Psychiatric History - Can I still become a nurse? | allnurses [rant]

My question is this. Is it even possible for me to become a nurse, and gain licensure after two psychiatric hospitalizations. My psychiatrist thinks I am doing quite well, I have spoken to lawyers, and the BON rep in my state both said I should be able to gain licensure if I earn it.

Allow me to rant about this (quoted from http://allnurses.com/nursing-advice-column/psychiatric-history-can-1049132.html). Reword it to "can I be a nurse if I am diabetic? I've been hospitalized for DKA several times." Or "I spent 6 months in the hospital when I had breast cancer. Can I still be a nurse?"

This is the same thing. Why are we even talking about it? Why is it an issue?

If you do your job, it shouldn't matter what MIGHT happen. I've seen nurses flip out completely who do not have a psych history, possibly because they needed treatment and didn't seek it on account of fear of retribution. So this is a serious problem in this profession.

I've also worked with doctors who openly discussed previous addiction issues. They seem to get away with it. I've never heard a nurse admit to same, although statistics show I must surely work with a bunch of them who have those issues. Is there a double standard there too? Are doctors allowed to be depressed or anxious or bipolar?

Now, if you have a history of getting homicidal and violent, nursing is not the profession for you. But I've worked with nurses who even have shizophrenia and did fine. These things are conditions that people can work with, just like diabetes, heart disease, and everything else. I even worked with a narcoleptic nurse once. You'd think that might disqualify you, but our manager worked with her, and she was a fantastic nurse.

I can't rant enough about this so I'll try to shut it down...but just one more thing. I'm sorry to break it to people, but those nurses who call in with migraines all the time or are always late or always call in on the equivalent of their Friday mornings? There's a good chance they're dealing with psychiatric or substance abuse issues, and they will not get the help they need because they're afraid. It has to stop.

Source: http://allnurses.com/nursing-advice-column...

Why do we call it "actively dying?"

I'd always heard the phrase actively dying and never thought much of it until I started seeing a lot of people die in hospice. I'd seen plenty of death in acute care, but following the process through provides an entirely different perspective. In the hospital, particularly in the ER, I saw the last bit of the process, and sometimes it was as fast as a few minutes (think aortic dissection). It's not that simple.

The first thing I learned was that alive/dead is not the easy dichotomy that you would think it is. Either you're dead or not. But I go uncommonly religious and tell people that the Bible says it's "the hour of our death" for a reason. In the ER, I saw one person during my entire time there be pronounced and then sit up and pull her tube out. Now I know to give it a while before pronouncing.

The next thing, and the topic of this post, is that I started to learn about the process itself. Dying, I thought, is a passive thing; it's something that happens to you. Not at all so. It takes a lot of energy (from both the dying person and her loved ones). Anyone who has ever sat vigil at the bedside of a dying person will know what I mean.

It happened to me with my dad. We sat and waited and found ourselves wishing he would just pass because it looked like such a struggle for him. We were exhausted. We hated ourselves for wishing he would go, for any reason. We told him it was okay to die. We told him we loved him a million times. Why was it taking so long? Was he being stubborn? I didn't know. I don't think we slept for days.

He, like many of the moribund, unbeknownst to me at that time, was actively dying, and that's normal.

What's so active about it? I wish I could tell you what was going on inside the consciousness of the dying person, but by this stage, usually the last 72 hours of life, nobody knows. I do know that many of my patients while still responsive often say things like, "why am I still here? Why can't I just go?" A few have outright shored themselves up and decided to pass, right then, and couldn't do it simply through power of will (seriously, "OK, I'm going to die now," with eyes squeezed shut).

Is there an internal debate? Is it simply physiological? Is it a necessary biological process like birth, in reverse? I wish I knew.

The body is busy during the actively dying phase. I think of it like a powerful jet engine going through the postflight checklist, system by system. Things stop working when systems shut down. Muscles stop: first the big ones that move arms and legs and then the little involuntary ones that move food and water along. So the person stays in bed and does not want to eat or drink (please don't water-log a dying person...they don't appreciate it).

Inevitably in this process, then, dehydration sets in. Vital signs get weird: typically, heart rate goes up, temperature goes up, and blood pressure goes down, just as they would with regular dehydration. Think of a radiator without as much fluid going through it day by day. It heats up. Most often actively dying people are not sick from an infectious process that can be treated to reverse the process. They're just working on dying.

All those fancy respiratory detectors and regulators we learned about in physiology seem unsure what to do with this new information, so their little dials spin and breathing changes. Spin, spin: breathe really fast. No spin: stop breathing. For a while the systems kick in from time to time and breathing begins again. Eventually, they don't.

Breathing also requires the help of some pretty big muscles, notably the diaphragm, and as I've mentioned those are shutting down. Breathing begins to therefore look labored. I don't know what this experience is like from the inside. People don't look bothered by it (the dying people, not the onlookers), and we give medications for air hunger just in case they are.

Finally, the heart, also a muscle, is winding down before it stops. Heartbeats become fast, thready, irregular, slow, hard to hear or palpate. What with all these circulatory shenanigans involving blood pressure and heart rate, the little bitty blood vessels on the periphery close down because the body shunts blood centrally. This, along with decreased efficacy of breathing, leads to cold, dark hands and feet (and, sometimes, nose) and eventually mottling, that distinctive pattern that appears on the feet, knees, dependent areas, and eventually anywhere.

Then there is the issue of swallowing, that hugely complicated and coordinated effort that we all do without any conscious thought, if we are lucky. Remember, muscles aren't working. When that happens, secretions pool in the back of the throat, causing the notorious death rattle. Sometimes we give atropine or scopalomine for these secretion noises, but I don't like it because we are just dehydrating the person even more.

My point with this incredibly unscientific recounting of dying is that there is a lot going on here. People don't just lie there and die; they are going through quite a lot physiologically. I often think of it as reverse labor. Everyone has a different experience of it, and the body has its own timetable.

Also, I should say that I believe these natural signs of the progression of death should not be personalized, meaning I believe that the apparent labored breathing, fever, and so on are typically not as bothersome to the dying person as they are to those observing, particularly when the person is being medicated. I'm all for medicating people if there is any sign at all that they are suffering.

Finally, part of the active dying process really seems to be mental or spiritual. Those who see a lot of death say things like, "what is he waiting on?" and then postulate things such as (a) waiting for a family member to come, (b) waiting for a family member to go, (c) waiting for everyone to gather around, and (d) waiting for everyone to leave. It sounded bizarre to me at first, but now I do it to because I've seen so many people apparently duking it out until something happens: a visit. A holiday. An anniversary. Some people will tough out a death vigil for days, and then when the person sitting vigil finally falls asleep they go ahead and die.

Again: there's a lot going on there. And that is why we call it active dying.

Do we need to declare war on *everything?*

Americans like to declare wars on things. Cancer, drugs, gun control...it's not an issue. It's a war!

I saw this floating around teh internetz just now and became irate. Must we be so...warlike? Can we not reserve "war" for those things where soldiers go risk their lives and lots of people get killed for some Important Cause?

The wars on opioids and cancer especially irk me. With the former, it's really a war against the people who take opioids. With the latter, I don't think it helps cancer patients to think about waging battle with themselves. Cancer is hard enough. And so on for all the other non-wars we speak of.

Speaking of a war against gun control is so absurd it almost doesn't deserve mention, but I no longer assume that common sense is either common or sense. Are you KIDDING me right now?

This "war on opioids" really sticks in my craw, as people who follow me anywhere online probably know. Not only do I find the term annoying, because it is misleading, but also I think the "battle" has been randomly chosen and the "rules of the game" invented to punish people who need these drugs and the doctors who want to help their patients.

Alcohol ruins way more lives than Norco. Why are we not focusing on getting alcoholics the help they need? Major depression is a fatal epidemic (it is, really; people die from it when they're untreated, so in my brain? That counts). Why aren't we focusing on that? This list goes on.

Are there statistics on how many prescription drug overdoses come from medications other than opioids? On how many deaths are a result of people being unable to get medications (of any kind) that they need? I've seen a lot of patients who are so done with having to live with chronic and horrific pain that they are suicidal. Why isn't this problem being addressed?

These wars are just people in power deciding what should go on our collective agenda and getting us all stirred up by using fighting words. We need to use our brains to ferret out what is really harming and killing people and then focus on helping those people, not declaring war against them.

Rhythm looks bad

Some reactions are ridiculously underpowered for the situation at hand. To say that I had a "busy week" would be like that. It reminds me of something that happened to me at my very first job in the cardiac ICU.

My patient was in and out of stable V-tach. This is a tricky situation if you work nights, because is the patient asleep or now in UNSTABLE V-tach? I moved the crash cart into his room and put patches on him early in the shift, and I resolved to monitor him like a helicopter parent. But I had 3 other patients who were up to mischief.

I looked at him or his monitor every few minutes. It was one of those shifts where you don't eat, drink, or pee for much longer than a person should go without doing those things. On one orbit I saw the V-tach return. I ran in and the guy was asleep. I rattled him and he acted like a normal person would on being rattled awake. Whew.

But I still got an EKG machine, from the other end of the unit, hooked him up, typed in all the info, and did a 12-lead; called the really unhappy cardiologist (I had one line filled with amiodarone and one filled with dopamine, as I recall); and bolused the guy with some cardiac drugs and followed some other orders.

Which I mention because all of this took, you know, some time. Imagine my surprise when I got a page after all that was done from the monitor tech:

 Yeah it was a fun night

"Check pt: rhythm looks bad."

RHYTHM LOOKS BAD? Yeah. And I had a busy week.

Body language: down and dirty

Body language is a part of communication I never paid much attention to before I became a nurse---specifically, before I ended up in highly emotionally charged situations in ERs, jails, prisons, and, currently, hospice. I've learned a few tricks and tips.

  • Make a basket. Meaning, don't fold your arms or shove them in your pockets; instead, fold your fingers or hold your wrists and let them fall down in a big loop. This is, for some reason known only to shrinks, a nonthreatening position.
  • Do a body scan. Of yourself. Force your muscles to relax. Force your voice to stop squeaking.
  • Do a situation scan. Is someone towering over you and shouting? Stand up. Are you trapped between the shouting person and an escape route? Move. Are you infringing on someone's space? Move back. Have you legitimately done something wrong? Apologize. Addendum: frequently it is not possible to tell what is causing an outburst. In that case, assume it is not about you. That makes it easier to deal with and is also true 99.9% of the time (I totally made that up).
  • Do a body scan again. It's amazing what making all your muscles relax will do to help many situations.
  • Avoid the following:
    • "I understand how you feel." Or variants, such as "I understand that this is frustrating." Do you? The angry person has no way to know. Better to say something less obvious, such as, "this must be very frustrating" or "I feel like you are really frustrated, but I may be able to do something to fix it." Much better than "I know how you feel." Clearly occasionally you may in fact have a good idea how someone is feeling, but I find that if you choose to share this, it's best not to start with "I know how you feel." It's like "calm down." Just don't say it. Instead say something like "when this similar situation happened to me, I felt this way...."
    • "Calm down." This has never made anyone calm down, ever, in the history of the world.
    • Talking to fill space. That's a thing people do when they're nervous. You don't want to appear nervous, so clam up. If you've asked a question, allow that horrible silence to drag on. And on. And on.
  • Move in to the discomfort. When people start getting mad, distraught, or upset in any way, our human instinct is to pull back. It can be as simple as leaning back in your chair or as dramatic as finding an excuse to leave the room. Go toward it. (Safety permitting.) If someone has a screaming fit, stay exactly where you are, relax your muscles, make a basket, and be silent for a while. Fits come to an end. Moving away from the fit will prolong it and give the fit-thrower an advantage. (Again, if objects are about to get thrown, all bets are off. Move.)
  • Do a body scan. This is the equivalent of, in nursing school, "wash your hands." Do it all the time. Are you shoulders up? Forward? Are you hunched over? Are you rattling your feet? Biting your nails? Twirling your hair? Stop it. Fold your arms in your lap, breathe, and LOOK RELAXED.
  • Pause. Just pause, before you respond. Allow yourself to say things like "I think we should have this conversation at another time," if possible. Often, you do get a say in when a conflict takes place. You don't have to accept every invitation.

I'll say that again because it was a miracle to me when I heard it. "Who offered you this ass-chewing?" said a supervisor once. I named the person. "Did you accept it?" he asked. I was dumbfounded.

You do have the ability to reject an ass-chewing or decline to meet an unmeetable need. There are often consequences, but you don't have to accept every invitation to an argument, ass-chewing, or guilt trip.

The idea here is to recognize and acknowledge power plays and how they are affecting you, or, occasionally, how your power plays may be making something worse. Are you antagonizing someone? It could be unintentional. But are you? Stop!

Is your energy feeding in to a bad situation? If you're clenched up tight, your voice is high, and your arms are folded, the answer is yes. If you are the nurse, the charge nurse, the manager, or just about anyone who's ever been in a conflict, fix that stuff and things will go better for you.

What if someone actually threatens you? This happened to me in the ER and corrections on a pretty regular basis.

Guess what? The same principles apply, whether a convicted murderer is treatening to kill you if she doesn't get her Tylenol RIGHT NOW or whether the checker at Wal-Mart is being snippy. The SAME.

Oh. And breathe. Especially if you're maintaining a silence, this can be super helpful.

Hope this helps!

Review: iPad Pro 12.9 UAG case

I don't know about anyone else, but when I buy a giant slab of glass, I immediately start buying cases to try on it. In this case, I found one pretty fast that I actually really like. It's the Urban Armor Gear composite case. I bought it at Best Buy for $79.99. I already had a Smart Keyboard and didn't realize that you can use them both, so, win.

It's supposed to be impact resistant and have some space-age materials, and you can read about all that on the company Web site. My liking for it is based on more practical considerations.

  • Weight and size. Whatever it's made of is super light, and it doesn't take up much room around the iPad. If you already have the aforementioned giant slab of glass, you becoming immediately interested in not adding much weight to it.
  • Grip. The iPad is slippery. All Apple devices are slippery. I like the skinny naked look for your average device, but it's only a matter of time before I drop them if they are unclothed. This case has grippy material and protects the back as well as keeps me from fumbling with it.
  • Built-in Apple Pencil clip. Talk about slippery. I love my Apple Pencil with a kind of deep panicked affection. In the same way I always know where my keys are, I have a kind of built-in radar for it. Still I fear losing it. It's both small AND slippery. This case has a rubber grippy clip on the side that it snaps in to.
  • Works with the Smart Keyboard. The case has a side on the smart connector side that you can snap off and hook up your Smart Keyboard, so it basically acts like a back case that allows a Smart Cover. I'm a big fan of the Keyboard, and this setup lets me just take it off if I'm reading or drawing or something and yet easily put it back on to type or cover the screen while it's in my bag.
  • Kickstand. Along those lines, the Keyboard gives you ONE angle for propping up the iPad, and it's a fine angle indeed. But if I'm not typing anything, the case has a kickstand that allows multiple angles. It's a flimsy piece of crap kickstand and I hope it doesn't snap off, but it does have a wide base to it and supports the iPad really well if I want it propped up low on a table, which I tend to do when I'm reading stuff that may result in some minimal typing, which I'll just do on the glass keyboard.

iPad, Smart Keyboard, and case weigh slightly over 3 pounds, which ain't light, particularly when my MacBook Pro weighs only half a pound more. It's all perception, though. The iPad setup FEELS much skinnier and lighter, and dragging it around without the keyboard shaves off weight and bulk.

More to the point, I'm not likely to pull out my laptop to do much of anything when I'm out and about, but as it turns out, I AM likely to pull out my iPad, even as big as it is. You never know when you'll want to sketch something or look at something on the big pretty screen. I do read a lot on my iPhone 6S, but if I'm going to be reading for a long time I prefer this big old two-column view. I know, that's weird, and it's just all a matter of personal preference. I'm probably as surprised as anyone else that I like this thing so much.

It IS big enough that my MacBook cases and bags are fine to chuck it in and tote it around without them looking silly and wasting a lot of space, but it's also skinnier enough that it goes in my regular (admittedly giant) everyday bag. It's like the size of a thick folder of paper, of which I have MANY in said bag.

I don't usually review cases, because I don't buy that many. They're a horrible ripoff so I'm a bit choosy. This one, however, is worth reviewing because it's so convenient, at least for what I want a case for. I recommend it despite the scary-flimsy-feeling kickstand on it.

It's not an emergency

Former ER nurses, it turns out, have a different definition of "emergency" than everyone else does. I will explain, then, what an emergency is and isn't.

In my world, emergency means you will quickly die if I don't do something about your problem. And by quickly I mean in the next few minutes. So basically, there are three emergencies, and only three.

  1. You aren't breathing.
  2. You don't have a pulse.
  3. You are bleeding profusely. It is an arterial bleed.

I'll also allow things that nearly invariably lead to one of those things in the next 5 minutes. If you're having such a severe asthma attack that a tiny squeak of air is still moving, I'll allow that. If you keel over in V-tach and still have a pulse for the moment, I'll allow that. Everything else might be a big problem. It might even necessitate some quick thinking and action. But it's not an emergency.

Here are things that are not emergencies.

  1. You forgot to tell me I needed to do something, and now you are behind. This applies even if it's shift change.
  2. The pharmacy closes in 30 minutes.
  3. Your patient "had" any sort of problem at all (emergencies cannot occur in the past tense).
  4. You think your patient might be about to [deteriorate, stop breathing, die, fall, choke]. (Emergencies cannot occur in the possible future.)
  5. You are vomiting. Vomiting seems to be often confused with an emergency and also for an activity that cannot be undertaken alone. "Oh my God, she's VOMITING!" OK, unless we're talking about a trauma victim on a backboard (thus invoking emergency #1), I don't need to attend this event.
  6. You have discovered a wound on your patient.

You get the idea. Note that the list of things that are not emergencies is much longer than the list of things that are emergencies and can be endlessly added to. Thank you for taking the time to read this helpful PSA!

Pseudoaddictive behavior

I learned about pseudoaddictive behavior at a pain management class a few months ago. Because I've been reading the new CDC opioid management guidelines, I've been pondering it again.

What is it? It's when people are undermedicated for pain so they start acting like drug seekers, only they're actually seeking drugs because they're in pain. Here is the common scenario presented in the class.

A patient gets pain medication every 4 hours, say. It is not a sufficient dose to last that whole time, so after 3 hours, he starts hurting and looking at the clock. He probably knows that he can have medication 30 minutes before or after the due time, so after 3.5 hours he's on the call light. The nurse is quickly irritated by this behavior and, often, reacts by withholding it. By the time the patient gets it, he is in really severe pain, so now he is going to be anxious about the pain returning and not being able to get his medication when he needs it.

Guess what? That's going to cause behavior that looks exactly like that of someone who just wants pain medication. This patient will ask earlier and earlier and get more and more anxious. He may insist on talking to the doctor and become angry and hostile. But he isn't "just a drug seeker." He's in pain and inadequately medicated.

The problem here is that in today's opio-phobic environment, anyone who asks for pain medication sets off alarm sirens in medical professionals. Oh my God, this person asks for his oxycodone every 3.5 hours! He's obviously addicted! No. It isn't obvious.

It's not hard to differentiate addictive from pseudoaddictive behavior. Increase the pain medication. If the patient is just drug-seeking, the behavior will not change. If he really is inadequately medicated, he will stop the pseudoaddictive behavior. But we can't help if we don't recognize this pattern and the possible reasons behind it.