Alright, so I met the Virgin Mary the other day. She was an amazing woman, although the priest that she was assaulting might not think so. I’m sure that he forgave her, because that’s what priest do. But someone called the police because even the Virgin Mary doesn’t get a pass when she assaults someone. I’m not sure what the argument was over but it ended with Mary being brought to the Psych triage for assessment. Some might be intimidated by assessing the Virgin Mary, but I’ve grown accustomed to assessing important high level people. I’ve assessed several FBI agents, countless CIA operatives, several from outer space, dozens of musicians, and endless so called celebrities, one Pope and the antichrist.

I received a guy who thought that he was popular Tejano singer. He came in with 3 pagers, 4 cell phones, telling me that he could not stay over night because he had a gig the next day and that he needed to get to. He promised if I could get him discharged he would come back the next weekend and do a performance in the ER parking lot for all of us for free. I told him that could not happen. He said that his gig was for then Governor Bush who was running for president. He wanted to make a call to the Secret Service so that maybe they could get him out. I encouraged him not to from my history with that agency, they tend to overplay anything to do with the people they are in charge of protecting. Of course he called them and they called me asking if he presented a danger to the Governor. I admitted that he seemed harmless to me, just delusional that he was set to perform for Governor Bush. They let him off with just a warning not to call them again.

Such is the life in psych. You meet all kinds of wonderful people. I’m not complaining it’s what makes my job interesting. Of course I’d much rather meet these people for real instead of some psychotic delusion. Although, I would probably be more intimidated by them in real life, I mean who would not be nervous in front of the Pope or Jesus’s Mom. These “celebrities” are pretty infrequent; we get mainly your normal everyday “Joes”

Let me give a rundown of some of the “regular Joes” we get. There are the ones that arrive before the rain or cold fronts come in. They have been suicidal for months but have picked this very advantageous day to come in seeking shelter….er……safety from themselves. We have the distraught loved one, who has been left by his or her boyfriend or girlfriend, for someone else. They have consumed alcoholic beverages and taken 5 Tylenol tablets (I took almost that much just to feel like coming to work) because they don’t want to live anymore. Now the moment that their ex does not appear concerned, and they begin to feel nauseous, they call 911 for help. Do you remember when your Mother told you not to “cross your eyes” because they can stick like that? It’s a good that “rolling your eyes” is not in that same category because mine would have been spinning for years by now.

Now don’t get me wrong, we do occasionally get a “real” patient, someone who is really mentally ill. But they are not the norm, but the exception, which is what makes my job hard, weeding out the poor drabble that are seeking shelter from the storms of life or the truly ill patient that needs help. More and more these days you find Doctors that think along the lines that you do and refer these hapless patients out, while still admitting the helpless ones. I had a Doctor that I worked with once before that would not admit Borderline Personality Disorder patients. He contention was that they are better treated in the out-patient setting and seem to just get worse while in-patient. I remember a Borderline patient that knew that the Doctor would be arriving soon through the double doors and placed herself prostrate in front of the doors having what I would call a pseudo-seizure. When the Doctor arrived, he calmly stepped over the patient without saying a word. He went straight to her chart and wrote an order for discharge, without even talking to her once. I had another Doctor when they found out that this patient was seeking shelter by stating that they were having thoughts of jumping off a bridge, ordered the patient discharge and make a comment to provide them with a Mapquest to the bridge. Now we are not so heartless to encourage a patient to jump off a bridge but with the lack of beds these days, there is a mindset that we keep beds open for those that need them. There are shelters where these homeless “want to be” patients can go for shelter.

We get several families that want to admit their loved one for drug and alcohol treatment against their will. Of course this is not allowed in Texas, except in cases where the patient has caused bodily harm as in a drunken driving accident, but this is by a judges ruling only. When we try to explain this to the families they become angry and say that we just don’t want to help them. Sometimes they get mental health warrants by lying to the judge and telling them that their loved one is suicidal when they are not, and are just seeking help for their addiction. They are places for them to go to seek treatment, not in a psychiatric facility.

So here I sit, guarding the doorway to the psych units. One hand on my pen, the other on the Mapquest button, unfortunately both require time and effort on my part. It’s a never dull, unending post that I sit at, with the fate of everyone that enters in the balance. But if done right, and we always do the right thing, we leave with no one hurt, and I can sleep nights knowing that we’ve helped the ones that need it and sent the ones out that don’t.

Why is it always the big ones?

If you’ve ever worked in a psych unit, from time to time there is a patient that becomes unmanageable and requires some medication to calm down. In my long career there have been many. Most are forgettable, but some you never forget.

I was working a day shift at a state facility and my shift was over, but I had admitted one of the biggest guys I’ve ever come across. He was around 6’8” and somewhere in the neighborhood of 300lbs. His father had been a professional football player and I’m sure this guy had played some college somewhere. He was psychotic as hell, but manageable during the admission. The fear in the oncoming shift was palpable.

Come as you are.

I had just gotten home and was eating dinner when I get a call from the hospital. The “Big Guy” was going off and needed some medication. They were asking me to come back and assist in giving him something to calm him. I told them I would be there in 10 minutes because I needed to change. They told me to come as I was because it couldn’t wait. When I arrived I was met in the lobby with the other instructor of PMAB (Prevention and Management of Aggressive Behavior). We took inventory of who we had to help in the take-down if it came to that. There were 4 guys and a janitor. Two of us were pretty big guys, but the other two were older and the janitor was about 100lbs soaking wet and was already shaking in his boots.

We entered the unit to find the “Big Guy” pacing the hallway. He was wearing only a pair of boxers, (as a do-rag on his head). He had a cigarette in his mouth and was screaming to have a smoke break. It was around 2300 (11pm) and the next smoke break was not until 7am. The staff was all locked tight in the nursing station and the patients were all in their rooms with their doors shut tight too, occasionally one would peek their heads out. We headed to the nursing station to re-group and finalize our plan. They were talking to the Doctor and I mentioned that this guy might need a larger dose than most. The Doctor ordered Haldol 10mg and Ativan 4mg. (twice the normal dose) This guy was so big that normal take procedures were out the door. We assigned one person per limb. Each of us knew that we would have to hold on for dear life because if one of the limbs got loose someone was going to get hurt.

First in battle, first to the ER.

We stepped into the hallway, because I had admitted him, I would be the “front man”. I asked why he was upset. He told me that he wanted to go smoke. I told him that as much as I would like to let him, the next smoke break was not until morning. I promised that he would be the first one out but that he would have to go to his room now. He went off screaming and paced down the hallway. We decided to take him down on his next lap. The two of us that had some size were to take the arms and the older guys would work on getting the legs pinned together. The janitor, if he hadn’t wet his pants by now would help out if anything got loose. The moment came and I gave the signal. We quickly got his arms and pushed him against the wall, his legs were together and we went to the ground hard. The older guy was stuck under him but had his legs pinned and we had his arms. It took everything we had to hold him there. He was faced up with the older guy underneath, and the two of us holding arms that were as big as most guys legs. The nurse approached and gave him a shot. We figured that we would stay here for about 20 minutes to let the medication take effect and then move him to his room or the seclusion room. Our 20 came and went and this guy would not let up. We waited about 15 more minutes without any relief and the Doctor was called again. He said to give the double dose again and he was on his way to the Hospital. The second dose was given and we waited. In about 20 minutes the guy was calmer and I asked if he would go to his room. He agreed and off we went.

Father knows best.

He sat down on his bed, still sporting only the “do-rag” boxers. I talked with him and promised that if he could maintain that I would personally take him for his smoke break in the morning. He agreed and we eventually left. The next morning I arrived on the unit. When it was time to go smoke I went to his room and he was still sitting on his bed as I had left him. Now, that amount of medication should have knocked him out for a day, but he didn’t appear too phased by it. We went to smoke and then were off to breakfast. On the way there, we met his father, who had been called during the night as a protocol. He was even bigger than his son and asked to have a private talk with his son. We ushered them into a conference room and he immediately went to a tirade. He told his son that he beat the crap out of him if he gave us any trouble again. (There were a few more cuss words than I care to write, so I am paraphrasing) When they came out the father thanked me and left. The patient never said a word.

On the job training.

We had that patient for about 3 weeks and from that morning on he was calm, in control, and would say, “Yes sir, no sir, please and thank you”. He never gave us any trouble. Actually, he was a big help. We had a transfer of an aggressive patient to our unit. One day that guy was going off and tearing up the place. He was a pretty big dude too. When he got into the day room with everyone watching TV, he picked up a chair and threw it at the window. As he moved towards the TV to do the same thing, “Big Guy” grabbed him by the shirt and pinned him against the wall. We went up to get the guy from him and he told us he had him so we could get everyone else out of the room. “Big Guy” was already learning our protocols. He held him there until we could get meds and clear the room. I told him if he needed a job or a reference I would be glad to help him out.

While we always try everything to keep from taking someone down or forcing them to have take meds, there are times when you have to make that call. I never take it lightly. I’d rather talk for an hour if it’s going to keep someone from hurting themselves or someone else, but then there are times when talking is out the door and force becomes your only option. I have thought many times about that night. “Big Guy” could have easily flicked up off like ragdolls, but he didn’t. No one was hurt and he got the meds that he surely needed. Another crisis averted!

We recently received a presentation outlining the features of the Royal Marsden online manual.

From the academic representative, here is an overview of the presentation:

1.       Overview of product

2.       How to browse

3.       How to search

4.       Linking from References (how articles link to CrossRef and PubMed)

5.       Help (online help to get the most out of the product)

6.       Administration (for lecturers)

a.       Content management: how to – add your own procedure guidelines, edit your own procedure guidelines, add comments to a procedure guideline, global instructions (how to add them).

You can download a copy of the presentation if you wish.

I’m just watering the plants.

One of my favorite patients ever was this guy from El Paso. He was brought in under a warrant because he was caught urinating in someone’s yard. The officers felt that he was a psych patient just from talking with him for a few minutes and brought him in limping in shackles. He was this little guy about 5’2” around 100lbs.

Careful that your not in someone’s little buddy section.

Where I worked there was a section where we put our rowdy patients or the ones that were too intrusive for the other patients. I usually took these patients as it was closer to my desk. I called them my “little buddies”. This guy became one of my favorite little buddies.

 I guess you’ll not leave you ball in the yard anymore.

When I sat down with him he was very cordial. But I quickly found out that he was quite delusional. First he tells me that he from another planet. That he was left here to propagate our planet with their seed pods. That’s what he was doing when he was arrested. What he was doing was finding balls that someone had left in their yard, like basketballs, footballs, tennis balls, etc… and he would bury them where he found them. Then he would go by periodically and “water” them, urinate on them.

Now, I’m an observant person, but it took me about 30 minutes to realize that he has a marble in each of his ears. I ask him what they are doing there and he replies that they are “grogs”, a way the he is able to communicate with his people. He was hearing them talk as we were chatting.

Of gardens and interplanetary horticulture. 

So we get him set up in a room by himself. Over the next few days, he kept to himself. When I went to check on him I noticed that he had coffee cups stacked all over his room. He had little coffee straws hooked up in a maze of what appeared to be an irrigation system. Inside the cups were various seeds, a peach pit, a few green bean seeds and a slice of tomato. Normally, I would have had him remove all of this, but he wasn’t hurting anyone and he was by himself so I let it go on. After a few days I found out that the peach pit had actually appeared to sprout.

Tie a yellow ribbon ’round the old oak tree.

Several days later his brother came by for a visit. He told a horrifying story of how he got his limp. His brother told that many years ago he was living with his Mother in El Paso. The guy said that his brother used to go to the local convenience store everyday. On month he decided to go visit his brother in New Mexico and was gone for several months. When he came back he found out that the couple that ran the convenience store had been brutally murdered. The police arrested the patient when they found that he was back. Someone had identified him as the murderer. He was convicted and went to prison.

His brother found out and tried to help out. He found that the murders had happen while he was in New Mexico, so he couldn’t have murdered anyone. While his case was being retried, he was involved in an altercation and was severely beaten by the prison guards. This resulted in his ankle being broken but he was never treated and it healed incorrectly. This gave him his prominent limp. When the psych records came back from his stay in New Mexico, he was finally released from prison, with only a limp to remind him of the experience. I felt very sorry for my little buddy.

A little something to remember me by. 

Well, to wrap this up, he was eventually sent to the State facility for further treatment. I never found out what happened to him. Before he left he told me that he had lost one of his “grogs”. We searched everywhere for it but didn’t find it. Months later, when we were re-tiling the floor, I found his grog under his bed and I have kept it since then as a memento of my “little buddy” from another planet.

For lack of a better topic – Escapes.

So my last few posts have been talking about the escaped mental patient in Washington. Now that that crisis has been averted, I’d thought that I would mention a few of escapes that I have been involved with during my career as a psych nurse. These are not all mine, I mean outside of a few girlfriends way back when, I’ve never lost anyone.

The Early Years.

My first witness to an escape was while I was still in nursing school. We were in our second week of clinical at the local state facility. One of my student peers had been assigned an 18 yo guy that had been admitted because he had run away and was using drugs. He seemed normal and probably was just a non-conformist. I mean, most teenagers are at heart. We had been there most of the day when it was time for the afternoon “smoke break”. Patients that want to smoke or just get outside are allowed into the fenced courtyard. We were all out there when one of the techs brings out a nerf football and we start tossing it around. Several patients get involved and we have a great time. As we were getting ready to go back inside, my friend’s 18yo patient asks him to throw him a long one. The kid takes off running and my buddy tosses him one deep. The kid never turns around and just hits the fence and is over in a flash. Security is notified, the sheriff’s department is called (he had been brought in under a mental health warrant). A few of the techs and my friend from school were in pursuit. In about an hour, my buddy comes back, soaking wet. He tells me that the kids dove into a Resaca (an old river bed used for irrigation) and swam to the other side and he followed him. Anyway, to end this, the sheriff’s department brought the kid back in a couple of hours later. He was just laughing and asking if we could go play football again.

I know I’m strong, but smell isn’t everything.

When I was working up north, you know up by Dallas, we had had an escape because the guy had kicked the magnetic fire escape door. It’s a problem we had known about and had informed management. But you know, it required money, and management didn’t see anything like that in our future. So the thing is, this guy kicked the fire door and the magnet doesn’t understand that and just releases for a split second. If you happen to be leaning on it, the door opens. He found this out and escaped. The next day, I happen to be working when management and maintenance show up to investigate. I take them to the fire door and show them how it’s done. I kick, “Walla”, the door is opened. Then we head down to the other end of the hallway and they ask if anyone has escaped out this door. I tell them no, because we rarely have anyone down this hall. They ask if I can get this door open as well, so I give it a swift kick, “Walla”, it doesn’t open, but there is a crack from the top to the bottom, including a crack on the “fire door” sign. Management is standing there with the mouths open and maintenance is just shaking his head, trying not to laugh. End of the story is that both doors had to be replaced. Oh, and I was allowed to “check” them for strength. They were good to go (no pun intended.)

Be careful what you wish for.

I was working an adolescent unit in Houston. It was primarily weekend shifts, but occasionally I worked during the week. One weekday, I was there and we had a big black guy that was repeating over and over that he wanted out of here. He didn’t like being around all these “crazies”. I had been redirecting him most of the morning and had him settled down. While I was at lunch, I hear a “code green”, that was the hospital’s code for security and every available staff member report to the unit calling the code. It was my unit making the call. When I get there, they tell me he made a run for the fire door (it was a thick Plexiglas there.) He had broken the door and had made his escape. I asked how he got over the 10 foot wooden fence outside, they said he used the little sapling tree to kind of “pole vault” over. About that time, I hear a voice calling for help. I find that it’s my escaped patient. He had jumped from our courtyard into the next one. The next one was for patients from the Psych Intensive care unit, the really psychotic patients. He was starting to cry, and so I went over and escorted him back to our unit.

Another “be careful what you wish for escape” involved a guy that the police brought in. He was making suicidal statements after he was arrested for public intoxication. We go through the whole assessment process, when it comes time check him for un-authorized belongings (patient is naked), we find a large Ziploc bag taped to his privates. It was cocaine, he had been carrying it the entire time he was being arrested and the cops never checked him. Of course since he is here in a psych facility, I can’t call the cops back. I did alert the administrator on call and the safety officer. We spent the next 4 hours flushing the cocaine down the toilet. Anyway, a few days later, this guy is all mouth, telling how he’s in a California gang and that he is making real big bucks. I mean really living it up here at the state’s expense. In the evening, he gets a call that there is a visitor up front for him. We had a visitation area in the front lobby, we would send a several techs up front to watch them and not let them take off. This guy had a female visitor and the visit seemed to be going well. It was until a group of about 6-7 guys with handkerchiefs covering their faces came in and spirited this guy away. The techs went out to try to talk the guy back in but they were already gone. We didn’t realize it until I was giving report that evening, one of the oncoming techs said that if he was in a gang and he had come in with all the dope, the gang would want to know where that dope is, he hadn’t been arrested with it in his possession, so he should have sold it or was keeping it. They would never think that we just took it and not turned it into the police. They had come for their dope or the guy they thought had it. We did not ever hear of that guy again.

Tunneling on a psych unit will get you nowhere.

We have had several patients attempt to get up into the crawlways of the ceiling in order to get out. For the most part those areas are sealed in too. But the patients don’t know that so a few have tried. I’ve seen 2 patients so far up into the ceiling that they couldn’t get out and we had to go up and help them untangle themselves. One patient, I remember was in the ceiling for two days before they realized he was still in the building. He had been in the ceiling all that time. He thought that he was out but just ended up in one of our storage rooms. When we went to do a room to room check (because we knew that the ceiling was blocked), we found him sleeping on some boxes of old forms, a little hungry and ready for group.

I’m too old and slow to chase you.

In the past few years the hospital has had some escapes. One involved an adolescent that tried to repel from their 6^th floor room. I say tried because it’s difficult to determine just how many sheets you need to get to the bottom. This was a severe case of getting “short sheeted”. They fell and broke some bones and ended up in ICU. Another incident involved my buddy, Dave. One of his patients broke through our line of defense, “I’m really laughing out loud”, and took off running. Dave and the security guard took off behind him. They come back in a few minutes. Dave tells me that he’s running after this guy but feels winded but remembers that there are security cameras in the parking lot where he’s running, so he pushes himself until he feels that he’s out of camera range and he shuts it down. We laughed for hours about that. The guy was brought back in about an hour by Police.

While these are not all of the ones I’ve been around, it’s enough for now. Enjoy!

Who says I don’t know what I’m talking about.

Yesterday, escaped “insane killer” Phillip Paul was caught in Washington state. He was driving a van the contents of which included; a backpack, food, water, and, oh yeah, a rusty sickle or slingblade. Now what self respecting escaped criminal would make their way down the road without a conspicuous “rusty sickle”? I mean it could come in handy if your tire goes flat, you can use it to…to…to steal someone else’s van. You might have to scrape snow or ice off your windshield. I’m sure that there is a possibility that being a convicted killer, you might get a job harvesting crops with your rusty sickle. But my mind keeps going back to the fact that your a schizophrenic and have killed in the past, assaulted a police officer, and it makes me think that you have this for other, more devious reasons, to kill again. Anyway, I’m glad the guys caught and I’m sure that his double meal portions and extra crafting privileges will be taken away from him down at the “nervous hospital” ….uh huh (in a gravelly grunt).

MEMO TO STATE HOSPITAL:

Dear nincompoops!

Please do not allow our boy Phillip “slingblade” Paul to go on anymore field trips because he has a mental illness and a long history of not “working and playing well with others.” In the future, should he appear to be able to go on these outings, please let it be to your house for Christmas dinner or let him go with your family to the vacation at the lake. I hear that he “loves the lake.” Make sure that you pack the “mustard and biscuits”, I’ll bring the Chianti.

Signed,

Dr. H. Lecter

For those engaged with research and evidence based practice you may like to take a look at a new book in the Learning Centre.

Cutcliffe, J. and Ward, M.  (2007)  Critiquing nursing research. 2nd ed, London: Quay Books.
Shelf mark 610.73072/CUT

Although this book is biased to mental health, it takes each of the methodologies of how to critique the nursing literature and evaluates them (Burns and Groves,  Morrisons,  Ryan-Wenger, Polit and Hungler, and Polit, Beck and Hungler).  Each chapter identifies the method of critique and includes a worked example, plus the strengths and weaknesses of each model.

Great jobs, good jobs, and getting jobbed.

I have only been working for thirty years of my life. I’ve had some bad jobs; I worked as gas attendant back in a small town that only had one gas station. That was back in the 70’s when there was no “self service”. I worked in some good jobs; lineman, psychiatric nursing. But I have also worked in some great jobs; lifeguard, sports radio commentator. OK, unless you’re a photographer for Playboy or a beer taster at Samuel Adams brewery, your job probably is just a job, a way to earn money so that you have a place to sleep, food to eat and a TV to watch your favorite programs on. (I thought about saying a computer to read my blog with, but I didn’t……well, I guess I just did) Anyway, our jobs can be tedious, boring, stressful, demanding, strenuous, as Tom Cruise’s character said in Jerry Maguire, “it’s an up at dawn, life sucking siege of a job.”

Atmosphere.

In all of my jobs I’ve always tried to make my workplace fun and entertaining. I usually “name” the day, like today in Monday, but I have the next 2 days off, so I’m calling it “First Friday.” On days when it’s an all male crew I will call it an “All Testosterone Thursday”, it’s not like we install a stripper pole or anything. OK, it was thought, (like I’ve been to a strip club.) OK, I have been, once. It was my brother’s bachelor’s party and 3 guys had to drag me in. Well, ok, it was only one. All right, I walked in on my own, but I didn’t put any dollars in someone’s panties. OK, just one, well maybe it was a few.  Getting back on track here, I use these kinds of phrases to give myself and my co-workers a grin. Those of you that know me know that I love to wear Hawaiian shirts to work. There have been places that I’ve worked that frowned on that, but I usually wore them anyway. I mean how can you be mad at someone who’s wearing such a festive shirt.

Your job is what you make of it.

One thing that we did when I was working a travel nursing job north of Dallas was have a special meal day. The place didn’t have a cafeteria so we had to bring our food or have them send a hospital tray over for us. So on Fridays, we would order Chicken Fried Steaks from this place across the street and called the day “Chicken Frydays.” It was a simple thing to do but it gave us something to look forward to. Sometimes we would do practical jokes. One guy I worked with would fill a ziplock bag up with shaving cream and put it in my bag. It was suppose to go off inside the bag if it was mashed. It never did but who ever had been given the bag would try and put it in the other’s bag the next time we worked, just harmless fun.

If I can do it, you can too.

You should know by now that I work as a psychiatric nurse in a psych ER. I see some pretty rough stuff, we sometimes make light of it because it keeps us sane. I’ve had patients tell that “you don’t care about me”, and I will say that, “If I didn’t care about you, I couldn’t possibly do this job day in and day out.” They usually look around the room and some screaming woman or a guy being “happy handed” with himself and they understand that maybe I do care. I’ve even come back from vacation and within 15 minutes my name is being written (POOP WARNING  -  POOP WARNING) on the window in human excrement. Now if I can make my workplace a happy place, then you can too. I wish you all the luck.

OK, here’s the “Grasshopper” story I promised. It’s short so this will be a “bonus” blog for the day. I was working a psych unit one day. This young kid comes in, must have been 19 or 20. This guy had a lot of attitude. I am doing his assessment and he is being very sarcastic and giving me a lot of crap. I patiently continue on, when it gets to the part about him being under a mental health warrant and that because he is here on a Friday afternoon, that his weekend with the ladies is being put on hold, he gets a bit peeved. He starts asking me how do “I” get out of here? I tell him I use my keys, which I jingle as I’m leaving the room. He says, “Hey old man (I’m about 41 then) I’ll just snatch those keys out of your hand and take off.” I turn to him and hold out the keys in the palm of my hand and say, “Ah young Grasshopper, when you can snatch the keys from my hands, it will be time for you to go.” Of course, he was too young to even get the obvious reference to the character “Kwai Chang Caine” from the “Kung Fu” TV series of the 70’s. Much is wasted on the youth.

I was working as a psychiatric nurse in a hospital on the night shift. For the most part it’s not a bad shift if you can adjust your sleep cycle. For the record, I can’t. But anyway, this guy had come in that day and was pretty manic with some psychosis. He had been pacing the floor most of the day without much redirection. 

When it came time for everyone to go to their room, he continued to roam the hallways. I’m a pretty laid-back guy, but this guy needed to go to his room and not keep going into others rooms and disturbing them.

We obtained an order for medication, Haldol 5 mg, either oral or by injection. I walked the guy into his room and explained to him what was going to happen. The doctor had ordered some medication for him and he had the option of taking it orally, or I would have to give it to him the other way.

As I said before I’m a very patient man. I would much rather take the time to explain the situation and have the patient comply than to wrestle this guy to the ground and give him a shot. It’s tough enough to develop a therapeutic relationship when you’ve been lying on top of someone and poking them in the butt with a shot. 

So I’m talking with the guy and he is pretty paranoid but he agrees to take the Haldol orally. It comes in a concentrated liquid form that you mix with juice, like orange juice. This guy is holding the cup of Haldol laced juice, but he’s not taking it. I’m encouraging him to take it or we will have to get the shot. This process takes about an hour or so, like I said, I’m very patient. 

He finally refused to take the med, so I had the other nurse prepare the shot. While I am attempting to retrieve the cup of juice from the patient, he throws the cup’s contents into my face. Now, I don’t have to tell you again, but I will. I’m a patient man. I just wiped the sticky juice off with a towel. 

The male nurse from next door arrives, as does the nurse with the injection. The male nurse is from Canada and is a great guy to work with, funny, hard worker, and willing to help out in any way. So we get this guy in a hold, with him locked between us and bent over the bed. The patient is wiggling his behind, I suppose in an attempt to make him a difficult target. It worked because the nurse giving the shot ends up with a bent needle and cannot give the shot. 

While the nurse goes to prepare another shot, the patient decides that he wants to take the juice now. So not wanting to have to hold this guy down, I send word to prepare another juice with Haldol too. When it’s time to take the med, he balks on the juice again, so I call for the Canadian nurse to come back to help out, we quickly get him bent over and ready for the shot. He’s wiggling but we press our hips into him and get him settled. 

Now get this picture, the patient is in the middle, bent over at the waist. There is a male psych nurse on either side of him, our hips pressed into him and we are also bent at the waist. I tell the nurse to give him the injection and the next thing I feel is her hand on my hip. Now if you’re a nurse and you’re going to give an injection into the buttocks, you know to place your hand on their hip in order to know where to give the shot and not cause nerve damage. 

This hand on my hip makes me think that she has identified MY HIP for the shot so I start wiggling. I reality she’s just trying to get to where she can give it to him, which she does and we release the guy and instruct him to remain in his room. To finish with him, he eventually fell asleep in about 25 minutes and cause no other problems for that night. 

I wished the story ended there, but it doesn’t. We meet back in the nurses’ station to have the customary talk about the take-down. Everything went as planned and we wrap it up rather quickly. I’m looking around for the extra cup of juice with the Haldol in it. It’s no where to be found. I mean we look everywhere. It had been in the nurses’ station while we were taking the guy down so no patient could have gotten to it. 

We are scratching our heads, when I see there is an empty cup in the trash can. I call over to the other unit and ask for the Canadian nurse. He is notorious for stealing your last swallow of coke, water, or “juice”. He answers and I ask him if he happened to drink any juice from the nursing station. He laughs and said “yes”. I start laughing and tell him that he has just been dosed with 5 mg of Haldol. 

He stops laughing. We still have about 6 hours to go in shift. He doesn’t want to report it because he’s trying to transfer to work in the ER. He goes to the kitchen and makes some REALLY strong coffee. He has about 6 cups and does make it to the end of the shift. I offer to drive him home (he only lives about 2 blocks from work) but he waves me off. 

I don’t work with him for about a week, but when we do see each other again, he says that he didn’t quite make it home that morning. He told me that he was walking down the sidewalk when it started to get very narrow, like in a nightmare, until he thinks he’s walking on a tightrope. He felt everything just spin on him and he falls off the “tightrope”. The next thing he remembered was waking up in someone’s yard, drooling down his face, with grass stuck to his cheek. He told me that he was probably there for about 2 hours before he woke up and stumbled the rest of the way to his apartment. 

The good thing is that he never stole the last drink of anything at our nurses’ station ever again.

“So you want to be a psych nurse, huh?” For those of you out there that haven’t read me before, that is going to be the title of book that I’m going to retire on. It will be about my career as a psychiatric nurse for what’s going on now for better than 15 years. It will be filled with insightful moments about the helping people with mental illness, and providing safety for those who need protection from themselves. But mostly there will be the funnier side of working the unit. One such incident happened. Since its football season, I thought I’d tell you about it.

I was working a Psych ICU. We got a call that they were bringing in a violent patient in from the county. We usually had a separate area for these patients, so we prepared it for his arrival. He was a local college football player. Of course he was close to the biggest man I’ve ever seen in my life. I just guessing but he was about 6’5” and very close to 370+ lbs. He came in with, what I figured, was the entire Sheriff’s Department.  He was in cuffs, shackles, and I was surprised not to see a muzzle. This guy was “Silence of the Lambs” meets “North Dallas 40”.

So he gets in here and I start to do his assessment. Now one of my hard and fast rules is NEVER lie to the patient. It always comes back to bite you in the BUTT. They are looking for someone to trust and lying to them will prevent them from forming a bond with you. So after getting most of the information that I need to do an assessment, (I’ll call him Butt Dikcus), I tell Butt that he is in a psych facility and that he is under what’s called a warrantless detention for mental illness.

I tell him that this can hold him for 24 hours until a psychiatrist can see him. As I usually say, you are here under warrant because of your behavior out there. I tell him whether he stays or goes, will be determined by his behavior in here. I usually add with the aggressive patients, (my little nurse with attitude phrase)…”you can spend your time in here either horizontal or vertical.” Just for the record, I didn’t say this to Mr. Dikcus. I didn’t think I had enough ass to back it up….lol.

So about 2 hours into his 24 hour commitment, Butt decides that it’s time to go. He politely comes up to the nursing station and asks for his belongings because he’s leaving. We politely explain back that he is here under a mental commitment and can’t leave. That’s when the screaming started. It wasn’t like a girl, so it wasn’t me. Butt is hollering and looking for the door.

I decide that it’s time to call the doctor and get an order for some medications to help calm down Mr. Dikcus. When the Doctor calls back, he’s trying to give me an order for a medication that has some desired effects, but clearly I need something that going to actually calm this big guy down before he hurts someone or himself.

While I’m explaining this to the doctor, I hear this “BOOM”, and I stop and look down the hallway. And I hear it again, “BOOM”. It’s like the whole hospital is shaking. The Doctor asks what that noise is. I tell him that this 400lb offensive lineman from the local college team. “BOOM” He is in a three point stance and firing off the line into our 1400lb magnetic door, trying to get out. “BOOM” (In the back of my mind, I’m almost hoping this guy knocks himself out), but the Doctor gives a nice double dose of Haldol and Ativan, one befitting a man of his size.

Now I’m figuring that I’m going to need about 20 guys to wrestle this big boy to the ground to give him some meds that he thinks he doesn’t need or I can talk him into taking them. Now mind you, I couldn’t talk him into staying. But as luck would have it, Butt’s girlfriend arrived, worrying about him. She was about 5’1” and 98lbs. But at least he stopped pounding the door.

I went out to speak with her and explained the situation to her. She was very understanding and explained that she could calm him down and get him to take the meds if I would let her in. Usually this is something I can’t do, but thinking someone is going to get hurt (probably me), I get an order from the doctor to allow her on the segregated part of the unit to help with calming Butt down.

To her credit, he calmed down and took the medications. He would not go to his room, because he said he wasn’t staying. So there he was sitting in a soft chair by the phone, talking with his girlfriend. The meds finally took effect, and he was drowsy. With the help of his girlfriend we coxed him to his bed like a slumbering 4 year old. I had to let his girlfriend out and told her that he would see the doctor tomorrow and he would determine what would happen from there.

Now I’m thinking that this medication is probably not going to last until he sees the doctor, so with the approval of the doctor, I attempt to get the Sheriff’s Department to come back and pick this patient up. There is a clause in their contract with us, that if there is a severe case where there is a patient that may be an imminent threat to the unit, they will come and take him and hold him at the jail.

Those “waskely wabbits” said they couldn’t come get him, but they could move his probably cause hearing up to the next morning so that after he saw the doctor, he would be taken to court and either sent home or sent to the state hospital. So then I only had to worry about the night crew and whether I would find them dead in the morning. (Ever have on of those days where you just want to call in to work for no reason?)

To provide a quick end to this, Butt woke up rather drowsy from his medication. He saw the doctor and the judge, but I’m thinking he didn’t really get awake until he arrived at the state hospital. All in all no one was hurt. Butt got to a safe environment. But what we found out the next morning was that Butt had not broken the door, but had dislodged the entire wall, door and all, from the foundation of the hospital. The 1400lb magnetic doorway was just swinging from a ceiling rafter.

In my nursing career in psychiatric medicine I’ve come to appreciate the lighter side of things. If you’ve read any of my previous posts you would know that by now. And it’s not that I am disrespecting the mentally ill, I most certainly do not. I could not keep putting myself out there, on the lineman…..er…. line, if I didn’t.

Late,

Thirdcoast

I was working one day on the unit. There was this young woman, really she was more of a girl, early twenties, very nice looking. She was a quiet young lady, quite demire, rarely made eye contact. She was here because she’d stopped taking her medication and was becoming very paranoid and causing disturbances at home.

It was a very typical day at work, some fires to put out with new clients and debates on when smoke breaks started, but nothing real bad and the unit was quiet for the most part. Just after lunch, I hear this loud commotion going down the hall coming from the livingroom area where the TV and couches are.

I look in the camera to see what is going on. All I see is everyone looking back at the camera, or rather looking at the area where the camera doesn’t show. So I head down there on the quick. I hear all this yelling and banging. My heart is pumping, adrenaline is flowing. I’m the only guy on the unit and I’m thinking I’m going to have to “dance” with someone.

Now let me remind you of all the years I’ve worked psych. I’ve seen quite a bit more than most, but I wasn’t ready for this one. When I get to the doorway, I turn back towards where the camera doesn’t show and on the table, this quiet demure young woman, is stark raving naked. She has a bible in her hand and she is preaching to the ones watching TV. (They’re watching Jerry Springer of course)

I grab one of the blankets and wrap it around her and escort her back to her room. I talk with her about the rules of the unit and that she can’t go around naked in front of the other clients. She calms rather quickly and appologizes.

There are no more problems with her and in a few days she is discharged home. Probably a month goes by and I am in the grogery store picking up a handful of snacks and drinks after a round of golf. I’m second in line and reading the magazines on the rack to see who’s having who’s alien baby when I look up and see that the demure young lady is now my check out person.

I look around to see if I can get out of line and I find that I’m blocked in. So I try and play it off like I don’t know her. Most patients don’t want to acknowledge you either.

When I get up to check out she looks me in the eye and says, “Hi Scott”.

I give a general response, “how are you doing?”

Her response is, “I’m still taking my medication and I don’t take my clothes off anymore”.

Most of my life, I have something funny to say about everything. I think I was redder than the Gatorade I had just purchased. I’m wondering what the other people in line are thinking.

My only retort was to say, “well that’s a good thing”, and scramble to get my Gatorade to the truck.

I’ve worked in just about every area of psych nursing. I’ve done the adolescent and children units, dual diagnosis units, chemical dependency units, your basic adult units, acute or ICU units. They have been in private facilities, home health agencies, county facilities, not for profit hospitals, and state facilities. Some people would say, “You’ve seen it all”. I probably have.

After 15 years of marriage that ended in divorce, I was searching for some kind of change. Some may say escape, but I have thoughts on that for later. No, I was looking for a change, a challenge. I had been working in a hospital, on night shift for the past year or two. My schedule was 12 hour shifts, seven days on and seven off. Of course I had told them that I wasn’t a night person and would love to be moved to day shift as soon as possible. They assured me I would be the first one they thought of. NOT, after being past over a few times, I started looking for other opportunities.

I live a small coastal town and there were few places for me to find work. I had been hearing about travel nursing from a guy that I was working with from Canada. So I came home that morning and logged onto the internet and filled out a few online applications for agencies. I went to bed and about 2 hours later, my phone was literally ringing off the wall. They asked if they could send their business packets and they did. They were all very elaborate and promised great pay, great benefits, and luxurious accommodations.

After perusing them I whittled them down to a few and called them back. I was looking for somewhere in Texas and settled on an agency in Houston. I had family there and thought it would be nice to have a support system near by. My agent was a guy by the name of John. John was a salesman, a whacky, goofball kind of salesman. I looked over the places he offered and decided to put in my application with a private psych hospital in north Houston. When he gave me the numbers, I had no idea whether this was a good opportunity. The pay was great, the apartment was close, and the hours were 40 hours/week guarantied.

With travel nursing you have a phone interview with the director and the agency person. I was a little nervous as I hate to talk on the phone. It seemed to go well, I answered her questions, she seemed pleased with what I was saying and I got the job. I would be working day shift, Friday an 8 hr shift and two 16 hr shifts on Saturday and Sunday. It all sounded good to me.

I was their first travel nurse so they were unfamiliar with the concept of how I got paid. I would arrive on Friday and they would be in a low census and send me home (I still got paid). John called me and asked why they were paying me so much. It seems that whacky John had quoted me an hourly rate for someone that was not getting housing. Oh darn John, I didn’t know. (Your loss dude). I worked there for almost 2 years! Finally, they started pressuring me to hire on as their employee, but for a lesser rate. I begged off and started looking for something else in Houston. This is where John got me back. He couldn’t find me anything else in big Metropolis of Houston.

I finally went back and picked another agency that found me a job. This agency was out on New York. I had a nice female agent that seemed to know everything about me. She was always nice and asked how my kids were doing. She said that there were only a few jobs for psych nurses in Texas at the time but she had a wonderful opportunity in the Virgin Islands. She talked of beautiful accommodations, great hours, and the pay rate was awesome. The way you get paid there is, you’re given an hourly wage of about $5.75. That doesn’t sound like much but that all that you pay taxes on. Then they give you a per diem of $100 a day that is tax free. You get that for every day that you’re on the island. I could hardly pass that up, except that I didn’t want to be that far from my kids and family for Thanksgiving and Christmas. The agency offered to fly the girls over during their time off from school but I just couldn’t make myself pull the trigger. I thought that maybe later I would go but the opportunity never came back up.

I ended up north of Dallas. The job offer was for an 8 week contract. I would be subbing for someone that was having surgery. I ended up staying there for over 3 years! The pay was good; the people I worked were great, we had a lot of fun there. My apartment there was owned by Jerry Jones, the owner of the Dallas Cowboys. It had it’s own golf course.

One of the things that we did for fun there was a thing called “Chicken Fridays”. We didn’t have a place to eat there so we usually brought something from home. On Fridays, we would order something from a café across the street. Their best thing was the chicken fried steak. So we would end up all ordering that and that’s how it became “Chicken Fridays”.

I’ll stop here and go into more funny things in future blogs.

Late,

Thirdcoast

It’s a beautiful Sunday morning here on the Gulf coast. The air is still humid but the cooling breezes of the coastal waters are soothing to my A/C compressor and to my soul. Some of us are getting ready for church, others of us heathens are praying from football season to begin. Instead of going to church or praying for football, I thought I would tell you a story about my run in with a biblical character.

Now in my years as a psych nurse, I’ve met Jesus, the Virgin Mary, even God himself, or at least those who’s mental state had them believing they were these people. The mind is a very complex thing. A little extra of a chemical here or lack of a chemical there, and you’ve got JC sitting across from you at the interview desk. Most of the time I just kind of shrug it off and go with the flow. I make notes to tell the Doctor or the unit nurse in my admission report. I bring this up because one particular night shift I was the only Registered Nurse in a 40 bed hospital. I was working an 8 hour shift and the admission had been very heavy. I believe it was a “blue moon” New Years Eve. I had a line of patients to be assessed; some were being watched by law enforcement officials, while others by themselves or with friends and family.

One particular group kept getting my attention every time I would step into the waiting area. There was this thin man about 40 years old surrounded by these two 60ish “Grant Wood” characters. I mean they were all but holding the pitch fork (remember the use of pitch fork for a later, ironic reference), just sitting there patiently waiting to be seen. I would go out and call the next patient in and there they would be, quietly staring back, biding their time. It’s not that they were scary or anything. They just caught my eye each time I went into the lobby.

So, I’m moving along slowly, getting each patient assessed and entered into the hospital. The cops are grumbling that I’m keeping them from their duties on the street. I’m thinking obviously the guy they have in 4 point restraints can wait a bit longer (kidding), I meant to say the homeless person that was trying to get a free chili dog at the local convenience store can wait a few more minutes(not kidding). Eventually, I get down to the last assessment of the night and I can go home and sleep this horrible shift off. And guess who it is? Yes, you’re right. It’s the “Grant Wood” couple and what turns out to be the son.

I call to them to come into the room. They sit down on either side of their son. I ask them the same question I have asked patients for all these years now. “So what brings you to the hospital today”? Everyone quiet, all staring back at me blankly. I scan their eyes for the answer. “Maw’s” looking down shamefully, wringing her hands in her apron. “Paw” is cleaning his round spectacles. So I looked to Junior. He calmly looks up and right into my eyes and says, “I am the anti-Christ”. Thank God (no pun intended), that he didn’t have James Earl Jones’s voice or I might have wet myself. OK, I was startled a bit. I’ve seen drug addicts as wild as rabid dogs, psychotic patients as strong 10 men, but this was my first run in with an anti-Christ, and he had insurance!

OK, so everyone knows that I have been a psych nurse for the past 15+ years, but do you know how decided to become one?

My wife at the time I was nursing school was a pediatric nurse and I was working part-time in a private school’s daycare before and after school. So naturally, I was thinking I would like to work with children. You know, most kids love me. I’m entertaining. I look funny. I’m teddybearesque. I have the total package. But when I went to my clinical rotation, the first patient I had was this 5yo girl and I had to give her a shot. From then on, every time I saw her in the hall she would start crying, so pediatrics was out. I’m still scarred emotionally from all the shots I received as a child.

My next rotation that I thought about was the nursery or delivery. I had been in the birthing room for my 2 kids and I have changed a few diapers, I thought would be cool. But with that unit you are sometimes pulled to post-partem where you have to teach “breast-feeding” and rub funduses of all things. Now without going into much detail, I have had some previous experience there. My first patient there was a 13yo with a 15yo boyfriend and he was not too keen on me teaching his “baby’s momma” anything about breast-feeding. So maybe that was out too.

So here I am, running out of places for me to focus my practice. My next to last rotation was in psychiatry. Now my Dad owned some apartments and had some section 8 housing, so I was familiar with psych patients. My first day on the unit I unlock the doors and step in. I find a 6′8″ tall black man with his underwear at his ankles making sounds like a choo choo train. I bowed my head, raised my hands…..and said “these are my people.” I’ve been here ever since.

Nursing Times logo

Did you know the popular weekly journal Nursing Times has a website?

Nursing Times is the UK’s leading independent nursing weekly magazine. We publish original nursing research and a host of clinical articles for nurses at all stages in their career, as well as professional and clinical news and opinions. We also bring you the best selection of nursing jobs.

You can access much of the material from the print version on the Nursing Times website for free. Some articles are summarised so you may still wish to read the full article in print (we have copies of the latest Nursing Times at Burton, Walsall and Wolverhampton Learning Centres), or you can take out a personal subscription via the website if you want your own copy (there’s an offer for students at the moment to get 12 copies for £12). There are also job listings on the website, as well as a community area with forums, blogs and debates.

Royal Marsden Clinical Nursing Procedures

As mentioned earlier on the blog, we have recently paid for online access to the Royal Marsden Clinical Nursing Procedures (you will need to log in with your IT account if accessing off campus). This is now available and ready to use – you can get to it from the above link or from the Databases A-Z page.

You can search across the whole resource for a particular procedure, or you can browse by topics which match the chapters in the print book. Browsing enables you to go directly to specific content, procedures, or figures. You can also download figures (for example if you would like to use them in your assignment).

We hope you enjoy using this new resource!

Issues in Mental Health Nursing seeks submissions for a special issue: Inpatient/Acute Care Psychiatric Environments

Manuscripts are being sought on contemporary issues in the area of inpatient/acute care psychiatric environments. Potential topics of interest include care quality, patient or family-centered care, psychiatric/mental health nursing workforce issues, consumer or patient perspectives, violence, and seclusion and restraint. Manuscripts may be research focused (qualitative or quantitative), practice oriented, or theoretical or conceptual in nature and may address needs or issues across the life span.

Deadline: Manuscripts must be received by July 1, 2009.

Please send all queries and manuscripts to: Kathleen R. Delaney, PhD, RN, PMH-NP, Professor of Nursing, Rush College of Nursing, Phone: 312-942-6208, Fax: 312- 942-2549. Email: Kathleen_R_Delaney@rush.edu

and

Mona M. Shattell, PhD, RN, Assistant Professor, University of North Carolina at Greensboro, School of Nursing, PO Box 26170, Moore Building, Greensboro, NC 27402, Office Phone: (336) 256-0379. Email: mona.shattell@gmail.com,

Manuscripts must be submitted through Manuscript Central: http://mc.manuscriptcentral.com:80/umhn

Instructions for Authors: http://www.informaworld.com/smpp/title~db=all~content=t713669522~tab=submit~mode=paper_submission_instructions

Back in 1996, Peter Nolan and Paul Crawford of the University of Birmingham (UK) issued an interesting article in the Journal of Advanced Nursing entitled: “Towards a rhetoric of spirituality in mental health care“.

Abstract (emphases mine):

The spiritual dimension of care is frequently alluded to in the nursing literature, but rarely examined in terms of what it means in practice or how it might be taught to students entering the profession. Some of those most in need of spiritual care are people suffering from mental illness or psychological distress. The aim of this paper is to explore the different meanings of spirituality and to suggest ways in which the spiritual care of clients can be implemented. It further recommends which aspects of spirituality could usefully be included in nursing curricula. The paper concludes by alerting nurses to the causes and manifestations of spiritual apathy in contemporary health care and calls for a rhetoric that will counter the jargon of cost analysis which currently prevails in the health services.

Obviously, this was written more the 10-years ago, but it remains very relevant. My own perspective is that whilst spirituality now features on the curriculum of many nursing programmes, little is done to help bridge the theory-practice gap in this area. Increasingly, “spirituality” and “religion” are equated, and – alarmingly – associated with post-mortem care planning (arranging for appropriate rituals to be observed, etc). Spirituality has become associated with ritual and is regarded as the domain of the chaplaincy department – who are regarded as professional spiritual carers.

Spiritual care has been compartmentalised in the same way that surgical intervention has. Nursing care plans often fail to realise that nurses cannot avoid implementing “spiritual care” – the interaction of two individuals is one rooted in a common, spiritual, experience of personhood. Student nurses, who endeavour to become skilled in caring for the human spirit, must learn a “way of being” with patients – an approach to spending time with, valuing and dignifying the human persons that are commended to their care. Christian theology contributes to this by understanding humanity in the Imago Dei, and by acknowleding a relational ontological approach to ethics.

As this article emphasises, therefore, spirituality is the necessary and universal responsibility of all healthcare practitioners. The responsibility for spiritual education of nurses falls both in the theoretical confines of the university and in the practical setting of the ward. Nursing theology and spirituality is cut at the coal-face of the nurse-client relationship. Nursing theology provides not a cognitive-proposition focussed set of data, but a grammatical framework which serves to regulate and add meaning to our common experience of humanity. Nurses are therefore tasked to become experts in human spirituality, even if their primary duty is not that of the pastor – to facilitate the encounter between man and God.