Freight Tools, costing $20.00, and the few times I’ve used it, the device was working quiet well. I am now able to check blood pressures of the patients assigned to me at their bedside without having to ask them to get up. I’m still using the hospital’s thermometer and pulse oximeter which don’t need to be plugged in. Sometimes you just have to find your own solutions to obstacles that come your way.

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Personal Vendetta or Witch Hunt?

Several weeks after I blogged about the fire alarm and intercom system at work (http://noeldlp.blogspot.com/2010/03/fire-drill-that-didnt-work-so-well.html) that got me in trouble thus receiving a final warning (http://noeldlp.blogspot.com/2010/04/final-warning-how-i-got-in-trouble-due.html), and despite my charge nurse reporting the same thing using the proper channels, our findings have not been addressed or maybe just totally ignored.

 I’m starting to believe what my friends have been telling me all along: that the safety officer/head of security has made the incident a vendetta against me by reporting my blog to the human resources department instead of looking at our concerns. I have not arrived at this conclusion easily, but the actions of the two departments who handled my write up didn’t seem to be concerned about how the alarm system did not work so well. Rather, they chose to find fault in the messenger instead of addressing the message. Maybe they took offense when a lowly employee found something they didn’t foresee.

This may be unrelated but there has been a rash of write ups against the Mental Health Unit staff in recent weeks, so maybe the administration is on a witch hunt for one reason or another.

Meanwhile, I’m trying to walk the straight and narrow path so they would not find another reason to counsel me again, or worst, fire me for exercising my freedom of speech.

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Gone Mental For The Marathon

People who don’t run often ask me: “What? You have to pay to run 26 miles?!” Wouldn’t you know it but I did it again: paid $86.20 for another chance to take a tour of Long Beach on foot this coming October. What would possess a person to run marathons, do triathlons, or other feats of human endurance when all that is required to stay fit is 30 minutes a day of exercise? Sometimes I wonder about my mental health and if it’s a sane decision to run another marathon considering the condition of my ankles. I figured I was able to do it last year using the Galloway method for the first time, so I can probably try the same thing this year. Last year, I signed up for the half marathon and ended up switching to the full marathon. This year, I registered for the full marathon right away so I could commit myself mentally to training for it. Maybe I should be committed to a mental hospital instead. Nuff said.

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