Pharmacology

Arghh. Exam was harder than I was expecting. Hardly anything I had actually revised came up, instead had to rely on my vague memories of stuff I'd read about in the past and things I'd seen in practice. I mean, I'm not being funny, but when exactly will I ever need to know that pimozide is a member of the diphenylbutylpiperidines? Think I fucked up most of the chemical groups questions, and the ones I kinda knew I think I spelt wrong. Oh well. Only need 50% to pass, will find out next week how I did. I daren't look up any of the answers cause I know I'll kick myself and get stressed. This way I can at least fantasize that I did well for a while...

Am hoping now I've got that out the way I can actually start some of my assignments. Should probably send in my bursary form too, although I have no idea if the evidence I'm sending will be enough.

Bah. Fed up.

J is for...

Continuing the ABC guide to secure mental health services.

Have also included a couple of 'I's that I forgot on the last update. Because I can. And because the J's were looking a bit weak.

Onwards...

Insight

What you lack if you dare disagree with your doctor.

Or, more properly, having insight is having the awareness that you have a mental illness. Many patients, particularly psychotic ones, don’t have any insight at all into the fact that they are ill. Others will have periods of insight, during which they can get very depressed, or remorseful, or embarrassed about their beliefs or behaviour whilst ill. If one minute you were running around naked because clothes are a tool of governmental oppression, and then the haloperidol kicks in and you realise you are in the middle of the day room fighting the staff who are trying to wrap you in a sheet, it can be a little mortifying. Similarly, if you are quite happily communicating with the Queen via the lights in your ceiling and then some nasty nurse comes and gives you some pills and you realise you are on a locked ward for the fourth time this year, your wife has left you and taken the kids because you’re mental, and you probably don’t have a job anymore...lack of insight can probably seem quite attractive.

Some patients, who might be resistant to treatment, will never have any insight into their condition. They will always believe that they are being locked up against their will with no cause and no amount of pointing out their odd and/or dangerous behaviour will ever make them see it otherwise. One patient used to phone the police on a daily basis and report us for locking him up; he’d been in one hospital or another for around 30 years. I can’t imagine how depressing that must be. Although, in his case the lack of insight was definitely a blessing, since he suffered from pica and often engaged in coprophagia. Ignorance truly is bliss sometimes.

Inquiry

There are lots and lots of these in mental health. I’ve been lucky enough to avoid being involved in any so far, but a few nurses I know have been witnesses in several. It’s only a matter of time I guess. When I worked in admin I did once get the fun job of photocopying 10 years worth of patient notes for an inquiry...with a 2 day deadline. I was getting high off the toner fumes by the end, which at least made it a bit more interesting.

J is for...


Junior doctors

I have no idea what the proper terms are for the junior doctors that hang around psych wards looking baffled and afraid. As far as I know, they are still SHO's (Senior House Officers). All I do know is the one on my last placement was asking me for advice during an admission. I was a second year at the time, and it was the first admission I'd been in on, hence the sum total of my advice was as follows:

1. Get some damn people skills. Quickly.
2. Don't talk to me about your patient as if she's not sitting in front of you (linked to 1).
3. This is a BNF. Use it please; guessing is not a good idea.
4. If you don't learn how to properly fill in a MAR sheet very quickly, you will get paged a lot. There's no point bitching about it.
5. Find someone better than me to ask for advice, FFS.

To be fair, they do seem to get chucked in at the deep end a bit, and there's a pretty steep learning curve involved. The one at the end of his rotation was actually pretty good; he almost didn't flinch at all when a patient got within 2 feet of him. Bless.


Justice

Deep. If you or your loved one was the victim of a crime commited by a person who was sent to a psychiatric secure unit instead of a prison, would you feel justice was served? What if it was murder, if they killed your son or daughter and you knew they were going to a place with en suite bathrooms, LCD TVs and trips to the shops if they'd been good? Would that piss you off? Or would you feel better, knowing they could be locked up for the rest of their life; that unless they convince several doctors (terrified of litigation) and the Ministry of Justice (terrified of the public) that they are no longer a risk, then they could be in much longer than they would be in prison? Knowing that it's harder to get out of prison than it is a hospital, would that help? Would you feel better knowing that they were ill and that they're now getting the treatment they need?

Fucked if I know.


Jesus

We have a few patients who have had religious conversions in hospital. Genuine ones, not delusional ones, although it's hard to tell the difference sometimes. Believe in God? Probably genuine. Believe you are God? I spy a delusion*. In a slight twist on the 'I've found God, parole me' thing that supposedly goes on in prison, finding God in a mental hospital is probably much less likely to convince people that you should be released; quite the contrary in fact. It will most likely be considered as evidence that you need more drugs.

*Don't get me started on at what point something stops being a delusion and starts becoming a religion. How many believers do you need to reach that point? Actually, no, don't answer that.

Ok, back to the revision. Although it's a formative exam, and so technically worthless, but I still want to pass 'cause my self esteem is tied up in academic achievement. *sigh*

Real life stuff

My dad is moving house. This is a huge, huge thing. My dad doesn't do change. Until he was made redundant, he'd had the same routine for 24 years. Seriously. I had to have his cup of tea made at 4.15 every day when he came in from work when I was growing up.* He's lived in this house for 27 years; it was the one I grew up in. I had a last wander round it today, and stood looking out of my old bedroom window for an emotional 5 minutes before I got shouted at for not packing stuff. Lot of memories, good and bad. Lot's of dead pets buried in the garden too, which will be an interesting surprise for the new tenants if they decide to reclaim the wilderness it has turned into recently.

Anyway. He's decided that a 3 bed house with an 80ft garden is a bit too much for him now, and he's managed to bag a council flat closer to his mum and brothers and, more importantly, within walking distance of 2 pubs and the working man's club. So today has been spent ferrying bits and pieces over to the flat in my and sister_door's cars. Of course, it's a second floor flat with no lift and a very narrow staircase, so getting his leather suite up there should be fun. Mr Door has been roped in to hire a van and help with the big stuff on Thursday. I plan to be very busy at uni that day.

As for uni...well, there's Politics going on. I'm loathe to go into the details, but basically something has happened that has upset the apple cart and the mental health degree students are suffering for it. There was talk of petitions and formal complaints. It's not exactly the end of the world, but it's enough to cause added stress since it involves the dissertation. Ho hum. I don't really have anyone to stress with about it either, as my equally cynical and like-minded friend has had to drop back a year following a really crappy (in a 'god, that's unlucky' way, not in a seriousness way) accident. I have a few other people to hang around with, but they don't always 'get' me (strange that...) so that sucks, and I really just can't wait till February when I go back on placement. Never thought I'd be saying that.

Oh, and my mum is ill again with a bug she can't seem to shake off. She still hasn't found out what happened during the surgery; the hospital was meant to phone her the day after apparently, and she was going to ask then, but they didn't ring. Completely unsurprised, to be honest.

So, yeah. Mood is not quite as bad as it was; I still feel overwhelmed, but am pretty much ostriching. Giving myself this week off from assignments in the hope that I can start everything fresh next week. Still eating erratically, and still mentally daring Mr Door to say anything when I leave stuff on my plate, but the appetite is recovering a bit.

Am still after more ideas for 'J' in my ABC of secure MH services. I might do a few more for 'I'
that I missed as well...


*Incidentally, he also only learnt how to use a cash machine at the age of 50 when my mum left him. He hadn't been in a bank for 25 years. He had a very steep learning curve that winter.

I is for...

Apologies for the delay, my brain stopped working. So this is probably of dubious quality, but compared to what I've scribbled for my assignment so far it's a work of Shakespearian genius.

Institutionalisation

Usually considered to be a problem for patients, but researchers tend to completely fail to take into account that more often than not the staff are much, much more institutionalised than the patients. Try and shake up a routine and the most of the staff will bitch like hell. However, some staff are more flexible than others...that is, if the patients will let them be.

This is best illustrated by a couple of stories from work.

(a)The case of the extra milk:

One of the wards has flasks of hot water put out for people to make their own drinks with*. At certain points during the day, we also put out tea bags, sugar and a couple of pints of milk for people who don’t have the cash to buy their own. The other day we had a few extra pints of milk knocking about so, rather than nick them for the office, we stuck it out with the flasks. Now I wasn’t expecting people to fall down and worship at the feet of the milk-bringers or anything, but nor was I expecting the barrage of shouts of “it’s not milk time!” that I received on doing so. Next time, I’m filching the damn milk for myself.

(b)The case of the early fag:

Cigarette times are usually strictly set, however on this occasion we knew we wouldn’t have enough staff to facilitate going out for a fag at the proper time. So we brought it forward by ten minutes so that people wouldn’t have to wait an extra hour for one. Cue so much sulking and complaining that I briefly wondered if I’d told them they’d have to walk naked over hot coals to get their smoke.

I guess, when you are dependent on a regime you have no influence over, ranting when it changes – even for the better – is part of regaining some control. Or at least pissing the staff off mightily and thus providing some entertainment on those boring afternoons.

*Which periodically have to be removed after being used as projectiles. But since it’s a pain in the ass having to get staff to make hot drinks, they get put out again pretty sharpish.

Intimidation

Tactic employed by big, scary patients and, often occasionally, dickhead staff to get others to do what they want. Being quite little, I tend to get loomed over a lot. Depending on the patient, this is either intimidating or just plain annoying. As long as there is plenty of back up around I’ll stand my ground, show no fear, be a man, etc. If I’m on my own I’ll run like hell and challenge them from a safe distance (i.e. from 30 foot across the day area); I’m not bloody stupid.

Intramuscular Injections (Depot)

What you are likely to end up on if you keep palming/refusing to take your prescribed antipsychotics. Basically, a long lasting (usually fortnightly) injection into the buttock or thigh muscle.

In mental health services, people on a section 3 of the MHA can be given medication against their will for the first three months of the section. After that, their RMO will arrange for a Second Opinion Appointed Doctor (SOAD) to come and evaluate whether they believe the patient needs to continue with the medication. If they agree that the patient needs it (after discussion with the patient, their nurse and various other people) and the patient consents to taking it, they fill in a Form 38. If the patient does not consent, they fill in a Form 39.

In secure services, if you have a Form 39 and refuse your depot, tough. Extra staff will be summoned, you will be restrained on your bed and given it.

This is one of the bits of the job that disturbs me. In an emergency situation, where someone is very psychotic and determined to hurt anyone that comes near them, then I can more easily reconcile the use of forced medication to calm them down particularly when the alternatives are several hours of restraint or seclusion. But when you are stood outside planning to go in and pin down the very calm woman sat doing a jigsaw...it’s unsettling. That’s not to say I don’t always think it’s wrong; the last time jigsaw woman missed her depot she broke a staff members rib in an unprovoked attack.* But I think if I didn’t have some qualms about it then I probably shouldn’t be allowed near patients. Perhaps a career as some sort of dominatrix, but not MH nursing.

*Medication as social control? Of course not.

Ahh alcohol

(Erm, some of this could maybe be triggering for people with food issues. I think? Just a heads up...)


I don't usually drink much; it just makes me sick. I probably have a drink a couple of times a month. But I've been drunk the last three nights out of 4. I'm drunk now, in fact.

I've been feeling stressed. I'm at the point where I've got so much to do that I'm frozen and can't do any of it. Mr Door was off with me for a change, so I gave myself the weekend off from anything MH related, to take the pressure off a bit. Was nice while it lasted, but then I went straight back into pharmacology revision and...stuff. The dissertation module is turning into a bit of a farce, for various reasons that I'll probably whinge about later. Needless to say, my uni's organisation is living up to it's usual appalling standards, and it's not helpful. I've filled in the 26 page bursary form, dug out P60's stretching back 7 years to prove I was/am living independently from my parents, and made endless photocopies of everything ready to send off. I know I should be working more shifts so that I'm not skint over christmas when they recalculate it, but every time I'm there I think should be doing my assignments. Nevermind that I don't actually do them when I'm off.

I've also lost some weight. I was skinny anyway, but now I'm a bit more. It's not amazingly drastic; BMI is in the 17's, which is classed as underweight, although I'm exactly skeletal. I was ill about a month ago and lost just over half a stone, and my appetite has never properly recovered. Possibly stress related. As a result, I have Mr Door looking over my shoulder - out of concern, I'm sure - at what I'm eating. It's a pain in the arse; I already got a lecture off the nurse at my GP's, and I know I'm too skinny. But nagging me to eat more isn't going to help if I have no appetite; when I've tried to ignore it and carry on eating I just get sick. Plus, I have no set routine at the minute, so my eating habits are a bit erratic, which isn't helping. And of course, the more people see you not finishing meals, the more people get suspicious. And the more you deny to people you have an eating disorder, the less they believe you. I kind of want to have a badge printed: "Ask me if I have an eating disorder. I FUCKING DARE YOU."

So overall, bit of a wreck. What I really want to do is press the giant PAUSE button on life and take a breather, but that's possibly a bit unrealistic. What I need to do is give myself a slap, start at least one of the damn assignments and stop getting panicky when I think about the huge amount of work I have to do. And finish my friggin dinner.


PS: I need ideas for I and J of the ABC. I have institutionalisation and intimidation and my brain has ground to a halt.

Degree v Diploma

So nursing is to change to being an all-degree profession from 2013. Not a huge surprise. Mental Nurse is having a proper discussion on it if you want to know more, because you know what?

I don't care.

Frankly, I don't give a damn what they make us do to be nurses. To be brutally honest, I'm hoping it will put some of the thicker applicants off doing it; you can be as caring as you want, but if you can't scrape a third in a degree with three attempts at every essay then there's no fucking way you should have people's lives in your hands.

Of course, the argument is that being able to write an assignment doesn't make you a good nurse. This is true. Assignments only show how well you can write assignments. However, if you still can't pass one on the third attempt after receiving feedback and support from tutors - and often just being told straight up what the hell to write - then that to me shows an inability to learn from your mistakes, to listen to and act appropriately on new information, and just an incredible density that means you should not be allowed to dish out potentially lethal drugs to sick people.

So I don't care. What I do care about, a great deal, is money. Of course.

I'm currently filling in a 26 page form begging the government to give me a pittance towards my living expenses, in order that I might qualify as a MH nurse and thus be graciously allowed to spend the next forty fucking years caring for people whom a fair percentage of society don't actually give a shit about.

You want to make sure people still go into nursing when it's all degree? Make sure they don't have to default on their mortgage to do it.

Parents, eh...

...they cause you nothing but stress.

Yeah, this isn't hugely mental health related, so feel free to go read something that has less of me getting stressed in it.

Ok. So regular readers will know that my mum is a falling-apart 54 year old who is already on her third hip replacement. Today, she had some more surgery; just a minor exploratory op for some womens' problems. The thing is, she is pretty sure she stopped breathing whilst under the anaesthetic; she heard them talking about it as she was coming round and woke up in the higher dependency bit with two nurses, rather than the recovery room they had told her she would be in. She didn't ask about it, though, and no-one has said anything to her. She's fine now, but it's making me a bit concerned cause she will almost certainly need more surgery in future given the crumbling nature of her joints. So I guess I'm after some reassurance from some doctors/proper nurses that this isn't likely to happen again. Please. I hope.

Otherwise, we had to submit dissertation topics today; was very short notice given that we only got the criteria half an hour before. After some negotiation with the bloke who I hope will be my supervisor, I'm going to investigate the effects of physical restraint on female patients. This is alongside the stuff on female sex offenders that I'm doing as a smaller essay. Am up to my eyeballs in women, basically. So, if anyone has any useful literature on either of these topics, my email address is at the bottom and it would make me love you forever :o)

I don't usually plug things, but....

...this could be useful for some people.

Someone from the Guardian has very kindly asked me to be a student 'expert' (hah!) on one of their live Q&A sessions about careers in the NHS tomorrow. I can't do it, unfortunately, due to my attempts to forage my own career in the NHS tomorrow afternoon. However, I did offer to plug the session, to make myself feel better. So, if you have any questions about getting an NHS career, then go here and some more helpful person will try and answer them.

Just...urgh.

Like nearly everyone else in Britain, I'm ill. I have a stupid cold. It's been developing very slowly over the last week, and I think I've had nearly every symptom of a cold seperate from every other symptom. So for three days I had a sore throat, then that went and I got a cough, now the cough has gone and I have a runny nose and hurty sinuses. All, however, were underpinned by a general feeling of crappiness. I would have rather had everything together and gotten it over with by now, but instead I think it's going to drag on.

So, forgive me if I'm a bit quiet lately but I just have very little energy and what small reserves I do have are dedicated to Uni work. I'm doing an essay on female sex offenders, which turns out to be quite topical, but it's pretty heavy going ploughing through the literature.

On the plus side, feeling crappy gives me a very good excuse to avoid taking any shifts at work. Avoidance is necessary right now because both ladies wards are, not to put it too finely, up the fucking pole, and the staff are dropping like flies. The thought of restraining with a dripping nose is not too appealing, although possibly the threat of being pinned down and having snot dripped on you might be a deterrent to any patient contemplating kicking off.

So, to summarise: Ill, skint, and buried under a mountain of sex offender literature.

Living the dream, people.

H is for...

So, I've got my next placement sorted...I'm going back to where I work. I'm choosing to see it as the logical progression given where my interests seem to lie (i.e. forensics) and not just that I'm taking the easy route. Which I am. I've really enjoyed some of my other placements, and if the local acute wards ever go to 12 hr shifts then I would seriously consider applying to work there. But for now I just want to not be stressing over starting somewhere new and having to go there five days a week whilst also fitting in bank shifts and trying to do a dissertation. Being at work means 4 days off a week, first choice of bank shifts (cause I'll be able to hunt down the almighty Rota Woman and harass her) and the absence of freaking out with those 'new starter' nerves (ohshitohshitohshitwheredoIparkwheredoIeatluncharetheygonnabenicetomearghhhhh!).

Sound like I'm trying to justify it much?

Also, work is probably the only place in the area that is going to be taking on staff when I qualify since they are expanding and are about 40 RMN's short.

Yeah, still justifying it.

So, while I wallow in the feeling that I should really be making more of my training, here's H...

Hygiene (Personal and Environmental)

I may have mentioned before, but patients have a varied relationship with hygiene. Some border on obsessive in their bathing, whilst others prefer to moulder in their own filth until their clothes become physically attached to their skin. Most fall in between. If a person becomes so dirty that it is offensive* (usually about the time you start to gag when they enter the room...or even the building) then we bully them into the shower in the nicest possible way. On these occasions HazMat suits would be useful, and it would be nice if in the summer months we were just allowed to hose them down in the courtyard. Damn Human Rights Act.

Strangely, some of the people who would prefer to kill rather than change their clothes tend to be fastidious about their environmental hygiene. Patients are expected (read: nagged, usually fruitlessly) to clean out their room at least once a week, but all other areas are cleaned - again, with varying degrees of success - by domestics provided by a contractor. Some of the long stay wards absolutely reek of lavender-air- freshner-with-a-hint-of-stale-urine.

We have a lot of mice, which provides endless entertainment on a night shift when you're teamed up with the type of person who screams and jumps on a chair at the sight of something two inches long and furry. A well-placed dustball in a draught can have hilarious results at 4am.

*Which, to be fair, can apply to some staff as well. Wonder if the Human Rights Act prohibits hosing them down in the courtyard.

Hostages

We get a very basic level of training in ‘how not to piss someone off when they’ve taken a hostage’, from both a negotiator perspective and a hostage perspective. Role-play is often a great experience for staff, giving them as it does the opportunity to vent any frustrations they may have on the poor bugger who gets to play their hostage. All in the name of realism, of course.

Actual hostage situations are very rare, but are obviously very serious. One staff member who was involved in a pretty nasty incident 20 years ago never worked again after developing PTSD. Basically, we always, always phone the police; they have better training, and weapons, and body armour. Apparently they are going to be giving people proper hostage negotiation training soon, which is the kind of thing it sounds fun to go in for until someone barricades themselves in the quiet room with a pool cue and a terrified member of staff and it's you they call...

Hostel

Scary places where patients are discharged to in the hope that they won’t offend again. Quality varies massively, from the 'this is fantastic I want to live here forever' to the 'you can just kill me now, there's no fucking way I'm spending even a night there'. The quality of the supprt they give can make or break a patients chances of surviving on the outside. They are always, always underfunded.

Handover

This is when the nurses huddle in the office and talk about the X Factor for half an hour. Occasionally a patient may get a mention if they did something particularly exciting, although usually little short of murder and/or suicide will warrant interrupting the argument about the merits of Jedward. If you need their attention during this time, you best come armed with biscuits.

High Security

Where patients go when they are very naughty. There are three high security 'special' hospitals in England; Rampton, Broadmoor and Ashworth. We send them our most violent patients and they keep hold of them for a few decades years until they are burnt out/medicated into a less threatening state, at which point they send them back and we attempt to resocialise them into not being afraid of the outside anymore.

The hospitals themselves have security more akin to a prison. They have been subject to massive investigations over the years, with complaints ranging from the mass abuse of patients by staff, to the staff being completely under the thumb of the patients to the extent that sadistic paedophiles were being left alone with child visitors (see here for a snapshot, but the entire report makes for disturbing reading if you have the inclination). Things have allegedly improved now. Certainly, a lot of our patients that come from there seem to want to go back.

And on that cheery note, I'm off to revise antipsychotic drug classifications. Diphenylbutylpiperidine, anyone?

G is for...

Not much, actually, so this may be brief. This is probably a good thing, as I have tons of other stuff I should be doing; revision for a pharmacology exam, an assignment on a topic of my own choosing (which is sadly exciting - yes I'm easily pleased), a fanfic to finish and a dissertation topic to find. Some of them are much more appealing than others, but it makes me tired just thinking about it all. And given that I've been surrounded by people coughing and spluttering inconsiderately in my direction, I think it's safe to say that my sniffles and headache are the beginning of an impending cold. Bah.

Anyway, onwards with G. I really couldn't think up much for it, so am open to adding a few extras if people want to make suggestions.

Gardens

Our unit has a few courtyards which are mostly used for smoking, hiding contraband in and, in the case of one patient, locating insects for use as a nutritious snack. Some of the courtyards have bits of grass and some plants. One of them has been turned into an allotment, thus we grow our own veg for patient cooking sessions and to sell to staff at christmas (big bag of mixed veg for a quid, bargain*). We also have ducks, chickens and a variety of small furry creatures which get used as a kind of 'pet therapy' and way of encouraging responsibility in people. I should probably add, maintenence of the allotment is on a voluntary basis; we don't make patients work the fields anymore. Maybe when the Tories get back in, who knows.

*Money goes back into buying stuff for the allotment, despite the staff's sneaky efforts to take a cut; patients may not be out there in all weather compulsorily, but the staff pretty much are. The unit did buy us some one-size-fits-none all waterproof jackets though, so now I am expected to try and supervise the collection of eggs whilst fighting to see out from underneath my massive, massive hood.

Guilt

Is a strange thing in secure services. We spend half our time helping some patients to feel less guilty about what they did, and the other half trying to make the rest feel any guilt at all. Some patients will never feel guilty about their actions, and so are very unlikely to ever get out given that an absence of empathy for their victims is a pretty good indicator of recidivism. If they're clever, they'll learn to fake it. Those are the scary ones.


Ground Leave

What you have when you are allowed out of the building but have to stay in the hospital grounds. It's about as exciting as it sounds. There is a map stuck on the office wall with the perimeter marked and the suggested route for walking round it. It takes about 15 minutes, so you can usually do two laps in your half-hour leave, which some people do. Others just head straight to the rec hall to get a cup of scalding yet watery 'tea'; at least , when it's open, as it's staffed by volunteers so the actual opening hours are incredibly variable. If you fancy a gentle introduction to mental health services, see if your local hospital needs volunteers in the patients cafe*; you will quickly find out if you are cut out for working with mentals and will meet some very interesting people. You will also see lots of staff hanging around; usually all sitting at a table with staff from other wards, trying to hide their radios** and look unobtrusive whilst they watch to make sure their patients don't do a runner/buy any drugs/hurl their tea-flavoured water at anyone. You will also see them turn a blind eye when said patients sneak outside for a cigarette (banned on hospital grounds)....until a known 'grass' walks in and they suddenly wrestle the fag out of their hands and start pretending they'd only just noticed they were smoking. Letting your patient smoke in the grounds is a disciplinary offence. Which personally, I think is pathetic. But I'll save that rant for when I get to 'S is for smoking'.

*Patients cafe= cheaper than staff cafe. It's not a segregartion thing; if patients fancy paying extortionate prices for the same food they get served on the ward then they are welcome in the staff cafe.

**Staff escorting patients in the grounds take walkie-talkies. Each ward has a security call sign and staff have to 'radio in' periodically to let control know they are alive and unmolested. If they radio that they need help, control will gather a respose team and send them out to assist. That is, if they can find you. And if it's not raining. Or snowing. Or a bit windy.