More Redemption in the Mines of Madness
Dear LJ, for my birthday I actually to got to break free from the psychiatric ward I've been spending time in for the past month. Freedom included discussing more mentally ill people living in the community in the morning, and then hooning around parts of the Derwent Valley in the afternoon pumping people full of antipsychotics. Sounds like fun, neh?
Actually, it was. I hadn't realised that I was beginning to feel a bit antsy being inside the same part of the same building every shift, until I actually got to do something outside it again. After the continual travel of the preceding month on placement with a rural community nursing service, and the even more continual travel of the past few years working for patient transport, I think I've grown accustomed to not being locked up in a building for 8+ hours a day. Which makes me wonder why spending two months on placement in Accident & Emergency over summer didn't seem to bug me greatly. Maybe it's just that I was so flat out there that I didn't have time to notice.
It was a pretty foregone conclusion that I'd like, and do well, in A&E. It was the toughest placement by a far (and was meant to be, as it was supposed to be my last placement as a nursing student) but also the one where I felt most at home. I was back in the North, in the hospital I know best down here, and dealing with an aspect and processes of health care with which I am most familiar. I wouldn't say that I absolutely excelled, and I still think handling four beds at once is a tough assignment for anyone (in terms of knowing what's going on, traffic control, continual observations, procedures, and fundamental nursing care), but I didn't completely suck either. I was lucky to have superb fellow students to commiserate with, and a great bunch of preceptors on the whole. One of the advantages that I took in with me was the experience of many, many years in first aid rooms with St. Jambulance at places like the MCG. They were often production lines, and taught me the concept that discharge planning begins on admission. The A&E experience absolutely hammered home that Fordist approach to delivering health care to the masses. I can't say I'm a fan of that, but I know where it's come from and why. The challenge is to do it better than McDonald's. Much, much better.
Community nursing was almost the antithesis of emerg. A busy day might include 6 patients to be visited, chatted with, assessed, and treated; all requiring a maximum of three hours of driving. It would have been a bit more challenging if there were more isolated patients further out from the rural towns in the service's territory, but there were none of those on the books at the time I was there. I imagine that winter would also add to the joys of getting to the odd, obscure little farmhouse down a graded dirt road but I wasn't there for that either. What I did discover was individual care, with time to do it right. The time to assess patients on their own turf and take in the whole view of their lifestyle and living conditions (something that ambos tend to get to do more than most nurses), and the effects and constraints that those have on overall health. Working collaboratively was a bit more of a challenge than in hospital, but even more satisfying when it did actually work. I'm still a bit chuffed that I may have got a girl with a pretty significant vascular ulcer onto a hyperbaric medicine trial.
After all of which I came to spend some time on the psych ward in a major hospital. And no, not as a customer... although I still think the cliche that there's not a lot of difference between some of the staff and some of the patients has some weight behind it. Spending the past three weeks there has futher cemented the 'There but for the grace of God...' feeling I have when it comes to mental illness. The gaps between what we consider pathological and normal are wafer-thin. In one of my textbooks there's a poem by a patient listing a range of human activities and behaviours, with the comment that if you (the reader) perform them it's a sign of X or Y, but when she does it's a clear sign of pathology. Smiling in her case = manic. And she's not wrong. We accuse paranoid patients of hyper-vigilance, but note down every twitch or change in the rate or volume of someone's speech as possible evidence of something going wrong inside. The confidence that some staff seem to have that their interpretation of someone's behavious is the correct one baffles me a little. I like to leave some room for doubt, and frankly a lot of the stuff that people do there doesn't strike me as all that unreasonable, given the circumstances.
All the fancy sociological theories that so annoy nursing and paramedic students when they're made to study them, such as Labelling Theory (I always was more of a micro-theorist than a macro one) are blindingly clear in such a place. I discovered on Friday that it's virtually impossible to change a diagnosis of schizophrenia once it's been given to you, and it doesn't have to come from a psychiatrist either. Issues around deviance and control, and questions about just what the hell mental health nurses actually do, and are meant to be doing are also very, very visible there. I'm not entirely thrilled about being society's gate-keeper and arbiter of 'normal'. On the other hand, I'm not thrilled about what society at large does, or doesn't do to some of the people in the ward as well.
Which is not to say that I haven't met some genuinely crazy people. Most of them are quite sweet, and hardly dangerous to anyone but themselves (unless accidentally), but also pretty delusional or having serious trouble with the way their thoughts work. One of my favourites have been the guy who marched himself up to the locked door of the ward, rather than going through his local shrink, GP, or even A&E, and requested to speak to three doctors. He was fairly sure that it would take three other minds to really comprehend the value and complexity of the realisations that had come to him over the past few weeks. When we started delving it revolved around the need for him to have his heart stopped (only for a few seconds, he assured us) in order to reharmonise the universe. Through a lot of careful thought, and the help of occasional small amounts of marijuana, he had been able to communicate with extra-terrestial entities. They had assured him that God and the Devil were delusions and mistakes, that the universe was seriously flawed in an inexplicable way, and that he was the man to set it right.
He spoke slowly and carefully, politely, and relatively articulately about all of this. It was fascinating to see the wheels turning behind the face as he struggled to dumb down what he could so clearly see for us nurses, while trying to work out if we could help him see a doctor or three that night. I wondered what was driving all of this. There was obviously some motivation for the delusion(?) going on. Was the sense that the universe was "all... wrong..." the last flash of fading insight: his brain trying to tell him that something in the interior world was wrong? Had something else happened in the past few months? Just what was going on behind the metaphysical issues he was attempting to explain to us. I can really get where Freud came from when developing a lot of his psycho-analytic theory, as a result of encounters with this guy, or the woman with the eight invisible (five legal and in this dimension, but three illegal and in a different dimension) children. It turns out that she does, in fact, have eight kids, scattered across the country with different fathers. It seems pretty likely that her need to go out and buy clothes for the invisible ones in her room is probably connected, but how and why has the rest of her delusional edifice arisen? Just what is going on in there..? Is it just a lck of a shared, or sufficiently useful language between us all to understand this properly, and provide help if actually required. It's fascinating (and sometimes tragic) stuff.
Given that level of inability to explain to others what you really know to be true, I'm not surprised that many mentally ill people report a lot of fear in their day-to-day dealings with the rest of the world. It must be pretty damn scary. It makes shuffling around, avoiding eye contact or any other unneccesary form of interaction with other people make perfect sense. Thought disorders must be worse again. At least for people with mania they're awash in sea of Getting Things Done or superiority.
It was also always a no-brainer that I'd enjoy psych nursing (with tooticky suggesting "Even if I don't know what it actually is" over my shoulder). I like to ponder this stuff. I'm usually pretty relaxed about other people's foibles. I'm not generally afraid of catching crazy germs. And so on. However, I've actually found I enjoy this slightly less than community nursing, which is a bit of a surprise. Don't know quite what to make of that one, or what it may mean for the future.
Next week I'm off to the intensive care section of the psych unit, where the really acutely nutty are. That may be a whole different ball game. I'll try and write some more at the end of it all.
Actually, it was. I hadn't realised that I was beginning to feel a bit antsy being inside the same part of the same building every shift, until I actually got to do something outside it again. After the continual travel of the preceding month on placement with a rural community nursing service, and the even more continual travel of the past few years working for patient transport, I think I've grown accustomed to not being locked up in a building for 8+ hours a day. Which makes me wonder why spending two months on placement in Accident & Emergency over summer didn't seem to bug me greatly. Maybe it's just that I was so flat out there that I didn't have time to notice.
It was a pretty foregone conclusion that I'd like, and do well, in A&E. It was the toughest placement by a far (and was meant to be, as it was supposed to be my last placement as a nursing student) but also the one where I felt most at home. I was back in the North, in the hospital I know best down here, and dealing with an aspect and processes of health care with which I am most familiar. I wouldn't say that I absolutely excelled, and I still think handling four beds at once is a tough assignment for anyone (in terms of knowing what's going on, traffic control, continual observations, procedures, and fundamental nursing care), but I didn't completely suck either. I was lucky to have superb fellow students to commiserate with, and a great bunch of preceptors on the whole. One of the advantages that I took in with me was the experience of many, many years in first aid rooms with St. Jambulance at places like the MCG. They were often production lines, and taught me the concept that discharge planning begins on admission. The A&E experience absolutely hammered home that Fordist approach to delivering health care to the masses. I can't say I'm a fan of that, but I know where it's come from and why. The challenge is to do it better than McDonald's. Much, much better.
Community nursing was almost the antithesis of emerg. A busy day might include 6 patients to be visited, chatted with, assessed, and treated; all requiring a maximum of three hours of driving. It would have been a bit more challenging if there were more isolated patients further out from the rural towns in the service's territory, but there were none of those on the books at the time I was there. I imagine that winter would also add to the joys of getting to the odd, obscure little farmhouse down a graded dirt road but I wasn't there for that either. What I did discover was individual care, with time to do it right. The time to assess patients on their own turf and take in the whole view of their lifestyle and living conditions (something that ambos tend to get to do more than most nurses), and the effects and constraints that those have on overall health. Working collaboratively was a bit more of a challenge than in hospital, but even more satisfying when it did actually work. I'm still a bit chuffed that I may have got a girl with a pretty significant vascular ulcer onto a hyperbaric medicine trial.
After all of which I came to spend some time on the psych ward in a major hospital. And no, not as a customer... although I still think the cliche that there's not a lot of difference between some of the staff and some of the patients has some weight behind it. Spending the past three weeks there has futher cemented the 'There but for the grace of God...' feeling I have when it comes to mental illness. The gaps between what we consider pathological and normal are wafer-thin. In one of my textbooks there's a poem by a patient listing a range of human activities and behaviours, with the comment that if you (the reader) perform them it's a sign of X or Y, but when she does it's a clear sign of pathology. Smiling in her case = manic. And she's not wrong. We accuse paranoid patients of hyper-vigilance, but note down every twitch or change in the rate or volume of someone's speech as possible evidence of something going wrong inside. The confidence that some staff seem to have that their interpretation of someone's behavious is the correct one baffles me a little. I like to leave some room for doubt, and frankly a lot of the stuff that people do there doesn't strike me as all that unreasonable, given the circumstances.
All the fancy sociological theories that so annoy nursing and paramedic students when they're made to study them, such as Labelling Theory (I always was more of a micro-theorist than a macro one) are blindingly clear in such a place. I discovered on Friday that it's virtually impossible to change a diagnosis of schizophrenia once it's been given to you, and it doesn't have to come from a psychiatrist either. Issues around deviance and control, and questions about just what the hell mental health nurses actually do, and are meant to be doing are also very, very visible there. I'm not entirely thrilled about being society's gate-keeper and arbiter of 'normal'. On the other hand, I'm not thrilled about what society at large does, or doesn't do to some of the people in the ward as well.
Which is not to say that I haven't met some genuinely crazy people. Most of them are quite sweet, and hardly dangerous to anyone but themselves (unless accidentally), but also pretty delusional or having serious trouble with the way their thoughts work. One of my favourites have been the guy who marched himself up to the locked door of the ward, rather than going through his local shrink, GP, or even A&E, and requested to speak to three doctors. He was fairly sure that it would take three other minds to really comprehend the value and complexity of the realisations that had come to him over the past few weeks. When we started delving it revolved around the need for him to have his heart stopped (only for a few seconds, he assured us) in order to reharmonise the universe. Through a lot of careful thought, and the help of occasional small amounts of marijuana, he had been able to communicate with extra-terrestial entities. They had assured him that God and the Devil were delusions and mistakes, that the universe was seriously flawed in an inexplicable way, and that he was the man to set it right.
He spoke slowly and carefully, politely, and relatively articulately about all of this. It was fascinating to see the wheels turning behind the face as he struggled to dumb down what he could so clearly see for us nurses, while trying to work out if we could help him see a doctor or three that night. I wondered what was driving all of this. There was obviously some motivation for the delusion(?) going on. Was the sense that the universe was "all... wrong..." the last flash of fading insight: his brain trying to tell him that something in the interior world was wrong? Had something else happened in the past few months? Just what was going on behind the metaphysical issues he was attempting to explain to us. I can really get where Freud came from when developing a lot of his psycho-analytic theory, as a result of encounters with this guy, or the woman with the eight invisible (five legal and in this dimension, but three illegal and in a different dimension) children. It turns out that she does, in fact, have eight kids, scattered across the country with different fathers. It seems pretty likely that her need to go out and buy clothes for the invisible ones in her room is probably connected, but how and why has the rest of her delusional edifice arisen? Just what is going on in there..? Is it just a lck of a shared, or sufficiently useful language between us all to understand this properly, and provide help if actually required. It's fascinating (and sometimes tragic) stuff.
Given that level of inability to explain to others what you really know to be true, I'm not surprised that many mentally ill people report a lot of fear in their day-to-day dealings with the rest of the world. It must be pretty damn scary. It makes shuffling around, avoiding eye contact or any other unneccesary form of interaction with other people make perfect sense. Thought disorders must be worse again. At least for people with mania they're awash in sea of Getting Things Done or superiority.
It was also always a no-brainer that I'd enjoy psych nursing (with tooticky suggesting "Even if I don't know what it actually is" over my shoulder). I like to ponder this stuff. I'm usually pretty relaxed about other people's foibles. I'm not generally afraid of catching crazy germs. And so on. However, I've actually found I enjoy this slightly less than community nursing, which is a bit of a surprise. Don't know quite what to make of that one, or what it may mean for the future.
Next week I'm off to the intensive care section of the psych unit, where the really acutely nutty are. That may be a whole different ball game. I'll try and write some more at the end of it all.