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Wednesday, April 15, 2009

Dx: mood swings

It was listed under past medical history in her chart, "Dx: Mood Swings." I ignored it because it wasn't relevant to her admission. "Jane" was a very sweet patient, s/p an assault that had left her with some muscle and bone pain but nothing (thank goodness) more serious than that. I was her nurse for two weeks straight and never had a single problem with her.
Until the day she was discharged.

Although she had been told about the discharge well in advance, she let the date sneak up on her. I saw it in her eyes first thing in the morning. She was walking with the NP, on her way to review her discharge paperwork. I saw her, but was on my way to a clinic to help another patient with a treatment.
I promised I'd be back to go over her medications right after I was done. She nodded, but managed to remind me somehow of a caged animal.

When I came out of the treatment clinic, a crowd had gathered near my med station. Jane was there berating one of the other floor nurses. "You're a liar, a good for nothing liar. My nurse isn't in report! Why would you f*&ing lie about that?" I intervened smoothly.
"She didn't know where I was, and so she was guessing. I'm back now, we can go over all your meds."
"She didn't need to lie."
"I'm sorry you felt lied too, but she was just guessing where I could have gone. You knew I'd be back, I told you I'd come back."

But she was too far gone. She was looking at me, but not seeing me. Like the snap of a twig her whole being changed. Her eyes were fierce and the smile on her face was twisted and ghastly. Her voice became high pitched and sickly sweet as she mocked everything I said to her.

"Jane, it sounds like you're feeling a little overwhelmed..." I started
She mimicked me exactly. I tried again.
"Jane, it seems..."
"Awww.. Does it? Does it "seem"? Why don't you just go ahead and write about it in your incompetent little notes then?" she asked as if she was cooing a baby to sleep in her arms. "You've been refusing to give me care all morning. I came here at 8am and overheard you talking about some poor girl in a tutu! Gossiping about patients. You should be ASHAMED, bad nurse!" her kabuki mask face didn't change and her tone dripped with sarcasm.

As early as 7:30am the DON was telling a story which involved an ER in a different town, but did not involve any of our patients. I tried to explain what she overheard and got nowhere.

Another patient standing in the hallway said, "You know, Jane, she's trying to help you out here. She didn't do anything wrong."

Jane continued to coo. "Aw, is she trying to help? Really? By gossiping and then disappearing all morning? Shame on her!"

I took a deep breath and felt someone tap my shoulder. It was the charge nurse.
"Can I help you?" he asked her, looking past me.
"You can kiss my behind," she said brightly, blinking at him. "You and your useless staff."

She refused to let me assist her with anything. I brought her medications to her room, and she grabbed them from my hand. I wished her luck and as I left she smiled beautifully and murmured loudly enough for her roommates to hear, "I hope you don't ruin anyone else's day today."

I was bewildered. I had never had a problem with her in two weeks. The charge nurse asked if she should be written up or barred. "No, " I answered carefully, "she had a completely appropriate admission until this morning."
"Still, that seemed like a pretty real side of her, " he insisted, "maybe a side of her we were just lucky we didn't see before today. She just couldn't shut that off."
I thought about "Dx: Mood Swings," and nodded.

Although I knew she couldn't help what she was saying, and didn't mean the things she said, I still felt the sting of her words. Nurses get dumped on a lot and most nurses develop a pretty thick skin as a result. My skin gets thicker every day. The danger is developing a skin so thick that truth can't get in and compassion can't get out. Care needs to be mindful and patient- focused.

Sometimes it's important to remind a rude patient that I'm a person too, that he needs to treat me with respect. It's a reminder of the dignity of each of us. It's necessary to do that so that the therapeutic relationship between a nurse and patient can be realigned. Plus, a lot of times other patients get distressed if you let someone treat you badly in the hallway. They might feel upset enough to defend you, to start a fight. Everyone on the team needs the nurse to be strong enough to stand up to rude patients, including the rude patients themselves.
I think I do a good job of knowing when to say "I'm not going to speak to you if you continue in this tone of voice, sir."

But... maybe sometimes a human being is called to just be a silent witness to another human being's absolute panic and pain.
I think it's especially true when dealing with patients who can't help it. If a nurse lets a patient act out, and the patient is in control of his or her behavior, the nurse is doing a disservice to everyone involved, including the patient. But this wasn't the case with Jane.

Jane wasn't just being rude. She was experiencing a psychotic break of some kind. Because of her history of abuse, she has clearly created a wall of defense. Her defense is an entire persona she can put on like a suit of armor. There wasn't a single hole in the chain link. Having experienced it, I can imagine it's a very effective defense against emotional abusers. She wouldn't let me, or anyone in at all. In fact, I don't even know if she'll realize how much she hurt me, or how disproportionate her reaction was. She was in a fight or flight zone, and it was clear watching her that it's a zone she lives in often on the outside. She may have survived her most recent assault without any serious physical injury, but I wouldn't say that she survived "unharmed."
So how much of a nurse's job is it to also be abused by this type of patient? It's an impossible question.

As I was walking down the hall contemplating this, the same patient who had tried to reason with Jane stopped me. "You know what I think of when I see you?" he asked. I shook my head.
"A ray of sunshine."

I thanked him quickly and rushed off to the staff area to shed the sudden tears his words had summoned.

Mood swings.

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