Memoirs of a Nursing Student in a Lock-Down Psychiatric Emergency Department

[place holder post to remind me to fill in soon!]

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Wow, so apparently this was a ridiculously busy quarter. It's now June 5th. I finished all my hundreds of practicum hours just yesterday. So naturally, now I have some time to update.

"Psychiatric Emergency, this is Jane,"

This is how I answer the phone down in the psych ED at Harborview Medical Center. It feels like we're in a basement with no windows (for safety), and it's kinda dreary with nothing on the walls; no eclectic hospital art or any color at all really (for safety in reference to the lack of art, but color?) But I love it. I love psychiatric patients. I love the team of providers and staff. It has been, by far, my most rewarding clinical experience in nursing school. I had chosen "Psych" for my senior practicum placement because I studied psych nursing in Thailand, and wanted to see what the American system was like. Now I have an idea. It's horrendous. Psychiatric illness and care carries an intense stigma in our culture, and it is one of the least resourced sectors of our healthcare system. In fact, the majority of our population suffering from psychiatric illness is homeless and the biggest provider of psychiatric "care" is our prison system.

This may very well be one of the main reasons why I feel so drawn to this patient population, it is one of the most vulnerable and disadvantaged communities in our country. For me, as a pseudo-provider, this means that often a small gesture can go a long way for an individual in crisis. I can do small gestures, I can make very small differences, and this helps because there is an infinite amount that I cannot do for this population...

Enough political advocacy for now, here are some of my favorite stories from the past 10 weeks.

A patient watches me give medications to another patient in the hallway. He comes up to afterward and says, "Hey, I take Topomax, and I haven't had it yet today..." and I replied, "Oh, I'm sorry, but you're here because you overdosed on Topomax." The patient starts laughing, "oh yeah, I forgot. I'm probably good for a few days."

My preceptor says to staffing on the phone: "We're great, we have three nurses" and I say, well maybe 2.5. He says again, "Oh no Jane, When we get a float nurse from the main ED, then we have 2.5. We count you as a whole nurse here."

Wow, a whole nurse!

Once we did get a float nurse from the main ED (see previous post: A Montage regarding the Harborview Emergency Department from August 2008-a serious ED that has amazing nurses, but they are not psych nurses..) She asks the group of us, or maybe no one in particular, "So what are you guys doing these days for folks with mental problems.. er, uh, mental issues or whatever it is you call it now?"

The Emergency overhead pager goes off: A voice crackles over our heads "51 year old male whose been involved in a scuffle with a gun-" is immediately interrupted by another, more snarky voice chiming in with "Ok Lexi, as soon as there's a gun involved, it's no longer a 'scuffle', new criteria have been met"

One new admit on the psych emergency unit demands "How can you detain Jesus?" RN answers: "Immaculate detention?" Later, same patient profoundly inquires "How can you inject Jesus?" RN suggests "Omnipotent injection?" Patient states matter-of-factly during an initial assessment on the unit, "Yes, I am Jesus... but I can't walk on water." Religious preoccupation was one of my favorite manifestations of an illness presentation.

And on a heavier note:

I became inducted into the team officially as a psychosis doula. I went to the admission room to collect a new patient. He was sitting at the processing desk with a ball point pen aimed at his jugular. The receptionist says "What are you doing with that pen, can I have it back?" I ask him to give me the pen, and I will take him back. He responds and mentions "I am supposed to do it, today is the day.." We enter the lock-down unit and he pauses in the doorway, "I don't know if I can go in here, they say it's not a good idea," We settle into his room and begin to talk. I leave to retrieve some water and a urine specimen cup for him to pee in. When I return to his room he is crouched on the floor lifting the head of the gurney and looking underneath. He turns to me when I distract him and says "I am supposed to lift this, and put my head here, and then pull it down, hard." We talk more. We discuss safety, and self-control. He asks to be placed in restraints, he doesn't feel that he can be in control. After doing so, he reacts to the physical restraint by yelling, and jerking his body on the gurney, which is now chained to the wall in this tiny fear-inducing room. I sit with him, with my hand on his shoulder, and all of a sudden doula voice sets in. It's ok, you are safe now. This is a safe place. When you feel anxious about not being able to move freely, take a deep breath--like this, with me--and tell yourself you are safe, you are safe. The patient breathes with me, deeply, like we have been transported to a beautiful sunny yuppie yoga studio. He repeats "I'm safe, I'm safe, it's ok, I'm safe" over and over until he actually falls asleep.

My preceptor walked by and observed this for a moment. She pulled me aside and said "I'd heard you were a doula... well done."

This is when I fell in love with schizophrenia, for anyone remotely interested please read this incredible story: The Day The Voices Stopped by Ken Steele.

After many more experiences on this unit I became twitter-pated with Autism, Asberger's, Borderline Personality Disorder, Delirium Tremens, methamphetamine-induced psychosis, hallucinations in general, mania, malingering and more. My love for them relates to a strong desire to learn everything about these conditions and how they effect a person, and how society in turn treats them. There is a lot to learn.

Self-induced premature quarter life crisis...

...which I fully realize means that I am apparently intending to live to be 104.

For me, so far, the quarter life crisis has been fantastic (it was mentioned to me that it cannot technically be a crisis then..) but I moved into my own place, I pop about 12 vitamins, minerals and supplements a day, including nutrient-rich alfalfa infused drinks--the chlorophyll I brought back from Bali. I exercise and dance to my heart's content and, oh yeah, had my nostril studded with a rhinestone. Not too bad really.

Then, for the clincher; this year I went to Miami for Spring Break, South Beach baby! I went to visit a girlfriend of mine, one I've known since we were 6 and 7 years old. She is a pastry chef at an uber swank hotel in Miami Beach. Miami has got to be one of the most fascinating cities in this world. It is so colorful, everything is pastel or flourescent, all is bright, which is perky and great, but then there are the Miamese..

People are amazing. I honestly felt like a naive farm girl. Miami is only-one-article-of-clothing-necessary if not clothing-optional entirely; your choice article can be namely a longish top, OR bottoms. Simply the bikini or speedo will do just fine as well. And anything that offers full view and leaves nothing to the imagination as far as shape, size, color or otherwise of any normally covered part of the body, is perfectly acceptable. I've witnessed many lifestyles, and I can appreciate the naked human form like no other, but I was caught gawking! I'm convinced that no where else are the '80's so alive and vibrantly celebrated as South Beach Miami during the Spring Break season. For full effect, Pflueg's husby Craig repeatedly sang me "Joey" by Concrete Blonde--a classic '80's jingle that was music to my ears this week in all this pastel and cheesy class (oh yes, cheesy class, apparently is not an oxymoron). Sadly, my fanny pack didn't actually fit the bill, where is that old black and hot pink nylon number anyway??

My first encounter with Miami folk was walking down the street with coffees and chocolates from Pflueg's pastry shop where an older babushka woman linked arms with a young woman wearing trendy scrubs, she swerves her body in front of us and says in a thick Slavic accent: Hyou dvinking Vodka??!! Ah the beauty and sadness of dementia, I'm sure she's not allowed, but would absolutely feel divine after a swig!

In light of the "crisis" I had been seriously considering a tattoo, which I figured Lynette would fully support as she has made a beautiful canvas of her own rad self. But, Lynette, being the all practical one, told me to try a pseudo tat first that would last one month. I wanted it on the back of my neck, but couldn't decide what to get. After contemplating getting just any old thing put there just to see what having something there was really like, I freaked out. Ohmysoul, thank goodness, but no thank you.

I haven't dolled up with another girly for a night out in a while, last time Nette and I did, I believe we were 18 and in Bali.

Ms. Lynette Louise and I had a proper catching up not to mention I finally met her husband of nearly two years! A charmer to be sure. I'm hoping they move closer someday, but not before I can pop back over for another guilty pleasure* visit to the wonder that is Miami...

*Next time I'm schlepping my white trousers and any and all pastels and flourescents I may possibly own! When in Miami wear blue eyeshadow and pink lipstick, huge earrings and your bikini for a bra with the best of 'em!

Wish I could pull off orange shades, hot pink bikini and blue eyeshadow in Seattle... Thanks for the make-over babe!

Undercover Doula

Disclaimer: I am a HIPAA-Happy provider, don't fret, details have been changed to protect privacy, or permission has been granted.

I am totally freaked out by L&D [labor and delivery] nursing.

I just finished my last clinical during this quarters' OB rotation. When the quarter started, the first thing I did was make an announcement on the doula community boards to warn them that there would be purple scrubbed nursing students roaming the halls of three major obstetrical units in the Seattle area, and to tell their clients to request that there be no students present for their births. To our credit, the nursing students were told it was an observational clinical only, and the most we could do was offer support, like be a doula!!

So the weeks ensued, and I attended a few births at the baby factory that is Swedish First Hill Hospital, where upwards of 800 births occur each month--holy crap--you know that means they put mama's on a ticking clock to make room for the next labor, at absolutely all costs. But I made the most of it, and resorted to my tried-and-true doula alter ego. I successfully avoided doing the charting and administration of procedures and injections and ordering of interventions. Phew. Ethically, I cannot phathom the role of the labor and delivery nurse [incidentally, pizzas are delivered and babies are born]. You leave a labor when your shift is up, not when the baby is born, and you meet the family in the throws of labor, not prentally where you have time to develop a trusting relationship and bond. So I'm just not on board with the whole concept.

A recent repeat doula client's newest babe--also photographed above holding dad's finger.

So on my last clinical day I attended a high risk birth, and morphed again into their doula and not the nursing student. I, alone, coached her through three hours of second stage pushing, with an epidrual, which requires a little coaching as you can't freakin' tell when you're contracting! And the nurse preceptor later tells me, "thanks for doing the pushing--I hate that part" Yikes. And ahem, I did no such thing, that mama pushed her baby out! The baby was called Joseph Michael, tribute is due here to a certain unaware namesake :)

I was later taken into a small hallway room where they keep "memory box" supplies and there was a nurse carrying what looked like just a baby blanket as if she were carrying a baby; nestled into the crux of her arm. She placed the blanket down and unwrapped it on the counter. A teeny less than 1 pound, 21 weeker baby girl was unveiled. She had just been born, after inducing her death because of spina bifida, a spinal cord deformity that is sometimes incapatible with life, as they say. Her tiny finger pads and toes looked like little tadpole digits. Her skin was sticky and transparent so that you could see the intense red of her vascular system barely beneath it. She had perfect ears and nose and eyebrows and even fingernails. She looked like a little tiny alien creature, and she was beautiful in her miniscule human way. The two nurses in the room with me were chatting amongst themselves about their various judgements they had toward the family. I listened, perturbed to the core at their very nerve, and softly touched this little being and sent her soul some reiki. I couldn't help it. Back out on the unit, I thanked my nurse for showing me the "fetal demise" and she said, "oh no problem, we get a lot of those here"...

I was then reading up on incoming patient's charts in the nurses' station, when I saw out of the corner of my eye a familiar face. A doula! I went out into the patient waiting room and chatted with long time doula, Jennifer Mendleson, we attended a birth together, ages ago now, my first home birth actually, the sixth time mom who labored for an hour and with a single push caught her own son and brought him straight out of her home jacuzzi onto her breast. It was so fun to see Jennifer there. She was waiting for her client to come out of surgery for an abdominal birth (sectioned as the L&D nurses affectionately call the cesarean). She asked me if I felt like I was undercover. I laughed. I absolutely do. I love it.

I love birth, and was happy to be a part of the one's I was assigned to, during this rotation, but now I know with conviction that I could never be a labor and delivery nurse, and that I will be a midwife. I think I could make a good birth nurse if I had to, a doula-esque nurse, but it would be ethically challenging for me to do so.

This is one of my doula babies, an awesome birth from 2007. I nanny for her twice a week now. We play, and she teaches me Mandarin. The other day she was playing on the fake phone and apparently having a conference call between my mom, President Obama, and her baby girlfiend. "Hi C. Lee, hi c lee hi clee Obama, Zoe, Obama, Maumi, (Mandarin for Kitty), Zoe, hi c lee, Obama" I love her to pieces!

Next quarter is my last in the nursing program, and my senior practicum placement is the Harborview Psych Emergency Department. Get ready to be spit on, pinned and swung at... says a few knowing colleagues. I'm totally stoked.