Manic Often?

I got a chance to deal with my first "real" psych inmate today. Sure, lots (maybe most) of the folks in jail have psych issues - diagnosed or not - but this was my first opportunity to do intake on a person who was completely in the grip of an unmedicated manic episode.

**I have to thank Crazy Tracy for writing such moving stories of her life and often manic times. Her thoughts and feelings led me to a deeper understanding of mania than any textbook ever could, and added texture to my own experience and attitude when I interacted with this inmate. I admire Tracy and thank her for her ability to share such a personal part of her with the rest of us.**

It really isn't much of a story. I took him back to the exam space and asked him about some of the things he had mentioned to the officers. You have to understand this is the EXTREMELY ABBREVIATED version. I just don't have enough time in the day to type as fast as he was talking. BTW, we chart in SOAP (different than hospital charting!) and this was the S part.

He said he never did drugs - his booking sheet said he told them he did "ALL" drugs.

He told me he had no history of SI/SA - he told them he had.

He told me he didn't have ADHD - he told them he did.

"Alright! So tell me is there anything I need to know about while you're here? Anything medical?"
"I got shot in the leg while these gangsters were invading my house and looking..."
"Do you have a scar you can show me?"
"Oh, yeah!" (rolling up pants leg)"The gangsters broke in and stole all of my stuff..."
[Hx GSW to RLL...]
"Yes, I see the scars. So how does this affect you?"
"It doesn't - I'm fine"
"No problems moving or anything?"
"Nope. It's perfect"
[Hx GSW to RLL "but fine now"] (sigh)

He told me he DID have a closed head injury (noted + on the booking questions)- flying 36 feet through the air during an MVA and hitting his head on a rock. I'm scribbling furiously: [Hx closed head injury r/t MVA ejection...]
"But that's all better now"
"What did the doctors at the hospital tell you about the injury?"
"No, I never went to the hospital. Just a concussion, but I'm fine"
[I/M Hx closed head injury r/t MVA ejection "but fine now"]
(ok, good save)

"I'm really looking for anything medical that's affecting you right now. I need to know so we can help you. So basically, you sound like besides the psych issues we've discussed you're medically ok?"

"I have a weak heart"
"A heart problem - that's important. What sort of weak heart do you have?"
"I don't know. I just have a weak heart."
"Are you taking any medication for it?
"My mother did."
"Your mother had a weak heart also?"
"My mother has the weak heart."
"Do you have a weak heart also, or is it just your mother?"
"It's just my mother."
"So you think you might have a weak heart because your mother had one - but has anyone ever told you that you have a weak heart also?
"No."

I sort of decided shortly after that that any further questioning would be useless unless we could get him back on his meds. Some of what he said was delusional and other parts were what I think is referred to as "flight of ideas", although I could follow and re-direct if need be. His vital signs were stable and he was in no apparent distress, so he had to go to psych eval. Luckily, I verified the meds easily and he's going to get his first dose tonight.

Like I said, that really is a lot less than what actually went on, but I had to stop and interrupt him so many times. The stories he was telling just went on and on. It was scary and fascinating at the same time, because I kept thinking about Tracy. I thought "So this is what it really looks like".

I have to thank God I don't know what it feels like.


Click the image to go to the wonderful Brain Atlas!

What's Your Issue?

The topic of knowing what a prisoner is in for was brought up in comments, and I thought I'd make a post on that.

In some ways I'm concerned that knowing what a person is in for might cloud my judgement when interviewing them about health concerns. Would you believe someone in on drug charges is drug seeking? Would you treat a rapist differently? I think it's better that I don't know, so I have an opportunity to treat everyone equally.

There are opportunities to find out anyway - when you're in booking, the charges against them are usually discussed at the desk right outside the exam room so you can't help but hear. You also might find out that someone is a "commercial sex worker" (don't ya love that - PC at it's finest!) when they're discussing what STDs they've been treated for in the past and which ones they think they have now. We can offer free STD testing and HIV/AIDS testing.

I want to do my best in giving care. I would like to think that some of these people can be helped, and can come out of jail in better condition than when they came in (yes, maybe I'm idealistic and living in a fantasy world...). This might give them an opportunity to change their life. True, some of them should be locked up and never let out, but that decision isn't mine to make at work - only at the polls.

On one of my first days shadowing another nurse we interviewed a young woman who was very pretty, polite, and well-spoken. She didn't fit in with the other inmates and we did end up looking her up to find she was in for burglary with a weapon. There's just nothing we can do with the information. We're not there to counsel or preach - there are plenty of people for that. I hope she straightens out before she becomes one of the repeat customers.

The title of this post is from a page of prison slang terms I was reading: What's your issue = What are you charged with. I never hear it, but I don't know if they talk amongst themselves like that. It may happen more often in prison than in jail.

More Triage

I walk over to the place where incoming prisoners are held before they're sent to whatever unit they're placed in. They wait there after giving up their outside clothes, being searched, and putting on jail scrubs and sandals. They can get called up by a social worker, fingerprinting and photos, the booking officers, or nurses.

I call the guy's name. We've got to see everyone who comes in who says they have a medical or psych issue, just to do a quick assessment and make sure they let us know if there are any meds they have to get while in jail. Sometimes it's really easy and they say they've had a BTK amputation or something and we'll just make sure they get a bottom bunk. Other times it's not so easy and we've got to make sure they can continue with whatever treatments they got on the outside i.e. dialysis, breathing treatments, wound care. Sometimes they've never had any medical help for something (like an abscess or wound) and this will be the first time someone has looked at it.

This guy starts following me back to my little exam room. It's pretty well stocked, and has quite a bit of equipment in it. Crash cart and everything. (is this story getting long??)

Anyway, he walks soooooo slowwwwwly and he's sort of hunched over and he's using a cane to help him walk.

Step.
Step.
Step.
Step.

He's not even that old, but he's certainly looking like a train wreck. All the slip said was "back pain" so I'm not really sure what I'm getting into - and how much of it is an act (you have NO IDEA unless you actually work in there what sort of things inmates will do for NO APPARENT REASON OR BENEFIT TO THEMSELVES). I think anyone who has worked in a jail or prison system can back me up on that. I'm still in shell-shock at how often I get straight-up LIED to! It's like a hobby to them or something. There's no reason I can think of for some of the crap they pull. I'm still learning.

He comes into the exam room. I'm already seated at the desk. He slowly lowers himself down into the chair I've motioned for him to sit in.

Once he's settled he just looks at me in a goofy way and sort of shrugs his shoulders.

Me: "Didn't take much to capture you, did it?"

He and I both bust out laughing.



My charge nurse says I'll do fine.

Winner for December!

Becoming a Nurse wins NurseBlog of the Month for December. She gets a fancy graphic trophy, top mention on the NurseBlog links, some good-smellin' Bath and Body Works antibacterial gel, and of course, the love and admiration of her peers!

Go check out her ultra-cool video posts, listen to stories of nursing school, and (as always) comment bunches.

Triage Exchange

"What are you taking Celexa for?"

"uh. I dunno."

"So how's it working for ya?"

Nursing Duties

I'm getting more comfortable at the LCJ and things are starting to come together. There are many differences between hospital nursing and correctional nursing, but one thing that really stands out is that we rotate (daily, not hourly!) through four different types of jobs.

The RNs in the booking help triage or flag patients who are coming in with problems. This is a full-time job and can get quite busy. Because we're a large jail "chains" of inmates often stop over while being transported between facilities, most forming new chains going in new directions - always splitting and reforming. It's like a freeway interchange, and the nurse up there needs to make sure that anyone who might be spending the night with us has their health needs addressed. It gets really busy sometimes, and I know today they sent two more RNs up there to help the one that was there already.

Another place you'll find RNs is in the infirmary. LPNs help with drawing blood, administering meds, taking vitals, and a lot of other stuff. I have only spent one shift in there, but it can get really busy too. There are no CNAs, but there is a medical records person. The RNs and LPNs work very well together, and it seems to run smoothly as busy as it is. Besides the inmates who are sick and need to see a provider (usually an NP, sometimes an MD, Dentist, or Mental Health provider), there are basic health assesments that must be done on every inmate after they've been there 2 weeks. That's a lot of people to see!

RN's go on rounds to each unit and triage the inmates there. Inmates can see a nurse by putting in a request. Obviously, if someone is very sick or injured they can get immediate attention any time of the day. Triage rounds take up the whole shift for the nurses who are assigned to them. If you see someone who needs to go into the clinic, you refer them and they'll go according to a priority. A dislocated shoulder would get higher priority than bacterial vaginosis - pretty basic stuff.

The fourth job is med pass. Most of the time this is done by an LPN, but RNs can do it if there aren't enough LPNs. This is pretty much an all-day gig too.

OK! Well, that's enough of a post for now. I don't want to bore you to death, just give you a basic idea of what I'll be doing. I had fun today - the RN I shadowed was great to work with.

More Voting For You

I just found out that I am in the running for Best Medical Weblog over at MedGadget! Although I SERIOUSLY DOUBT that I am anywhere near the best medical weblog... it would be nice to at least make a showing. I see that 3 people voted for me already - Woo Hoo! Thanks people! That makes me feel good. :)

If you'd like to give me a vote, click here. There are a few other nursing blogs nominated in best new blog including The Nurse Practitioner's Place, and Emergiblog. Vote for them, too, and show those med folks that nurses can blog with the best of them! I'm going to go back and see if I find any more NurseBlogs in the mix.

I looked for a picture that said "Vote", but I found this. It is slightly dated but (no offense, Floridians) it IS pretty funny:

December Vote

Sorry, I'm running a bit behind here. I've been getting up somewhat earlier than I did when I worked at the hospital, and MUCH earlier than I did for the month and a half that I just lounged around the house unemployed!!! :P

That said, I'm proud to present to you the nominations for December's NurseBlog of the Month:

Becoming a Nurse, who has some really cool video posts on her blog that I have yet to be able to figure out how to accomplish. Geek Nurse, who gives us pictures of the inside of a NZ PICU. The Nurse Practitioner's Place, who stirred up quite a hornet's nest regarding the qualifications and ability of NPs when she commented on a stuffed animal (I'll leave you in some suspense there, because the whole thing was so wild you've got to see it to believe it....). Head Nurse, who took an in-depth look at sexual harrassment and nursing. Haiku of the Id posted this picture I thought was really funny of some very un-politically-correct Christmas decorations - look at your own risk unless you don't mind blood (Wait a sec.. who am I kidding? Go ahead and look!). Third Degree Nurse's husband wrote a super guest-post on her blog about what it's like to be the SONS (Significant Other of a Nursing Student) - well worth a read. Death Maiden wrote a poem and said "I don't want to go to the morgue today". Livin' Large finally met her Dutch Boy!

Now, of course, these aren't the only posts they've made. I just picked ones that I particularly liked. So read up on what they have to say then come back here and vote. You can vote only once, but at that time you can vote for more than one blog - it will even itself out. Since I'm posting this sort of late on the 4th, lets close voting sometime in the evening of the 9th.

Who is December's NurseBlogger of the Month?
	Becoming a Nurse
	Geek Nurse
	Nurse Practitioners Save Lives
	Livin' Large
	Head Nurse
	Haiku of the Id
	Third Degree Nurse
	Death Maiden
Free polls from Pollhost.com

Big Dog Nurse

I found this t-shirt at the mall yesterday!



Click on the picture and select 'graphic tees' if you'd like one for yourself. They're cheaper at the Big Dogs retail store than they are online. I like the idea of "Get 'er Done!" better than all the dorky angel stuff they make for nurses.