I'm a Rules Girl

And thank you to you too, Rebecca, my other reader.

Part of the problem with getting myself to blog are the groundrules I've set for myself: only blog about things that have happened in the last couple of days, and no material about other staff or complaining about the hospital in general. The reasoning behind the first rule is that it would be way too easy to just store up a bucketful of amusing anecdotes in my head and write them all down when I get a chance. That feels a little disingenuous to me -- the immediacy is the whole point to a blog, right? The problem is that thought-provoking things don't happen to me everyday. At least they don't happen everyday that I happen to have time and energy to write about it after work. Or they provoke the same thoughts you've already heard.

As for Rule #2, well that's just fair play (and self-preseveration). But I have to admit, the groundrules do end up limiting the available material. Not that I'm necessarily withholding lots of little gems from several months ago, or bursting with juicy rants about the Nuthatch. But you know, I don't work alone -- very often other people are a big part of what goes on here. For better or worse, there have been a number of significant staff changes here in the last several months, and the adjustment takes up a lot of my mental energy. But telling you about it would probably be against the rules, so you'll just have to take my word for it.

So I'm going to break the other rule and tell you a story from several months ago. We had 50-something year old woman with schizophrenia here last spring. She was pretty catatonic when we admitted her -- she stared into space and not much else. It might help you to know that some of the side effects of antipsychotic medications can be things like high cholesterol and diabetes. She was on a medication as an outpatient that seemed to be working for her just fine, but she was having some metabolic changes that could be problematic down the road, so her doctor took her off that medication and started a new one, which didn't work.

Enter Laura, staring into space. Laura then spikes a fever and stops eating and drinking. She starts antibiotics, but also becomes incontinent of urine and feces. At this point, she will also neither stay dressed nor stay in her room. She screams if anyone approaches her and resists all attempts to drape her with a sheet or johnny. I develop this trick where I walk up to her holding a johnny open and basically just wrap her up in it before she knows what's really happening. We can usually get her to keep it on long enough to get her into her room and put someone outside her door so that she can't come out again. I have a similar trick when I go into her room and hold a sheet up in front of me so that she can see my face and I can see hers, but nothing else. I'll talk to her like that if she won't let me drape the sheet over her. I do my best to make it clear to her that I will absolutely not meet with her if she is exposed.

I'm not sure what she actually understands. She's no longer catatonic, but still severely decompensated. Her eyes dart back and forth, she looks at me suspiciously, she rocks forward and back. She looks at times as if no matter how hard she concentrates, she just can't get words out of her mouth. Often she throws me out of her room. Her low-grade fever persists, as does her incontinence.

Weeks go by. Her outreach workers call often and are very troubled by the continuing bad news. They've never seen her like this before. The unit staff cannot believe that a few weeks ago this lady was living in her own apartment with two roommates -- they figure her for a nursing home for sure. Finally the infection clears up and her antipsychotic meds have a chance. Little by little she gets dressed and may answer a few questions before saying to me, "What do you want? I don't have to talk to you!"

After a month or so, we start to get nervous that she won't get back to herself and be able to leave the hospital. We start to think about whether we need to apply for a state hospital bed or have her screened for a nursing home. The outreach workers are devastated -- this just isn't Laura. How could she disappear just like that? And why can't you bring her back? In the end we decide to put her back on the first med that gave her the metabolic syndrome -- when (if) she's recompensated, we can review the risks with her and she'll be able to give or withdraw her informed consent to be on this medication.

More days go by and she starts to show some real improvement. She is still pretty paranoid and doesn't like to leave her room. She talks to me sometimes in a whisper because she's afraid that others can hear. One day she asks if she can make a phone call. I tell her that of course she can and can I help her in some way. She says yes, and I motion for her to follow me to the patient phone. She tries, but she just can't -- she can't bring herself to leave her room. This goes on for days -- can I call someone for you and give them a message? Who? Who is it you want to call? Maybe I can get the number for you if you don't remember it. We creep closer and closer to the door. One day, she leans over the threshold and peers out, looks up and down the hall. No, nevermind, I don't want to make the call. Ok, maybe tomorrow if you want.

Finally, she comes with me out into the hall and down the corridor to the phone. She looks around a few times, to see who might hear. I dial for her and she waves me off. She can take it from here.

I don't go too far, though, because I want to listen in. "Mom?" she says. "Hi, it's me, Laura. Yeah. I'm fine. I'm in the hospital. How are you, Mom?"

I almost burst into tears right on the spot. It's moments like that that really keep me going. Like the time when Andy flirted with a girl (see January 26). The absolute, stunning, searing, heartbreaking humanness of it. Forgive me if I've said this before, but I've figured out that one of the big appeals in working with this population is the ability to connect with certain universalities of human experience in a very simple and direct way. Maybe it's because so many of my patients, in terms of their ability to get along in the world, are pared down to basic survival that these universals are that much more striking to me. Like being playful with another human being or wanting to talk to your Mom. Nevermind that Laura's pushing 60 herself, and can barely work up the courage to leave her room after six weeks of staring, streaking, peeing, pooping, screaming and swearing. She just wanted to talk to her Mom.

Happy Thanksgiving, if I don't see you before then.

Madeline