Calling Dr. Strong!

Today I *FINALLY* got the real experience of what I thought a psych facility would be like. How naive I was, thinking that the whole experience would go by so smoothly and without any excitement. Today I was on the high acuity adult unit again, and I was paired with another student in my class. That was good because it sucked being alone those couple of weeks, it made the day long. Today was long but there was enough excitement to keep the clock moving.

This morning started out a little rough around the edges. I should have known. I had my usual pre-clinical insomnia, I woke up at 1:30 and was awake until maybe 3 or later, and then the alarm blasted my groggy ass out of bed at 4:45. Dale grunted at me to let him sleep another 15 minutes. I went out to make coffee and forgot to wake Dale up, so he was running late and grumpy, and I was stressed out because I had to do all the dog stuff myself and I could not get them to go out and do their usual routine, eat their food and go out to poop. The dogsitter wouldn't be in until at least 11 and I didn't want them to have to poop the whole time.

As it turned out, worrying about poop would be the theme of the whole morning.

With guilt I headed out the door nearly 10 minutes late after unsuccessful attempts to get them to go out and poop. I drove to clinical and realized our regular instructor would be gone until noon and the sub was our assessment teacher, I didn't want to be late if she was there. Fortunately traffic wasn't bad and I arrived at exactly 6:30. We got report and found that the charge nurse on the unit jabbered through the whole report so it was hard to catch everything. They had a registry nurse come in to cover someone who was sick. This poor registry nurse had little experience in psych and the charge nurse put her on the PIC (psych intensive care) side of the unit! The other nurse on the unit was one I'd worked with before and she is cool.

There was a full census on the entire unit and they were trying to get some of the patients out of the intensive care side and on to the general floor. Two of the patients were being discharged from the general side of the unit. The PIC unit was full with two patients sleeping out on cots in the open, all the beds were filled. The best laid plans...

We started out by helping the tech with vital signs. Most of the patients were a lot sicker than I'd ever seen before. Lots of people with schizophrenia, paranoid delusions, and hallucinations. We were halfway through vital signs and suddenly there was a code over the loudspeaker: Code Dr. Strong, 4th floor. The tech got called away and I told him we would finish up for him. The nurse told him she'd get goals group for him. The tech was gone maybe 10 minutes before they called another code. Same code, same place. Must have been bad, we thought. The tech ended up being gone for an hour and a half.

Turned out a patient who was in for electroconvulsive therapy was agitated before they got him sedated and he attacked a nurse, punched him in the forehead and cut him, the nurse needed stitches. The tech said the nurse was bleeding all over. And of course they decided to admit this patient to the PIC after his ECT treatment.

The nurse was trying to get some of the PIC patients who were getting better onto the general side to make room. She took two women and brought them over. There was another guy she brought over but we were told to pay attention to what he was doing because she wasn't sure if he was ready. This guy had been in prison for years and had a violent history, he also had poor sexual impulse control so we were told to be careful about eye contact with him, and to watch him if he seemed to be getting fixated on any of the women in the unit.

After goals group I was walking out onto the floor and a patient approached me. He was a young guy and had Asperger’s (similar to but more high functioning than autism) and some other stuff going on, and he asked me if he could talk to me about something in private. I said sure, let's sit down, and we sat at a table in the kitchen area. He told me he felt like he could talk to me, so I listened to him and he started telling me about his problem. This guy was telling me he was having a lot of pain in different places in his body. His vitals were normal but he said he had a sore throat, and pain in his stomach and upper abdomen. That's called somatization. He could talk and talk and he was going off on tangents and brought up all kinds of other issues about his psychiatric conditions, and I tried to get him back on the topic of what he wanted to talk about in the first place. Then he told me. He was having stomach pains because he wouldn't have a bowel movement, he kept holding it in and had not gone for several days. They gave him some kind of laxative but he said he only went a little. I tired to find out what was keeping him from going, and he told me he got distracted easily. He was reading books in the bathroom and they distracted him from the task, I guess. I let him talk for a while and asked him some questions about how he was going to work on getting the job done, so to speak. Finally I realized he was monopolizing me and I found a way to end the conversation.

Right after I walked away from him I heard a commotion at the nurses station and two of the women patients were in a fight, they were arguing over who should get their medications first. I have to admit it did sound like a catfight. Neither one of them was prone to violence but they got into it, and the nurse got out there and had to get between them before they went after each other physically. She sent them to separate areas and had to bring them their meds. All the patients were watching, everyone stopped what they were doing and there was dead silence on the unit except for the nurse telling each of the women to go to their rooms. It was easy to see how all hell could break loose if there wasn't enough supervision at a time like this. Any patient could have gone back to the nurses station and got into the meds or who knows what contraband and there could be serious problems. This incident happened before the tech came back and I was scared that we, the students, were going to have to do something to keep the patients in line until the nurse got those two under control. But it worked out okay.

There was an education group on stress management when the tech got back and afterwards he gave out packets for the patients to work on stress management. I saw one of the PIC patients they sent over, a little woman about my age who was psychotic and also slightly mentally retarded. She looked lost so I went over to her and asked her if she'd like help working on her packet. She spoke slowly and quietly. She was dressed in two hospital gowns to stay warm and some knee-high fuzzy gray socks. Her hair was short, graying, and messed up, and her teeth looked horrible, like they hadn't been brushed in weeks. There was some kind of reddish-looking food stuck all along her gumline on her top teeth and her breath was nasty!

We went over to the kitchen tables and sat down, and she opened up her packet. I wasn't sure if she could read, but she read the words well. She stopped at some of the longer words like "overwhelming" and "substance abuse" but she pronounced them okay. She asked me what the words meant and I asked her what she thought they meant. She was pretty close on them. I had to keep stopping her from reading the words on the page out loud and making sure she was understanding some of it. After every paragraph I had her pause and I asked her what it meant to her and how she felt about it. We did this for a good 15 minutes before she suddenly stopped and looked up at me, and got this devilish looking grin revealing the red teeth, and started giggling in this chilling, ominous sounding, brief laugh.

She stopped laughing as fast as she started. I said, "What's so funny?" She said, "I'm going to shit myself." And then she smiled again. I must have had a look of horror on my face. I got up halfway from my chair and asked her, "Do you need help to the bathroom?" She started laughing. She said, "Oh, no, it's not that at all." Her face got serious, like she was concerned about what I was thinking.

I said, "Are you sure? I can help you get to the bathroom if you need to go."

Then she said, "Did you hear that?"

I said, "What?"

She started laughing again with those teeth. "That crashing noise."

I didn't hear anything crashing. I realized she must be responding to internal stimuli.

She persisted. "Yes, that crashing. You don't hear that?"

Trying to be therapeutic, I said, "I don't hear anything crashing. How do you feel about the crashing?"

She looked at me, confused. Then I asked, "Do you feel afraid of the crashing?"

She nodded. I asked "Do you hear anything else?" She shook her head. "No, not now, they aren't saying anything now. Just making things crash."

Then she got that red-toothed grin again and started laughing in that eerie way, then cutting it off again. "I need to go." She nodded in the direction of the bathroom.

I asked her if she needed help. I was thinking, ugh, I bet she doesn't wash her hands. The nurse happened to be walking by so I went over and asked the nurse if the patient needed assistance in the bathroom. The nurse said, "Yeah, but I'll take her." I was relieved. I would have done it, but I didn't feel like dealing with wiping butts. I wasn't in scrubs and I would have had to find gloves, washcloths, and who knows what else.

While I waited, I wondered, do I have some kind of tattoo on my forehead today that says, "Talk to me about your poop!"

After that, another commotion broke out. The nurse came out of the bathroom with the patient as one of the psychiatrists on the unit was talking to the other patient who had been liberated from the PIC earlier. This woman was on the phone and the psychiatrist came over to talk to her and she started screaming at him, "you bastard, you people fuck everything up" and so on, started screaming all kinds of obscenities at him and started lunging at him. The doctor shouted at the tech to call a code, and "Code Dr. Strong" came over the loudspeakers. Fortunately between the tech, nurse, doctor and a few other administrative people and social workers who were there, they were able to hold her down. The doctor told the nurse to give Haldol and Ativan (injections to calm her down) and by the time anyone else came on the unit, they had her subdued and four of them were basically dragging her back over to the PIC. She was a big woman too, probably 200 pounds, every vicious ounce of her. Sounds borderline to me.

Right after all that excitement, the guy who attacked the nurse came back from his ECT and needed to get put in a room on the PIC side too. It was a zoo but there was nothing I could do except keep the other patients busy. Most of them seemed content to watch TV, go out on the smoking patio, or keep working on their packets. Only my poop guy from the morning seemed unduly distressed by the commotion and he went over to the other student from class and started monopolizing her.

Soon it was time to go to the gym with the activity therapists and I was so glad to get off the unit!

We had lunch and then came back to the unit afterwards, and things calmed down a lot. Our little monopolizing poop man got discharged, and we did our paperwork and I sat in on afternoon report with the nurses while the other student attended Process group. One of the patients who had been pacing all day said her feet hurt, and I tried to get her to put her feet up for a while but she wasn't going to do that, she couldn't sit still. Another patient told my classmate that the voices were telling her to throw up the apple pie she ate.

At 3:00 we went to art therapy and that was cool, I watched this one patient unload a ton of stress right in front of my eyes. I've never watched anyone else go through this process before but it was interesting because I do this all the time. When I paint, I can get absorbed in my painting yet do all this silent mental unloading at the same time, and I don't do it consciously but I know I've done it after I get done painting. It's like solving a puzzle in a semi-aware state. I can do this when I go walking or running too. I watched this patient do exactly that but out loud as she spoke to the activity therapist and me as she painted a papier mache mask. It was pretty cool to watch her mood change from tense and guarded to relaxed and gentle in an hour as the therapist talked her through all the stress and helped her identify ways to cope with things.

I was so exhausted by 4:00 I could hardly stay awake. I went in the back of the nurses station and tried to read charts. Some of the stuff was scary, especially the ones with the criminal histories. I also read about my little lady with the red teeth. She had come in with auditory hallucinations and but it sounded like they were a lot worse then, with commands to do things, but not to hurt herself. Now she was hearing things crash. The medication must be helping.

Afterwards we had postconference and the other half of the class gave their care plan presentations. The teacher told us the state minimum wage for nurses got raised to $24 an hour.

One of the students in our group got a big smile on her face. "Really?! Cool! I can tell him, I don't need to date you, you're a loser!"

Peace, love, and hallucinations,

Towanda, RN2B

From Nerd to Dork

Spring is coming. We still have had no rain, the dusty trails are starting to resemble powder skiing, but the trees are leafing out and that light spring green is visible in the washes. Allergies are coming too, I am sneezing! It's cold here, for here, but everywhere else it is cold.

This semester has been interesting and I'm enjoying the content of what we're learning, much more than last semester. Last semester was pretty much pure med surg except for a little of Peds and OB. We do switch back to MedSurg again in a few weeks but it will be more focused and preparing us for the real thing. The only thing that's still weird is Assessment. I feel like I'm not getting anything out of the class and the teacher seems totally unable to connect with us. I am hoping that as we move into the real hands-on stuff with Med Surg and head to toe assessment, plus some of the other teachers coming in, it will be better. I'm pretty frustrated and so is the rest of the class.

This week we didn't have class on Monday. It was a good day to study. I only have 13 chapters to read in Assessment before next week. We also have an exam in both Assessment and Process classes next Tuesday. I haven't even looked yet to see what our reading assignments will be like in the other classes. I tried to go easy on myself over the weekend, managed to catch up in Pharm and do a little studying, and that was all. This week I have Process class on Tuesday and I meet before it with the director of the nursing program, she's coming up to talk to the class about something and I want to talk with her about my decision not to switch clinical groups, despite the fact that the class creep will be in our group. Fortunately so far, not a peep out of the creep.

I'm so tired. Sleep has been a major challenge. Our neighbors got bark collars for their dogs which has settled everything down. They went over and talked to the dog nazi neighbor, and he offered to take care of their dogs for beer if they were gone! That's better than what he offered our neighbor across the street, she needed help shoveling gravel in her yard and he offered to do it for sex. So far no one has taken him up on his offers.

I find myself looking forward to med-surg. I don't know why, I was so sick of it by the end of Block 2, but I guess I'm feeling like I'm not getting to do as much in psych as I hoped, and it's going to be good to get back on the hospital floors. We'll be giving IV medications this semester which wll be good, and we're expected to be able to take care of most of the patients' needs, I'm not sure if we'll be able to actually take orders from the physicians though. Plus I found out we will have some rotations to the ED, which will be cool. I bet we don't have to do care plans that week either! I figured out today on my run that technically we only have 10 weeks of school in Block 4, and 10 more weeks in Block 3, so we're down to 20 weeks. I have to find ways to make the time go by quickly and 20 weeks doesn't sound long. We will be down to 6 clinical days after Spring Break, which will also make it seem short. Clinical days are sooooo long, and the extra day of care plans makes it twice as long.

Tuesday in our afternoon class I sat on the other side of class, on the far right side in the front row. It's one seat in front of where I started out sitting in Block One. There's a new transfer student right next to me, he seems like he's okay and doesn't give me any weird vibes. The two students behind me like to talk during class and it's annoying sometimes, but Susan, who sits right behind me, she is one of the youngest students in the class and was in my Block One clinical group and she is funny. Yesterday I thought I was going to have to leave the room she had us all laughing so hard with her commentary.

As COS was asking if anyone in the class had ever experienced a situation she was describing, Miss Anxiety piped up as usual on the other side of the room, she has to always put in her 2 cents worth as if she's already experienced everything under the sun in nursing. COS asked if anyone had ever seen a certain kind of response to drug overdose in the ED. Miss Anxiety works as a phlebotomist in one of the hospitals so sometimes she draws blood on ED admits, but she has somehow experienced EVERYTHING that happens in the ED (even though we have 2 or 3 other students in class who work in the ED in direct patient care but they don't seem to know EVERYTHING). It was so funny, Susan rolled her eyes and huffed, "you're a phlebotomist!" and then the next time Miss Anxiety raised her hand, Susan muttered through her clenched teeth, "Why don't you TEACH the freakin class". There were about 6 of us cracking up there in our corner because everyone in the class by this point rolls their eyes every time Miss Anxiety monopolizes the discussion. I missed all the fun while I was on the dark side...

It feels like the class has reached a point where we are all familiar with each others' quirks and we put up with each other but there are a few people who have distinguished themselves in less than admirable ways. Seems like they keep dropping off though. One good thing did happen, I let the director of the nursing program know that I have decided not to change clinical groups. I was telling Anne about my decision and Miss Anxiety, who is our clinical group, heard us and said she wants to move to the other hospital, in the spot I would have taken. I said, Go tell them right now! Anne and I both looked each other, trying to restrain ourselves. That would be great not to have both the stalker and Miss Anxiety in our group. Otherwise our group is good, and Miss Anxiety has actually been well behaved in clinical this semester. Maybe it's because she doesn't have any experience drawing blood on psych patients. At least this way there will only be one oddball in the group, and I am sure Roger won't put up with any crap.

The director also passed out information about our Block 4 schedule. We will be doing Peds, high risk OB, and med-surg ICU during Block 4, at Childrens Hospital, County, and/or South. Prep work (care plans) on Sunday, back to back 12 hour shifts Monday Tuesday plus all day in class on Thursday. It looks like I won't get much sleep or running in for about 10 weeks. I'll have to do what I can. August 10th is our pinning (graduation ceremony) and I'll get my life back on August 11th.

Thursday I met Anne in town and we went to the agency visit, it was an acute care geriatric psych facility for inpatients. They are mostly in with dementia but some for depression or psychotic disorders. I was amazed at how well staffed they were. It was so calm. The nurses weren't hurried, the patients seemed content and not agitated at all, the staff was smiling. They are staffed with 2 physicians, several social workers, rec therapists, OTs and PTs, plus 3 nurses, and 3 techs, all for 16 patients. This place is the exception, I found out. They are affiliated with a for profit network of hospitals and they are still getting reimbursed on a cost basis from Medicare, which is being phased out over the next 4 years and changing to a different method of reimbursement. I was so impressed, I thought, I'd like to work here. I wonder if after the Medicare reimbursement changes if their staffing will drop off. The nursing director of the agency told us that in 3 years they have not once had to use seclusion and restraint on any patient. I can tell why, the place is so calming, the patients are well taken care of and the staff have time to work with them. I know if I ever work in psych, I am going to be careful to research the agency before I apply for a job.

Seeing how well a place can function when it is adequately staffed and then experiencing the usual state of chaos in most health care facilities, you have to wonder how much better off patients would be if the hospitals were adequately staffed, if nurses had only 3 patients each on a med surg floor, for example. I wonder what the salaries of the CEOs of the HMOs and hospital administrators would be. I wonder about these things.

I have heard the horror stories from some of the students in our class at other facilities, they are getting feces thrown at them. We have been lucky, the patients at our clinical location have been much better functioning. I shouldn't speak too soon though, Friday I go back to the acute adult psych unit.

Speaking of horror stories, I got the schedule for med surg in the spring and I am hoping Miss Anxiety switches because otherwise I am paired with her for nearly every week. We are on the same unit for 6 out of 7 weeks. She will drive me crazy. It was done alphabetically and she is right next to me in last names on the roster. Oh well it's better than the creep. I noticed they put him by himself, it's like he's been banished to his own little world. Good. I see that I will be on the crazy med surg unit for 2 weeks, then ortho/neuro and med-surg renal for the other weeks. I'll be at Telemetry one week. The 13 hour days will be long but what's one more hour when you're already doing 12. Sometimes it will be longer if report goes past 7:30, which happens fairly often. I am going to be living on energy bars. Maybe I'll lose some of my Block 2 butt in Block 3.

It was absolutely freezing here this week. It only got up to 59 degrees at our house one day. It had to be in the 30s at night because the bougainvilleas keep getting more and more frost-burnt. I keep telling myself this is good practice for moving back to Colorado. I am trying to make myself wear shorts to run in the morning even though I have the heat on in the house and about 6 blankets piled on my side of the bed. Dale has two.

I had a dream the other night that we were in Grand Junction but we were looking at the San Juans from Ridgway. I remember seeing Mt. Sneffels and it was so vivid. I can't wait to get back up there and take some pictures and paint. I used to love looking at the San Juan ridgeline from Gunnison, and from south of Montrose it's even more rugged and dramatic. I guess it's been in the back of my mind that Grand Junction is a possibility. I think I was there in my dream.

I finally broke down and got some reading glasses. I have been struggling with the small print on the handouts and I was hoping I could make it to 42 without them, but I caved a few weeks early. Damn that was hard. I felt like such a dork trying on those dorky looking glasses in Walgreens and Safeway, I couldn't find any that I could stand to wear while looking at myself in the mirror, so in an act of pure vanity, I went to a third store, Target, and settled on a pair for 7.99 with blue metal frames that don't look too dorky. I feel like I should go out in the garage and sit in Dale's grandma's rocking chair and wear my glasses on a long chain and knit a sweater. Lucky for me the dogs are spayed. Plus I don't think I'll be brave enough to wear the glasses in class yet. Wearing them in public is still a bit of a stretch. The one good thing about reading glasses is that they don't look nerdy on me. Dorky. The 7.99 makeover.

Speaking of which, I need a haircut so bad. I am waiting for spring break because I don't have time during the week to sit there for an hour and a half. That's how long it takes to cut all my hair. Spring break I will be doing everything to catch up. Mammogram, haircut, taxes, thyroid followup labs, clean the grout, paint the bedrooms, it will be such a fun week!

Peace, love, and coping skills,

Towanda, RN2B

Split Ends and Zits!

This week was the Child & Adolescent week. It was a theme for the entire week, not psych clinical.

I have continued to have problems sleeping all week. Not surprising given all the stress I've had. You'll see as you read on. On the night before clinical, I couldn't settle down and I got up around 9:30 and sat in the kitchen and read a chapter of my Pharm book. That helped, but it was hard to drag myself out of bed at 4:45. I also forgot to put gas in my truck and halfway down the east freeway I realized I would be running on fumes on my way home. There was no time to stop for gas in the morning or I'd be late for clinical, and you can't be late or it counts as an absence. I figured I would get it on my way home once I got out of the Washington Street area.

I was on the child & adolescent unit, by myself, which was scary. So many of the kids there are usually from juvenile detention or have homicidal tendencies, torture animals and other children, cut themselves, and so on. The nurse who got there first was helpful, she talked to me before report and explained what she was doing and asked me what I needed to do while I was there. That was the first time a nurse has ever tried to accommodate students' needs before she planned her day, which I appreciated. I needed to see more of what a nurse does since we have been spending so much time with the techs, social workers, and the patients. Our instructor told us to try to watch the nurses do the medications. She waited a little while for another nurse to show up and she found out the usual person called in sick so someone else would be coming in.

As we waited, a woman came in, at first I thought she was one of the patients, but then I looked at her face and she was more like my age. She had wild, uncombed bleached and spiky blonde hair and was wearing low-cut jeans with a big chrome belt buckle and studded leather dog collar-looking things on both wrists. She wore a tight bright green t-shirt and a big, fresh tattoo was visible on one shoulder. She had another big tattoo on her lower back above her butt. It was visible in the gap between her tshirt and jeans. She walked into the office and started talking to the nurse, she was talking about partying and started getting into some graphic sexual details. The techs and secretary walked in about that time and started oohing and aahing over her new tattoo, and the room was busy, then the techs, the nurse, and the wild woman sat down at the table and started taking report. I listened and when it was done, I introduced myself to everyone, and found out that the wild woman was the other nurse! Later on I found out she graduated from my brother's nursing class a few years back. One nurse was conservatively dressed and the other one looked like a teenager herself. Maybe that's what you have to do to relate to these kids, I don't know, but it turned out the wild one was on the child side (under 13) and the other nurse was on the adolescent side.

There were a lot of kids on the unit, they are slow to wake up and get their breakfast and goals group didn't start until 9, so I spent a long time reading charts and matching faces to report. I walked out a few times and checked out the unit. I am always amazed at how whatever number of kids are present, it always seems like two or three times as many. The nurse took me back with her to get the meds and I went out with her while she gave meds. She was collecting the little plastic pill cups because the kids will stash them and then use them to cut themselves.

There was one boy who was sitting on a bench, hunched over and wrapped up in blankets. He didn't respond to the nurse when she approached him. He was depressed and the nurse told me that he wasn't eating, and that the doctor told her to place an NG tube to feed him if he didn't eat that day. I wondered if I was going to be placing an NG tube later! She finally convinced him to eat a bagel and some pudding, and he did eat. She said he's doing this as a control tactic. The threat of an NG tube worked.

I sat in on goals group and it turned out that most of the kids were pretty mellow. They were ages 13-17, mostly girls. There were 5 boys and 9 girls. There weren't any troublemakers, no one was overtly seeking attention. There was a corrections officer sitting outside one of the rooms for one of the girls, some of the kids come in from juvenile detention centers and there is a corrections officer 24 hours a day observing those kids, which helps the nurses a lot. The kids hang out, talk, read, meet individually with therapists or doctors, and the girls fix each others hair. They do get some free time but it's mostly structured all day. I didn't see any of the kids challenge the techs or nurses in the morning but after shift change when the new nurses and techs came on, a couple of the kids were stubborn.

When I talked to other people in my class, they said they must have discharged a lot of the trouble makers because in previous weeks this unit was absolutely horrifying. Kids fighting, cutting their arms, threatening the nurses and techs, and so on. I didn't see any of that behavior all day. I did have to keep track of all the plastic spoons the kids ate with, some of the kids will stash the spoons and chew on them until they make a weapon out of it. Two of the girls who were working on their hair styles asked if they could have scissors to cut the frizzy ends off the one girl's hair. Denied!

The activity therapist came in and the kids made collages by tearing pictures out of magazines. They weren't allowed to have scissors, they had to tear the pictures out. They were supposed to fold up a piece of paper and put pictures on the outside that represent their outside image and on the inside they were supposed to put images that represent what they feel inside and don't show other people.

I talked with one girl for a while. She was being discharged. She had substance abuse issues and depression, had a lot of problems with her mom, who had recently remarried. This girl was in denial about a lot of things, and minimized everything. It was hard to get her to talk honestly. When the mom came in the afternoon to pick her up, I noticed how cool and detached her mom seemed to be. Another girl had long scars on her arm from cutting herself. I didn't interact closely with many of them, they seemed to be okay with me in the room, but when I walked around looking at their work on their collages, a few of them seemed suspicious and guarded about what they were doing, so I backed off and observed from a distance. Some of them will avert their eyes if you make eye contact with them, they are so self-conscious and distrustful.

The kids I saw were not severely psychotic. Most of them were there for acting out in school, some substance abuse mixed in, crisis situations at home. The social worker talked about how the parents need as much help as the kids, and that often it's the kids who get blamed for the problems when the parents need better coping skills. That's for the kids who have parents. There were also a lot of kids who have run away, are waiting for placement in foster care or residential treatment centers. Most of the kids have been abused and all the stories are heartbreaking. They don't allow students to attend the process groups with the kids, I think it's for confidentiality issues, and kids at this age have a hard enough time trusting adults and would probably shut down with any extra attention in the room. It's also much more complicated because of parental consent to treatment, etc.

At lunch our class went out to a restaurant down the street from the facility. There is this Mexican restaurant that is supposed to be one of the best in town, about 6 blocks away. We all piled into two cars and went there. They have a Mexican bakery and they make tortillas there. I thought about bringing some tortillas home but we ran out of time and had to go back, and the lines were too long.

After lunch the kids were doing their "school" time, where the ones who are in school work on their homework, or are provided with tutoring. I spent this time with the nurse. She showed me how she checks the medication sheets, and checks the charts for new orders, and prepares for report. Then I sat in while she taped her report for the evening shift. She talked to me a lot, she told me about her other nursing experience and why she got into psych. She said med-surg was exhausting and got boring after a while. She also wanted to work with kids but not sick, hospitalized kids.

There wasn't much to do all day except observe, it made the day go by slowly. Our instructor stopped by and we went over my notes for the day, and then it was shift change time, the kids had another wrap-up group to check their progress on their goals, and then it was time for post-conference. I gave my presentation on my care plan first, then three other people gave theirs. We talked about seclusion and restraint for a while. We got out before 6:30 and it is still light outside! There was an awesome sunset (smog and clouds). I made it about halfway home and stopped for gas when I got off the freeway.

When I got home a little after 7, I found out that our dog nazi neighbor called the sheriff about our dogs. Dale came home to a note on the door. Some new people moved in to the house next door, which is a rental, this past week and they have two boy dogs. They seem like nice dogs but they have been barky, trying to get used to their new place. Our dogs were inside the house all day though. On my clinical days we have the dogsitter come to let them out to play in the middle of the day, the rest of the time the dogs are inside. I hate it but it has worked, since last fall we haven't heard a peep out of the dog nazi. Unfortunately now the new dogs are outside all day barking, and our dogs bark inside the house at them. The people were gone all evening too and the dogs barked constantly from when I got home around 7 until maybe 10 or so, whenever they got home and I finally fell asleep. I am not happy about the barking outside our bedroom wall either but I would at least give the dogs a chance to get used to their new neighborhood and new noises. I met one of the new neighbors the other day and she was nice, she told me that the dog nazi already complained to her landlord about it. I told her we had problems with him too, I told her about how we got a dogsitter because we were so sick of him leaving us little notes and leaving beer cans and walmart bags on our front yard to get our attention. This guy is weird. I will have to go over and talk with the new neighbor today, maybe we can figure out something to help each other. This dog nazi guy is such a jerk, the people moved in and the next day he complained to the landlord, and I was here all that day and the dogs only barked for a little while in the afternoon and not at all at night. The dog nazi is totally unreasonable and my guess is that he suffers from multi-infarct dementia combined with alcoholism.

The other thing that happened this week is that I had to do something about this weird guy in my class who seems like he's a stalker. As if nursing school isn't stressful enough, this creepy little twerp I sat next to all last semester has been doing weird things and I finally decided enough is enough. Basically this guy has no concept of personal space and doesn't understand boundaries. He has bugged several of the other women in my class, and he was e-mailing one of them and sort of stalking her in Block One. I only sat next to him in Block Two because it was the only seat up in front so I could see and hear- I'm short and there are always these side conversations in the room that I have a hard time hearing over. I wanted to move after last semester because he was so weird, but there were no available seats up close. I have tried to be tolerant. I have asked him several times to back off and give me more room. He tends to crowd you and hover a little too close.

After class last week I was meeting with my group on our Valley fever project and this guy was sticking around and standing right behind me, hovering over me so I asked him to give me more space and he got defensive about it and belligerent with me. He waited around and in the parking lot was yelling across the parking lot at me if that was enough. I ignored that but then this past week I moved to a different seat, he approached me during a break in class and came up behind me and touched me on the back to get my attention and sat down in an empty seat next to me and got right in my face. I told him that he is violating my personal and social space and boundaries and to leave me alone. I felt so angry but when he left, my hands were shaking. I get such a creepy feeling, this guy scares me. He is also belligerent and rude with the teachers. He doesn't get it. Then after class he waited around, while I was meeting with my group again. I have this gut feeling about this guy, he is a stalker. I was there with my group for about a half hour and I think he eventually left because I didn't see him in the parking lot when we got done.

Then when I woke up Thursday morning and checked my e-mail, he had written me an e-mail message. We have a list for the class that was distributed, that's how he got my email. I didn't even read the message closely, it was so long and dramatized and excessive, he went into all this stuff about how sensitive he is and how his feelings were hurt and how he was only trying to apologize and blah blah blah. It had to be several pages long. Anyway I immediately recognized it as an attempt to manipulate and as a power thing, and it scares the living crap out of me. I thought about writing back and telling him not to email me ever again, but then I was afraid I'd make things worse by playing into his trap. I thought about calling one of my classmates to ask what she thought, but it was early in the morning. I felt that jittery scared feeling again. I thought about how other people had been bothered by him and it seems to be a pattern. I also thought about what we've learned in psych about not enabling inappropriate behaviors. I have asked him no less than half a dozen times in the past to back off and he doesn't get it. He is also such a jerk in class and everyone recoils at his behavior when he berates the teacher if he gets frustrated. I realized that I have been afraid of him when he does that, he is so nasty and our Pharm teacher called him on it once in Block Two.

I decided to tell the teacher (COS) and I sent her an email and left a voice message. She called me back and listened to me and she said, "I thought it might be him. I don't know why but this doesn't surprise me." I talked with her about what to do. She said no student should have to be afraid of another student. She felt I should send him a pointed and direct e-mail back and set limits on his behavior, with copies to her and to the director of the nursing school. She said I could also go to the Dean of Students if I felt that strongly about it. I told her I have so much on my plate I don't want to make this more complicated. I decided to try her e-mail suggestion and I wrote him a direct e-mail and told him that he should not try to contact me in any way in or outside of class, and that I don't want a response, and to leave me alone. I CCed it to COS and the director and sent it off. So far so good, no response. We'll see what happens in class.

Then to top things off the director wrote me to tell me that she had already made arrangements to move this guy into our clinical group for the med-surg portion, apparently to balance out the group- we have no male students in our group. So she offered me the opportunity to switch to the other hospital, but I purposely don't want to go back there- I need a change of scenery after working there plus two semesters already there. Plus Roger is going to be our instructor and I know he's better than the instructor they have for the other group. The Director told me I have the option to switch or she'll talk to Roger about making sure I don't get stuck on the same unit with the creepy guy. Now I feel bad about needing accommodations made for me. I don't want to have to deal with this creep but I feel like I should get to do clinicals where I want to. Why should I have to switch because of this jerk?

I talked to some members of my clinicals group about it on the way to lunch and they told me that this guy has bothered a lot of people and that he got in trouble at that hospital during Block One, and that they thought he wasn't allowed to go back there! If that's true, then I don't know why they are doing this. And I also know that Roger did not like this guy when he taught our Block One class. One of my classmates said she thinks they are trying to set this guy up, maybe to get him kicked out of the program. After all I've heard already, he should have been kicked out long ago. Maybe that will happen now. Anyway, I am reluctant to switch clinical groups and I think I will see what happens in class over the next few weeks. I like my group and they were bummed too when they heard this creep is being added to our group. He will disrupt the energy of our group, which up to now has been good.

I didn't want to go to the faculty but I decided it would be better to be safe, given my gut feeling. COS agreed with me. She said I should always go with my gut. I know how dangerous stalkers can be. And the whole nursing faculty is proactive about stuff like this after the University of Arizona incident several years back when that disgruntled student killed several nursing faculty members. Hopefully this will be all that's necessary.

I can only hope that the next several weeks will result in a dramatic reduction of stress. At any rate, it's only 3 weeks to spring break. I should be able to rack up 8 hours of sleep by then.

Peace, love, & clear skin,

Towanda, RN2B

Entering the Home Stretch

I got back from an effortful but insightful hour and 15 minutes of running. It's a beautiful clear day, this time of year is about as perfect as you can get. Yesterday I was so tired I didn't get outside at all until late in the day. I don't like to miss nice days. The hardest part is missing those long treks outside. The opportunities will return in another 6 months. Today it occurred to me that time-wise, we're about 2/3 of the way through. It's all downhill from here!

Wishful thinking. I am so tired. Now that we're into the last third of the nursing program, the work is intense, the fatigue isn't subsiding and neither is the anxiety.

The other night, before clinicals, I could not sleep. It took forever for me to fall asleep and then I woke up around 2 am and could not sleep again. After the long clinical day, again I could not fall asleep and finally I got up, opened a bottle of wine, and drank half a glass. That was all it took and I fell asleep as soon as I put my head on the pillow. I woke up early yesterday and again today. Yesterday I managed to take an afternoon nap but was too tired to concentrate on studying. I couldn't read, my head was too foggy. I did finish my papers, writing wasn't too hard on my brain.

The teachers are holding a meeting on Tuesday after class. They want class officers, representatives from each clinical group, and anyone else interested to attend this short meeting with the faculty. There have been some concerns raised- like the reading assignments not being clear, the notes not being supplied, having to guess at what we're supposed to be getting out of the classes. The teachers have been less than understanding when it comes to the students' concerns. There are a few things going on in our class that are creating all this tension. COS is the coordinator and she is actually a good teacher. I like her a lot, she's caring about people and she does a good job of teaching us in class. Her notes can be hard to read- they aren't the most organized, and there's a ton of stuff- too much detail without being organized, like puke on paper. Sitting through her class is no problem. She keeps it interesting and so far the reading assignments have been easy to follow. Her assignments for Process and clinical have been confusing, there was a ton of work and the instructions were like a textbook in themselves, and that was a major stressor for the first few weeks. I think most people in the class have worked through that at this point.

The other problem we're having is with the Assessment class. Kate is teaching it and I don't know if she's not a experienced teacher or what, but it is hell. It makes Tuesdays so agonizing. I am always in the worst mood, so irritable, and so is everyone else, by the end of her class. She doesn't present the material in an organized way. She puts these slides up on the overhead and has us read them, one student at a time, we have to read the slides out loud to the whole class. There isn't any discussion of the content of the slides, either. It's like 6th grade. Let's see if everyone can read. I hate it, because I am not learning anything and I could easily sit there at home and read the slides on my own if I had them in front of me, and do it in 15 minutes and get more out of it than sitting through a 3 hour class of people reading out loud! AAARRRRGH! We are 4 weeks into the semester and I can't tell you what I've learned in Assessment so far. I wish now that I'd signed up for the evening section with COS. At least I might be getting more out of the class. We have our first exam in 2 weeks and I feel like I don't have a grip on what we're supposed to be learning. And everyone else expresses similar sentiments. On the breaks from that class, everyone is grumbling. I am hoping that we get some relief when we get to the Peds part of the class, Kari, our pediatrics teacher and the mommy baby coconut lady are coming back to class to teach some of those sections on pediatric and neonatal assessment.

I feel physically and mentally exhausted now. Maybe it wasn't such a good idea to run the 50K because this week I have been too tired to run much at all. Running is a huge stress reliever for me and I get a lot of mind clearing done during that time. I didn't have that opportunity this week, and my physical exhaustion didn't help my difficulty concentrating. We did get our exams back from last week. I don't know if this semester is going to be so great for grades but I'm not going to worry about it as long as I pass. I checked on my Pharm grade after I technically failed the exam but typical of Denise, she ended up dropping a bunch of the questions and I ended up with 90%, which is a B. On the Process exam I also got a B. I am doing the best I can with my mental resources and I am happy with those grades at this point.

Psych has been intense. I like it, I think I could do it in the right setting but I'm not sure what that is. I don't want to start out in psych. It's been a lot of new information and new skills, I took a ton of psychology in graduate school, all behaviorally and theoretically oriented, plus all my research methodology classes were in the behavioral sciences, but none of it was clinically oriented so this is all new stuff. I am learning a lot about myself and interacting with other people, understanding a lot of family dynamics, and it's interesting, but it's so much coming at you at once, that it gets overwhelming. It's almost like you need an extra chunk of time to allow yourself to process this stuff and integrate it into your brain before you can absorb more. It's emotionally exhausting for me. But we move on. It will be a relief when psych is over, too, because of the number of extra assignments.

I guess I feel like my coping resources are taxed right now and I feel like I'm being pushed to the edge of something, I don't what that edge is. I also know that it's 5 months and change until it's all done and that more interesting stuff is coming soon. It's also 4 weeks until spring break. I find myself looking forward to getting back to the med-surg because I do feel more comfortable with it at this point. Psych totally throws you out there into unfamiliar territory. I am aware of needing to experience the unfamiliar and I'm not resisting it, I am actually enjoying it more than almost anyone else in the class and trying hard to immerse myself in it. So far there are two of us who say we might want to work in psych. That's out of 40 students.

Today I have been trying to get done with some reading and fortunately it was lightweight reading, mostly review from Block One. I am going to take it easy on myself again today and finish reading last weeks handouts and relax the rest of the day. The next 4 weeks are going to be a test of all my reserves! I think they are trying to weed us out before the second half of Block 3.

Peace, love, & recovery,

Towanda, RN2B

Creative Delusions

Yesterday was Psych clinical #4. I was on the main adult psych unit. It's the one where people are usually admitted to when they first come in, so they tend to be the least stable and still in crisis. I got to see lots of schizoaffective, schizophrenia, and personality disorders. There were also a few people with borderline personality disorder. There were also some new admits with severe depression. There is also a psychiatric intensive care unit off this one where they put people who are so unstable that their behavior is dangerous to themselves or the other patients.

Having most of my busywork done, I was able to relax more and attend groups and spend more time talking with patients. There were three of us students in this unit, and I could tell the nurses weren't too thrilled about having to deal with all of us. They sent us off to the techs again. At this facility we haven't been able to work much with the nurses, but that's okay because I see that most of what they do is paperwork and giving meds. We started by doing vital signs for the tech and waking people up. The tech ran the goals group and I listened to everyone. There were about 25 patients on this unit. The interaction was different. It wasn't chaotic on the floor, but it didn't feel as calm as the other units I'd been in. The mixture of personalities and the fact that most of them were more unstable was obvious when they talked.

There was one guy with schizophrenia who was having bad side effects from some of the medications he was on. He was sitting there and his mouth was constantly moving. He was also restless and kept pacing the floor. They were changing some of his medications. Other than that he seemed stable and seemed to be functioning well mentally. There was a group of about half a dozen patients, mostly women, I could tell that they were all the borderline personality disorders, they were all hanging out together on the smoking patio. There were some substance abuse issues and there were a couple of them who were trying to manipulate the staff into giving them medications. The nurses suspected one of them of cheeking her medications and giving it to another patient. There was quite a bit of that going on in this unit. The nurses had to keep checking to see that the patients weren't cheeking their meds and stashing them somewhere. Sometimes the patients will give their medications to their visitors who will go sell them on the street.

One of the patients with personality disorder was a cutter, she made all these superficial cuts across her wrist. The nurses have a way of dealing with that, because these patients will do it in a way to get attention. They are trying to teach coping skills and they have to know when they can tell the patient to go away, you're not getting any attention for this- or if telling them that will result in the person resorting to more serious injury. There was one guy who had low blood pressure from his meds and he was sitting there eating breakfast and suddenly he slumped forward onto the table, and bumped his head on the edge of the table and fell on the floor. The nurse had to run over and pick him up. He hit his head hard enough to slit the skin and was bleeding a little. That was the excitement for the morning. They got a wheelchair and took him back to his room and told him he needed to stay in bed, then she called his doctor.

I attended the education group, which was on anger awareness. The tech from the intensive care unit ran that group and he was good. There were about 6 patients in attendance. On this unit there is a smaller percentage of patients participating in the groups because so many of them are so unstable and anxious that they can't sit still for an hour, and they are unable to focus their attention on any topic. I found it amazing what patients revealed in group. A lot of them were honest about what they were thinking and their fears when they were in crisis. The phrase "hiding the body" comes up a lot. Several of them talked about that being one of their worries, that they would get to the point where they would have to do that.

I walked around and had several conversations with people. I tried to focus on the patients with disorders other than depression, like schizophrenia and schizoaffective disorder. It is easy for some of the people, especially those with schizophrenia, to misinterpret behavioral cues. They think that because you're paying attention to them it means something else. One guy I talked to started asking me, "are you married" and I realized he was looking at my hand, which was resting on the edge of the chair. Then I knew it was time to redirect his attention, so I turned it around to him and asked about his wife and started to try to move the conversation in the direction of his goals, which was unsuccessful. I ended up saying, I've got to get ready for the next group and thanked him for talking with me and got away. One of my classmates had that happen at the state hospital and the patient ended up getting in a fight with another patient over her attention!

One patient was a young woman with schizoaffective disorder and she normally functions pretty well and lives independently but her medications stopped working. It was hard for me to tell if she was slightly mentally retarded or if she was so medicated. I never got to look at her chart. She looked a little like she had Down's syndrome but I don't know if it was. There was something about her features- her eyes, ears, and mouth that looked like there was some kind genetic thing going on. I wish I'd seen her chart. I talked with her for quite a while, and she seemed child-like and needy in some ways but also seemed to have good judgment and insight into her illness.

Another woman had obsessive compulsive disorder and the nurses warned us about her- she tries to clean up the whole kitchen area and will go into the drawers and reorganize everything. She was interesting to listen to. She liked to talk and had a lot to say in the groups. She was also taking notes the entire time during the group sessions and was concerned that she didn't get every little detail that the tech or the social worker said. Kind of like one of those straight-A students in class who drive you nuts because if they don't get one little detail they ask a million questions and hold up the whole class. I wondered what she was like in school. The COS always tells us that in order to be a good nurse you have to have some OCD traits because otherwise you won't be able to do all the checking on your patients and paying attention to details that are necessary.

There were a couple of men in their 50s who were in for severe depression and in crisis over work-related stressors. They were the oldest ones on the unit. I wanted to go talk to them but all morning I made myself stick to the patients who had diagnoses I was less experienced with. Finally after lunch I allowed myself to satisfy my curiosity and go talk with them. I ended up choosing one of them for another of my assignments because he gave me so much information. The afternoon process group was interesting. A social worker ran it and he talked about taking action and not taking action depending on things that you can or can't control in your life. I found the patients' responses fascinating and the way they interacted with each other. The one guy who was having the work crisis was talking about how his company used the same words as the social worker. He told us how his company says they are "empowering" their employees, yet they lay off staff and therefore they are "empowering" each the remaining staff to take on the work of 3 people, so they aren't supporting their workers or empowering them, and they create more stress. After he talked, he got validation from one of the other patients who I could tell had bonded with him. It was one of the younger guys (probably young enough to be his son) who was in with grandiose and paranoid delusions was talking about how he faces a situation where he's not in control but tries to work through it anyway and no matter what brick wall he runs into, he will try to go through the brick wall, injuring himself in the process. This guy was having problems with his girlfriend as part of the crisis situation that brought him into the facility. The OCD woman said to both of them, "it takes a bigger man to recognize that and come in here for help, than someone who would beat himself up trying to knock down through all the brick walls." It was cool to watch the patients support each other.

When you're in this little cocoon of the psych facility and you see how well the patients respond to these group sessions, it's amazing because out on the floor when you watch their behavior, some of them seem to be self-absorbed or depressed or so anxious they can't sit still. Several of them pace the floor all day long. They stop to eat and get their medications, they go outside to smoke, and then they walk around the floor of the common area. The groups give them a safe place to explore their feelings and behavior, and the other patients provide support, insight and validation. You have a group of 8 or 10 patients, some are homeless, some are mothers of 5 kids with a 6th grade education, single men in their 20s, some corporate executives and professionals, and they can all relate to each other and understand each other's experiences. As I was listening to the two oldest men talk about what was going on in their heads, I wondered why we can't have this type of process group as primary prevention rather than the way it's used, as post-crisis intervention. I think if diverse groups of people took the time to get together and share their struggles in life, the insight and feedback that would result could be so transformative, it would probably eliminate a huge percentage of the mental health problems we have. This is seeing mental illness as the teachers tell us, it is a continuum and it's a part of everyone's state of wellness. I would say that on any given day in a workplace, most of the people are probably functioning poorly and could derive huge benefits from something like this. Of course it would destroy the corporate status quo because everyone would see through the corporate "empowerment" schemes. I think a huge part of mental health is stopping to take the time to examine your own life and reasons for doing what you do. I don't see a lot of people questioning their choices. I'm not talking about work, I'm talking about everything. In this country so many people are fixated on work as what defines who they are and they need to get beyond that. I guess that's why the PA I met this week at the Occupational Health facility was so blown away by what I was saying. It was like he'd never considered looking at the world from that point of view before.

Then I started thinking more about the corporate wellness programs. Your average corporate wellness program model is about physical activity and maybe some relaxation. These are nice to have but you can provide all the amenities you want but if you don't free up the employees time to allow them to use it, you're not helping them be well. Making the company look good on paper doesn't always help the bottom line, and those programs get cut in the first budget crunch. What would help is process groups! All you need is a room with chairs and a white board and a group leader. And if you told that to the average CEO they'd be sending you to a psych facility, they'd be shitting their pants.

The little wheels in my brain are turning again, but not much else to report. Next week is scary though because I have to be on the Child & Adolescent unit and those are the scary patients. The stories I hear coming out of that unit scare the crap out of me. We only have 3 more weeks of psych and then move on to med surg. It will be a relief in a way because all this busy work they are piling on us is driving me crazy. I have two more papers to write this weekend in addition to trying to catch up on all my reading.

Good news. As of today, it is 5 months and 27 days to graduation! Wahoo!

Peace, love, and delusions,

Towanda, RN2B

Myth # 1: There is no free lunch

Yes I did make it through the Mesquite. Didn't get sore either. A few little aches. I proved it *IS* possible to run a short ultra during nursing school and survive. I did take a full day off from school stuff and it was great for my spirits. I had a great day out there on the trail, got to see lots of people, some of the new years run crew and running friends I used to hang out with a lot more, but hardly get to see anymore. GK had the rattlesnake out at her aid station and got revenge on some mountain bikers.

The nice day on Saturday quickly faded to a day of studying and working on the care plan all day Sunday. I am so far behind on reading now. One day of not studying for 8 hours is enough to set you back in a bad way. I will have to work in the evenings all week to get the care plan done by Friday.

This week so far sucked. Monday I spent the morning working on my care plan and then studying for the pharm exam. I had an appointment with a client in the afternoon before class and then I went to Pharm. When I got there everyone was waiting outside for the Block One class to get out so we could go in and sit down. Everyone was in their usual pre-exam frenzy. Someone started asking me questions about the different isotonic, hypertonic and hypotonic solutions as if I was the encyclopedia of IVs. I can't even remember who. I sat on the floor and then asked the teacher a question about one of the hospitals in western Colorado I'm going to visit in May. She's lived in the area before and I wanted to know her opinion of whether it would be a good place for a new nurse to go, if I could get just as much experience there and learn as much as at one of the big front range hospitals. She said it would be as good, and that it might even be better because parts are parts. What you don't have in one setting, you find ways to do the same thing in another setting. But she thinks they are as advanced as most major hospitals in Denver. She said I would get all the training I need, all the critical care certification, ACLS, all the training I'd need, and that they see as much as anywhere with their trauma and cardiovascular stuff. They do open heart surgery, etc. I didn't realize that.

Anyway that was a nice distraction and then the reality of the test smacked us upside the head. Denise was in her best form, once again she has proven that she can write an exam to make your eyes roll back and your head spin on it's axis. On the first two pages alone I think I circled every one of the questions to go back to at the end because I wasn't sure. It also took me the entire hour to do the exam, and I usually get done with a lot of time to spare. She didn't have a lecture planned for after the exam, which was a good thing because she went over the exam and it took forever. Everyone was totally confused. Sounds like most people didn't do all that well. I missed 8 out of 30, which is not passing. Knowing Denise though, she'll have to make some adjustments. She usually ends up throwing out a few of the questions because no one gets them right. I've heard that if you can pass Denise's exams, you will have no problem on the NCLEX (the boards) because her tests are way harder. As long as I get 23 correct I will pass and I am gambling on that. One lucky break is all I need.

Tuesday sucked even worse though. That's our all day in class day. Our morning class is Assessment and it is so unstructured it's driving everyone crazy. I have no idea where we are, what we're doing, what we're supposed to be learning, or how we will apply this in nursing. Everyone was wigged out and I started to get a headache halfway through class. It is so frustrating for everyone. We walk out on our break and everyone is grumbling about how confusing it is. She is so hard to follow. Then the guy who sits next to me, who is this little twerp, I don't know a nice way to describe him, he started getting belligerent with the teacher. He doesn't know how to be tactful at all. I feel sorry for the teacher and it's almost scary. I get this weird feeling that this guy could go off the deep end. He gets more freaked out by things than anyone in the class. He also has this bad habit of invading my personal space. I've asked him several times if he can move over, I don't think he does it on purpose but he always ends up leaning over in my direction and spreading his papers out on my side of the table so I end up with about 2 feet to myself and he has 4 feet to himself. He gets under my skin. I've asked him to move back over lots of times and he always does, but he always has to make a snide comment about it. Miss Anxiety used to sit next to him in Block One and he bugged the shit out of her too. I tried not to sit next to him this semester but I needed a seat toward the front so I could hear and see, and that was the only chair left. I have an alternative on the other side of the room scoped out if I can get there early enough next week.

I had a headache by noon and then she went over into the break. I left along with most of the class and went to get some food. I always bring my lunch on Tuesdays and sometimes when I need some peace and quiet I'll sit in the truck while I eat, then I sit outside the trailer and talk with people as they come back from lunch. My head was hurting and I forgot about the other exam at 1 pm. That was okay because I didn't know what else to study. I went inside and COS was there with her million handouts. She started the exam at noon and I didn't do as well this time. I think I got 9 out of 11 but I'm not sure. She didn't go over it. I thought about going home and blowing off the rest of class but I took some ibuprofen right before the exam and my headache got a little better by the end of the exam.

Between the anxiety we had all morning and the test anxiety, everyone was loud and wouldn't settle down and COS was getting annoyed with us when she tried to start her lecture. Finally we did somatoform disorders and anxiety! and we got done 15 mintues early and she decided not to go on to the next topic and let us go early. I had to meet with Christine and Patti so we could plan our Valley fever case study and presentation, which we found out is due on March 7th. Great. At this rate, if I make it to my 42nd birthday, I'll be lucky. That second week of March is going to suck. Two exams, a presentation and paper due, orientation for med-surg clinicals followed by med surg care plans all on the 9th (which should make it about a 20 hour day), followed by our first 13 hour med surg clinical, happy birthday. Spring break starts on the 11th. I will be lucky if I survive to see spring break!

Get this. I finally heard from University about the extern job. I called the Nurse Recruiter back first thing Monday morning to find out about the job. It sounded like she was offering me the position. I asked, "Is this for the Progressive Care Unit? Does he want to interview me?" The manager never talked to me, and I had no idea what this was about. The recruiter sounded dumbfounded. "You didn't get an interview?" I said, "No." Silence on the other end. I said, "I need to find out what I'm getting into before I accept anything" She said, "Yes, that is strange. I'll have him call you." He called me an hour later. He was totally laid back, basically he was offering me the job, without saying it directly. He even said he was willing to let me work 8 hour shifts, which is unheard of in most ICUs. He didn't even care if I came down to see the place. It felt weird. I thought it would be nice to go down there and see what it was like and get an interview. At first I said I wanted to come down and see it and talk to him and meet the staff before I take it. He said that was okay and we set an appointment for 10:00 on Thursday. After we got off the phone I started thinking about it and realized I wasn't even going to get an interview out of it, which is what I wanted. And I have so much to do. I didn't want to make more work for myself. So I called him back Tuesday and told him I had second thoughts and to remove my name from consideration. All I need is to work for another nurse manager who doesn't give a crap about who they hire. They took forever to get a hold of me. Two months. I wonder if someone else took the job first and then quit after it wasn't so great, and then they decided to call me.

Wednesday I went to Occupational Health department and shadowed a nurse all day. The morning was pretty slow. I got to do lots of TB screenings and PPD injections for the TB tests. I sat in with the PA on a pre-employment screening where the newly hired nurse had back problems and the PA wouldn't clear her for work. She was in a lot of pain and I thought it was a good call. Otherwise she'd probably get hurt her first week on the job. The nurse I shadowed was cool, she took the time to answer my questions and introduce me to everyone, and she had a good attitude even when some of the employees were sort of nasty. They get so impatient having to wait. Some are from the hospital and others are from their contracts with other companies. My psych knowledge helped too.

There was someone in for a pre-employment health assessment for some local company and the doctor was going through the chart and reading the list of medications she was on. One of them was Abilify, a new antipsychotic, and the doctor immediately said, we're going to have to get clearance from a psychiatrist. The nurse didn't know what it was. I thought the doctor assumed too quickly that this person might not be able to work, and I told the nurse I thought she was probably on it for bipolar disorder or depression. I was right, it was for depression, not schizophrenia. Maybe she had severe psychotic depression. I don't know if these companies have to look at the meds a person is on and get clearance for employment if someone is on certain meds. I can see drug screening for people who are driving and doing risky things. But this one wasn't operating any equpiment or driving at work. I didn't get a chance to ask the nurse that. I'll ask my teacher.

One of the maintenance workers came in because he got something in his eye, and the PA flushed it out and found the object using this dye. They did some drug screening, including some doctors and dentists. They don't do too much education. I was suprised at the percentage of people who do take antidepressants and things like Xanax, Ativan, and sleeping pills. Pretty amazing. More people do take one or more of these than don't! At least in the group we had today, it was that way.

I also watched them do the fit test for the N95 masks- that filter out particulates that you wear on the floors in the hospital when someone has TB or is on respiratory isolation. They have to wear this hood that looks like a hazmat suit hat, it is white and has a clear plastic panel in front. They wear the mask inside the hood and the nurse sprays this saccharin spray inside and they aren't supposed to be able to taste it if the mask fits right. It was pretty funny watching people walk around with this hood on. I never got fitted when I got hired. I think I only had respiratory isolation patients once or twice the whole time I was working on the floor.

The funniest thing that happened today was the PA. He started asking me all these questions after the pre-employment screening I watched him do. He was drilling me on all these things and I guess he was impressed with my answers. Then I asked him questions about whether he assesses the people for workplace and life stressors when they come in for work-related injuries. Then he started asking me questions about my background. I don't disclose a lot up front with people at first. But he kept asking and eventually it came out that I have an advanced degree, which happens to be in a completely different area than nursing. But he was totally over the top impressed with that. He kept asking me all these questions like, "Why don't you tell people you have it? Don't they treat you differently?” I tried to explain, in a way he could understand, that if they were going to treat me so differently maybe I didn't want to know them in the first place. He, like other people, assumed that nursing school was easy for me and I corrected his misconception. Nursing school kicks your butt. Graduate school was never this intense. Except maybe oral preliminary exams. I seriously thought about jumping out the window both before and after those. But defending your dissertation in front of a bunch of old over the hill fuddy-duddy tweed-draped know-it-alls never was as pushing-you-over-the-edge-of-your-comfort-zone intense as nursing school.

He thought with my background that the manager of the facility would want to hire me- they are starting this new wellness program for hospital employees. After the 1990s corporate fitness boom and bust, I am highly skeptical of any company that say it's going to do something for its employees out of the kindness of its heart. They found out corporate wellness programs were not profitable in the last century. Corporate altruism is an oxymoron. So is "corporate wellness". I can see them funding it for a year, and then as soon as the next budget comes up, it's gone. I have no interest in doing that as a nurse. Certainly not through some corporate-directed "wellness" program. I didn't tell him that, though. I just listened to him.

Anyway this PA was just so impressed. At lunchtime we went over to the hospital to get our lunches and food for the nurse and to bring it back to the Occupational Health building. I started going toward the cafeteria and he said, "No, we're going to the doctor's lounge!" I said, "Why?" He said, "Because you belong in there." I started laughing. I could see all the buttheaded surgeons like my favorite gastroenterologist who won't even make eye contact with me on the floor, looking down their noses at me. "who let the riff raff in" But I followed him in there and they have free food set up for the doctors. Same old cafeteria slop, but still, I couldn't believe it. They give the doctors free food and the slave nurses have to pay for theirs. NOT FAIR!!!!!! But anyway, I got a free lunch out of it so I guess you could say that today the damn degree finally paid off for me.

That pretty much sums up my week so far. Next psych clinical is on Friday. I hope it will be a good one, we only have 4 more psych clinical days left and then it's back to med-surg.

Peace, love, and free lunch,

Towanda, RN2B

Garlic Breath

I am so glad this week is over. Three weeks of the semester down already. I feel like we're making slow progress. But all the assignments are coming due and I have all these days planned with visits to different agencies and events and shadowing, my head is going to explode. I resent the infringement upon my study time.

Today for clinicals I had my community agency visit. The place we went is Sunrise Center, it is downtown and is funded by the state, it provides outpatient mental health services to low income clients. People go there for medications, checkups & followup exams, to see a psychiatrist, and for court ordered treatment and evaluation. There are nurses and case managers who work with the clients to assess their needs and to follow up with whatever services they are to receive. There are also activity and wellness groups who coordinate their meetings and events through the agency. It's a chance to see mental health services and nursing care in an outpatient setting instead of the inpatient hospital where we are for most of our psych rotation. I got to go in later, didn't have to leave the house until 7. I woke up at 4 anyway and couldn't go back to sleep. This sleep thing sucks. I know it's school stress.

This was a slow day for them. The nurse I worked with said she thinks it's because it's Superbowl weekend that no one is coming in. There were lots of no-shows, more than usual, she said. I was there with Miss Anxiety from class. We each got assigned to separate nurses. We sat in on the morning meeting with the nurses and case managers and they talked about their clients. No one was going out today. Usually they are doing home visits, or going out and meeting with homeless clients, or seeing clients who are in the hospital or in jail. There were a few possibilities but as the day went on one by one they cancelled or changed their plans, so it was impossible to go out with a case manager.

I sat in with the nurse on 3 different patients. The first two were women and were both being treated for schizoaffective disorder. That is basically schizophrenic symptoms- hallucinations and delusions, but also with a mood disorder- like depression. The first one was a woman who needed to get a follow up visit and blood draws for her medication levels. The next one was similar but she needed an injection of Haldol, she comes to the clinic monthly to get these injections that are long-acting, kind of like extended release into the blood and it improves their compliance, since getting so many of these patients to take their meds regularly is a problem. That way they don't have to remember to take pills, or keeps them from feeling paranoid every day. Many of them do think they are being poisoned. On the second client I could see some of the Parkinsonian-like side effects, her face had this kind of blank look, and she spoke slowly, but she was pleasant and seemed to be functioning well otherwise. The nurse checks for involuntary movements like tremors, face and tongue movement, leg, arm and torso movements and restlessness, which are all side effects of some of the antipsychotic drugs.

The third client was interesting. He was being treated for depression with psychotic features. He weighed over 300 pounds. They had a special scale for him. One of the other nurses, a guy who is a travel nurse, was working with him, so I went in to see how he handled the clients. This client was not cooperative with the nurse, he sat there with his arms folded across his chest and answered the nurse's questions in one-word answers. I felt a little uncomfortable in the room but I looked around at other things, I could tell he didn't like to make eye contact. He needed a blood draw. The nurse had a hard time getting this guy's veins, he had to stick him twice. I was afraid the client would get pissed and walk out, or sit on the nurse, or something, but he didn't. The nurse talked to him about his weight, and the guy did not like it. The nurse said, "you know you'd feel better if you could take off some weight. I don't like to have to tell you this but I need to. I don't like it when people tell me that." The client didn't look happy at first but then he almost smiled and said, "yeah, more exercise would be good for me." Interesting. Maybe it was the way the nurse read the guy.

I heard the nurses talking about this one client they have, they were trying to figure out what to do with him, they finally decided it would be best to give him to the male nurse and see if they could get this client to work with her again at another time if he's functioning better. I didn't get to meet this client, but this guy has a hard time with women. The nurse I was with said he was hallucinating and screaming the day before and wouldn't let her get near him. He was screaming "All you women do this", that women were coming at him with knives and getting into his body and torturing him, he could "feel it in his balls", that they crawled in through his penis and got in there and were carving him up inside. He was freaking out about it in her office. She had to get the new male nurse to come in and the guy only calmed down after she left the room completely. Damn, I missed all the interesting stuff.

Miss Anxiety's nurse's work load was equally slow, and they told us to go take a long lunch and they'd see if they could figure out more stuff for us to do in the afternoon. We went for lunch at this Middle Eastern restaurant, which has awesome food. I had the best meal I've had in ages. I knew I'd smell like garlic all afternoon but it was so good. We talked about school and stuff we want to do when we get done. It was good to have some relaxation time. We realized that we only have 4 more psych clinical days left and then it's med-surg. Wah. I think I'll miss psych.

When we got back, the nurses found a bunch of videos for us to watch, about medications and side effects and treating patients with different disorders. None of the case managers were going out and nothing was happening. The nurses said they were both trying to get caught up on paperwork. So Miss Anxiety & I sat in an empty office for a couple of hours flipping through the videos. Some were good and some sucked. By 3:30 we were both falling asleep and decided to go talk to the nurses and see what was up. They said we might as well go home early because nothing was happening.

My nurse talked with us for a little while before we left and told us what she feels is her role as a psych nurse. She can see these clients in an outpatient setting and feel like she can do them some good, even in the 15-30 minute time slots they get to see clients. She says she reminds them of the parts of themselves that are still there and are not being attended to while the client is so busy getting through day to day. I liked the way she put it, she said she reminds them of their spiritual side, no matter what they believe in. If they go to church she encourages them to go, at least to get involved in something. And if not, she helps them find something they feel good about and encourages them to spend time on things that allow them to feel connected to something outside themselves.

The psych clients get so caught up in dealing with their illnesses and in dealing with getting through every day activities, if they are lucky it's to eat and keep themselves alive, that once they get stabilized they need to be reminded that there is more to life than dealing with their illness, which is so all-consuming when it isn't being treated adequately and their symptoms come back. Once these people get some of their basic needs met like the ability to think clearly again, if they have enough resources like housing, family support, a little money, and food, they can start to come back and rebuild their lives. So much of their lives get destroyed in the time that their illness is not under control, it makes it that much harder to climb back up once they are feeling better. I could see that the nurse understands that and I think that's why she can do this job. She sees a way to make a difference within the confines of the agency and regulations she has to work with.

She can get clients to come in weekly instead of monthly, she can have them schedule another appointment if they come in and aren't doing well enough to get their vital signs taken, if they are desperate for someone to talk to, she'll spend the 15 minutes talking with them and have them come back at a different time and do vitals then. I can see how in this setting, if you were so focused on giving the patient their meds or their treatment and getting them through the technical stuff, then you would feel frustrated and you wouldn't be accomplishing anything, but what she is doing is helping them to function better in their overall lives. I thought that was cool.

I left around 4 and was home a little after 4:30, which is good because I'm tired and the Mesquite 50K is tomorrow. I am running and hope to have a fun social experience. One of the runners I met at the new years run is coming down from Colorado and I am looking forward to running some with her. I will spend the national holiday of Superbowl Sunday attached to my laptop writing my paper, care plan, and studying for our two exams on Monday and Tuesday. But tomorrow will be devoted 100% to fun.

Oh yeah, one more thing happened. I checked the voice mail when I got home and I had a call late this (Friday) afternoon from the nurse recruiter at University about the step-down ICU extern job I applied for like 2 months ago. I guess she wants me to call her, I wonder if they'll set up another interview. I barely have time now, I wouldn't even be able to start until March when psych is over. But since it is ICU, I don't want to pass up the opportunity. Plus another interview experience can't hurt, even if that's as far as it goes. I can't believe them, they are so slow. I started looking into this in early November. I had given up on them, figured they hired someone inside for the position. By the time they get around to hiring people I'll be graduated already! Are they waiting for the nursing shortage to end? I might think about it over the weekend and decide not to do it. But I'd go for the interview practice. I'll call her Monday. They made me wait long enough, they can wait for me.

188 days to graduation!

Peace, love & baba ganoush,

Towanda, RN2B