Sunrise, Sunset (Swiftly Flow the Days...)

Wow, time flies! I didn't realize how long it'd been since my last dispatch, but time has a way of getting away from us in The Nuthatch.

You probably wouldn't have guessed this, but the idea of time looms large in our work here. We have daily rounds with psychiatry, nursing and social work to discuss the progress of every patient in our care. How long have they been here? When was the last med change? How many days since the last bout of head-banging? How many more hours of unit restriction? And, of course: How many days of insurance coverage left?

Since most of my patients have chronic illnesses, most are insured by Medicaid and/or Medicare. Some may have 30, 60 or even 90 covered hospital days. That might seem like a lot of time, and I suppose it is, but nevertheless it's sometimes not enough.

Gloria (the manic lady that Andy from One Small Step For Man played a game of cards with) got steadily better for a couple of weeks. But whenever I've talked to Gloria about her son, she says he's great, he's fine, she can manage him just fine. She doesn't know why her family keeps calling me with concerns; she doesn't know why they want to send him to family out of state; she doesn't know why her mother would say that she beats him. They're lying. They're the crazy ones. No, you can't talk to them; it's between us.

The more she's getting herself pulled together, the more we can challenge her to be realistic and candid about her son. Each time she gets pushed a litte, she falls apart a little. Then she pulls it together again and we start over. This last time, though, she fell apart a lot. She's back to being intrusive and illogical, belligerent, and laughing to herself. She's gotten a blank hospital wristband and has written "Chai" on it. I asked her what that meant and she said, "You know," holding up the wristband for me to see, "Chai, chai, chai. You know." She pronounces it like the tea and not like a lyric from Fiddler (she's Hispanic, besides), and I'm just baffled. She's back to writing "Chai" on her artwork -- she colors relentlessly -- as well as on that of others and on random items she finds on the unit (like the sign on the nursing office door). Her functional tests show that right now she doesn't have the judgement to avoid common hazards and so needs to be supervised 24/7.

But the worst news? She's out of covered days early next week. So on Monday, I'll face the wrath of utilization review. This'll be one of those heated, but ultimately pointless discussions with The Powers That Be that they have just to be able to say they addressed the issue with the offending party. Think scolding from a first-grade teacher. It won't actually change anything, and it certainly won't get the patient out the door any faster; it's just one of those exercises we go through to feel like we're doing all we can. Kind of like invoking an invented mantra time and time again.

Guest Blogger: RobinMSW

Hey folks, I was so pleased to bet a story from my colleague RobinMSW that I'm promoting her to guest blogger!

Here's what RobinMSW said in her comment:

I am proud to leave the quote of the day. "Judge Hirsch [actor from tv show 'Taxi'] is the devil." I will leave it to all of you to judge the accuracy of that one! Granted, this is from the same guy who said "Tom Brady [football player, I think he's Pats quarterback or something] told me he went to NY and one of the guys on Saturday Night Live told him to have sex with a dog. He didn't do it, but he did go back to NY and that time he did have sex with a dog." "Tom Brady told you that?" "Yes." "Why do you think all these celebrities talk to you?" (He had mentioned others such as The Rock, Morgan Freeman, Tyler Perry, etc.) "Because I'm the god of love and the god of movies." (Duh)

One Small Step For Man

One thing you really need on this job is an appreciation for little successes. A little progress is still progress, afterall, and if you want to do more than just survive working with folks with chronic mental illnesses, you have to learn to love whatever little progress you get.

Andy has been pacing a lap around our acute admissions unit for, no kidding, about a month. He's mostly silent, although some days he might stop to answer a question or two with, "I'm all set," before returning to his vigil. He's a young guy, only 21, and when he's well, he lives with a roommate in his own apartment. Trouble is, when he's not well, it takes him a long time to get better -- his last hospitalization lasted four months.

He came to us on a drug called Clozaril, which is a little unusual in a guy his age. Because of a potentially lethal side effect, Clozaril is often considered a treatment of last resort. People who take it have to have their white blood cell counts taken every week to make sure their immune systems remain intact. Since his last hospitalization was very long, and since he was discharged on the med of last resort, we're assuming that he's been tried on pretty much every other antipsychotic med already.

So we're not surprised that after a month his improvement has been only marginal. He's out of bed, which is a plus. He's dressed, he showers every now and again (clothes washing remains elusive). He sometimes can sit in group for a good while before he needs to go pace again. And this week, he's started to leave the unit to go down to the cafeteria with the other patients for his meals.

He's just the kind of guy who can fall between the cracks on an inpatient psychiatric unit. Nobody seems to mind all his pacing -- not even the other patients. If there's a little traffic jam, he'll just wait for his opening or go around without bothering anybody. He's not demanding anything, he takes his meds and he keeps out of the way. You might think that all of that is good, and believe me, it is. But the downside is that unit staff can stop trying to engage a guy like him, stop noticing him really, and assume that what you see now is all there is.

So if you weren't paying attention, here's what you would have missed: The other day, at a moment when the unit was pretty quiet, very-manic-but-starting-to-settle-down Gloria was walking down the hall toward Andy. They exchanged a few words with each other, then moved over to the wall and slowly sat themselves down. Gloria took the deck of cards out of the box she had been clutching and began to shuffle, then deal. I didn't watch for long, because I didn't want to ruin it for them by letting them catch me watching, but I think they stayed there for a couple of minutes, at least.

Don't take this the wrong way, but I felt that same mix of luck, joy and awe that I get when I'm in the woods and run across some critter doing something interesting -- lucky I ran across it, glad I noticed it before I scared it away, and amazed at what I'm seeing.

A small breakthrough, I know. But I'll take it.

Peace out,

Madeline

Quote of the Day

The idea for the Nuthatch started with my giving friends and family the best line I'd heard from a patient that day. Here's today's: I was just, moments ago, talking to a patient who was telling me about the compelling thoughts she has of using just about anything she could find to hurt herself with. She held her head in her hands, cast down her eyes, and spoke with a quiver about her pain and hopelessness. I asked her if she would agree to go to unit staff if she felt like the impulses to hurt herself were too strong for her to control on her own. She was accomplished at this kind of conversation, and used the tricks of the trade well. She's not sure any of us can understand what that kind of depression feels like, she said. Going to staff won't help. What are they going to do? If a person wants to die, we should let them die, she said. She asked me if any of my patients had ever committed suicide. This went on for several minutes, and I kept at trying to get the safety contract.

Then something new. Something I've never heard before from any patient in this situation. "I'll make that promise if you go downstairs and get me some French fries and a Snickers bar."

After I said no she tried to bargain me down to a cup of Dunkin' Donuts coffee.

Madeline