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.

Explanation of Papers Signed by Patients

As Behavioral Health Workers (a.k.a. Mental Health Workers), when a patient is being admitted to the psych unit, we are tasked to have the patients sign admission papers. The forms listed below are those papers and I’m going to provide a brief explanation of what the patients are signing in the simplest language I can that they can understand, which may not necessarily be what is exactly written on the forms. This is how I’ve simplified the process:

Conditions of Service – This is basically a consent for treatment form. I tell the patients to sign this paper so the doctors and nurses can treat them while they are in the hospital. The form itself is more elaborate and is in very fine print.

Message to Medicare – This form explains Medicare rights for patients who have Medicare, however most of our patients don’t. So to simplify it, I just tell the patient that we are going to check if they are covered with Medicare insurance.

Patient’s Rights – This is self explanatory. It lists the rights of patients in a psychiatric unit.

Privacy Notification – What I tell patients about this form is that – we respect their privacy and will not release information unless they give permission to do so. It also asks if the patient has and Advance Medical Directive.

Consent to Photograph – We ask the patients’ permission to take their photograph so they can be identified correctly by the staff (in addition to their ID wristbands).

Release of Siderails – In case a patient does not want to use the siderails on the bed, they have to sign this form, but since most of the beds on the psych unit don’t have siderails, I just tell them to please be careful to not fall off the bed.

Notification of Patient Admission – Contrary to what some workers tell the patient, this form is not to get the name of the person to contact in case of an emergency. This form asks whom the patient wants us to notify of his or her admission to the hospital. It also asks if they want to notify anyone in case he or she is placed in locked seclusion or restraints. The third part of this form is in case the patient doesn’t want anyone notified. And the fourth part is a list of people the patient gives consent for us to release information to about their well being.

Hospital Ownership Disclosure – This form is fairly recent and it just to disclose that our hospital is owned by a group of doctors. I’m surmising that this is required by law.

Property List – This form is where we list all of the belongings the patient brings into the hospital. Some workers also list the items being sent to the safe with the security guard. However, the security guard also makes a list of those items that we don’t keep on the unit, so it’s a waste of time to double list them. In fact, our previous department manager said so and most people have forgotten that.

Well, that’s about it. I don’t know how else I could simplify the explanations and in my experience this hastens the admission process which the patient has too many papers to sign. Heck, in the emergency room, they only have to sign 2 or 3 forms!

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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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The Perils of Working in an Asylum

In an unfortunate night at work early Sunday morning, two of my co-workers got hurt by an assaultive patient. A female nurse got kicked in the head while a male mental health worker jammed his right ring finger while trying to get control of the patient's leg. Because of that they had to be examined at the employee injury clinic. I don't know the results yet because the two hardy souls still reported back to work the next night. So far, there wasn't a visible bruise on the nurse's face which we hope stays that way. You should have seen the stunned look on her face after the kick. She just sat with her back against the wall with blank stare until the charge nurse asked her to get the restraints and set them up. The sprain on the mental health worker's finger might take longer to heal and I'm basing that on my own experience.

It was hard to determine what got the patient agitated in the first place but when they are paranoid, any voices they hear in their heads can set them off at any time. That was probably what happened in this case because all of a sudden, the patient started ripping things off the wall and kicking the wall. At this point no amount of verbal intervention helped. In order for us to keep the patient from hurting himself or damaging property, we had no choice but to take him down to the ground. It's the same as what the police call the swarming technique: three to five people each try to grab hold of a limb then put the patient against the wall or on the ground then hang on until the patient tires him or herself. Kinda like riding a bucking bronco. This is reality. In the movies where you see the protagonist beats up a whole bunch of bad guys? Well that just doesn't happen in real life. We try as much as possible to keep the patient from getting injured but as this case shows, the staff can get injured instead because the patient is the aggressor while the staff has to take protective and defensive measures. We of course have to attend annual classes on how to handle assaultive patients. However the role playing being done in class is in slow motion and often not necessarily the same as how the patient acts or moves. We just try our best to apply the techniques taught to us and hope that neither the patient nor we get injured.

These are the perils and risks we take while working in an insane asylum. Fortunately incidents like the one I mentioned above doesn't happen very often on the unit I work in. That, I can be thankful for. Lord knows that I’ve had my share of hits, grabs, hair pulls, bruises and soreness through the years as part of the job.

The Case For Tray Tables

Tray tables or overbed tables are those rolling things used in hospitals for patients to eat on while confined in bed. We mental health workers on the other hand have different uses for them which I’m going to enumerate here shortly. Why am I talking about this in the first place? Well, our Nurse Manager, out of the blue, sent out an email last week that we should not be using those tables anymore other than on the geriatric psych unit. The reason given was that they shouldn’t be used for passing medications, for staff to eat on, or to lay our clipboards on (these are clipboards with a sheet for each patient where we mark their location and behaviors). Okay, I can understand the reason regarding medications, and eating, but there are a lot of other legitimate uses for the table:

*When the staff takes patient vital signs in the hallway, they need something to lay the clipboard to write on.

*On the night shift, we often cannot find another staff member to monitor the hallway when we are doing admissions, thus, we have to cover the hallway at the same time we are asking the new patient to sign papers and inspect their belongings. We use the tray table to lay the papers which the new patient has to sign. Without the table, we have to pull one staff member off the floor and go inside a consult room. God forbid if we get two admissions at the same time which does happen!

*For the same multitasking reason, we monitor the hallway at the same time we are charting on the work supplied laptop. And where do you think we put the laptop on? Yep, you are right – the tray table.

*Frequent items asked for by patients are paper and pencil. The tray table has a small drawer where we can keep those, thus preventing the patients from having to go to the nurse’s station every time they need those items.

*When I make new admission chart packs, I lay paper clips and assemble the necessary sheets on the table. I mean, really, I cannot make those packs without a table!

I implore the powers that be to return the tray tables because they make us more productive with our job. Working without them is like losing a limb. By the way, this was the same Nurse Manager who approved the purchase of four of these tables when we asked for them several years ago. I don’t know what changed between then and now.

Our nurse manager is never going to see this blog so what’s the point of writing it? Just airing my frustration over the seemingly unjustified removal of a very important equipment. That’s all.

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A Displeased and Unappreciative Worker

When I showed up for work last Saturday evening, I already knew that one of my regular coworkers was taking the weekend off. This was a very reliable guy whom I work with very well because we knew each other’s work habits. Despite him being off, I knew I could rely on my other coworker who even though a little lacking in initiative, can pull his weight when asked to. To my disappointment, he had called in sick (or cancelled himself – how does one do that?!). I didn’t even know whom I was going to work with on the floor. A licensed vocational nurse (LVN) showed up shortly and she was assigned to work with me. Well, she didn’t like that idea because she was expecting to work in the medication room. Not even concealing her displeasure, she asked the charge nurse right away if she could go home instead. That wasn’t really an option so she made it plain that she didn’t really want to work in the position assigned to her that night. You would think that what she was going to ask next was what she had to do, but noooo. She asked when she can take a break. Oh my goodness! All she had to do was check on her assigned patients to make sure they were present, alive, and not having sex with each other. On the other hand, I had to do that same job plus the rest of the night shift paperwork, making new charts, doing vital signs, and charting, because she didn’t know the routine and how to do them. I was quite content on doing all of them, which I eventually finished in a slightly longer time than usual. I was just very surprised and disappointed at the way she reacted when asked to work on the floor as a mental health worker. She was still getting her LVN salary after all. She also said she didn’t like that there were cameras all over the place watching our every move (oh well, welcome to my world).  We had to be very nice to her despite that because we needed her. If not, she would have been reported to the supervisor already for such terrible attitude. Some people just don’t appreciate having a job and if she didn’t need it, why even bother to apply?

We were lucky somehow because we didn’t have difficult-to-deal-with patients that night. I couldn’t say the same for a certain LVN.

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So Why Didn't I Get a Raise?!?

I started writing this last week upon finding out that all my coworkers had gotten a salary increase in their last paycheck while I did not. Three years ago, our employer gave us a raise and a month later when the recession struck, they not only laid people off, they also took away three percent from the remaining employees’ hourly pay. At the time, most employees got a three percent raise but when the employer took three percent off the new hourly rate, the workers actually got lesser money than before the raise took effect.

 So back to my problem. What I wrote below was in preparation for me to plead my case to my supervisor and human resources, because my annual review was quite good. Well, practically everyone gets good reviews anyway based on past evaluations and if so, why did my coworkers get a raise and I did not. Here is what I wrote last week:

Reasons Why I Deserve a Raise:

*Mentored coworkers when Electronic Medical Records system started.

*Keeps unit stocked with admission chart packs by streamlining the way they are assembled.

*I’m the only one who makes chart packs in our unit on South Campus.

*Does the most frequent rounds of any night shift Mental Health Worker.

*Does not fall asleep while monitoring the hallways at night.

*Developed a list of Mental Health Worker duties and responsibilities and revised them as the job evolved.

**Has been  proactive with having the Registered Nurse sign the back part of the rounds sheet because often times they forget that it needs to be done.

*Does most of the heavy lifting during the works shift (I usually do more work than my coworkers).

*I often go the extra mile by doing work I’m not required to do like filing the rounds sheets before I clock out in the morning.

*When admitting a patient, I’m the only one who automatically gives them gowns, pajama bottoms, and towels (extra blanket too if the room they are going to is cold).

*Cut down a patient from the ceiling who trying to hang herself in the shower.

*I’m very organized and work is done in the most efficient way possible.

These may appear like inconsequential things and they go unnoticed and probably taken for granted because it’s work that I do on a consistent basis. I have never wavered in this work ethic since I started working here, unlike others who become too comfortable and show apathy after just the first few weeks of being on the job.

I’m not the type to toot my own horn but I felt slighted when my paycheck didn’t reflect a raise a couple of weeks ago. I haven't gotten complacent either. That’s why I wrote those reasons above. I started to think that all that hard work doesn’t pay off since the slackers got a raise while I did not. Holding out hope that there must have been a mistake, I decided to wait for the next paycheck to see if there were any changes before calling my supervisor and presenting my reasons. Hallelujah! When I checked my paystub online last Thursday night (we don’t get paper stubs any more, money is directly deposited in the bank and stubs are in pdf), I saw that I was getting two paychecks: one for the a correction of the previous paycheck and the regular check showing that I had indeed received a fair increase for all the hard work I have been doing. Will that raise enable me to retire in a couple of years? Well, it was only a few cents per hour. I don't know how many percent my coworkers got, but I'm happy with mine. Let’s just hope they don’t take that away again in the near future.

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