Those Nortriptyline Blehs

Nortriptyline, according to Wikipedia,

is a second-generation tricyclic antidepressant (TCA) marketed as the hydrochloride salt under the trade names Sensoval, Aventyl,Pamelor, Norpress, Allegron, Noritren and Nortrilen. It is used in the treatment of major depression and childhood nocturnal enuresis (bedwetting). In addition, it is sometimes used for chronic illnesses such as chronic fatigue syndrome, chronic pain and migraine, and labile affect in some neurological conditions.

A few weeks ago I had a fall (when it comes to falling down, I’m a Viking) which exacerbated an old injury from another fall — bottom line, was in a considerable amount of pain, and what was worse I couldn’t sleep becuase of the pain. So after about a week of sleeplessness and overdosing on AC & C, I finally gave up and went to  my GP. She prescribed some wicked bad-ass anti-inflammatories, and she also suggested I try nortriptyline. Besides being a rather dated anti-depressant, nortriptyline has some pretty nifty pain-control properties as well as the ability of  inducing sweet, restful sleep.

And, I must report, it worked amazingly well for the last couple of weeks. I’ve been sleeping like the dead, the pain is far, far better now, and I can function normally — sort of. Aside from a dry mouth, I’ve had no physical side effects at all.

Take two of these, and your ability to snark will vanish

But there’s this: nortriptyline, as I mentioned, is an antidepressant and mood stabilizer, and I guess I would describe my mood over the last week or so as tranquil, sedate, calm, unstressed, cool, placid, and serene to the point of having to check my pulse for a heart rate. Part of this new found attitude of repose is being completely demotivated to do anything creative at all, including any writing. For the last two weeks I have opened up the blog utility, fooled around a little, and after a half-hour, said, “Meh,” and went back to playing Words with Friends.

It’s plainly obvious, at least for me, having some emotional friction and turbulence feeds the creative daemon. It prods me to write, and I would guess this is true for most people who think of themselves as creative. So an interesting question: at what point would you sacrifice creativity for pain control — or relief of any condition, especially if it’s central to who you are as a human being? And on a larger scale, if everyone is medicated (it seems) for everything, what is it doing to culture as a whole?

Fortunately for me, I’ve finished the nortriptyline. It was a temporary thing. We now, as they say, return to our regularly scheduled moodiness. But here’s the thing: when I was on the drug, not only was I completely uninterested in writing, I didn’t care whether I was writing or not. The fact I could throw over something which I’ve done daily (in one way or another, even if I have written a couple of lines) for nearly three years is remarkable.

Charge Mommy

A few days ago, one of my colleagues said to me after a particularly frantic day in the ED, “You guys aren’t Charge Nurses, you’re Charge Mommies.” She is right. This is what we do:

• tell all the kids don’t fight and play nice

• fix boo-boos

• give hugs as needed, or tissue

• make sure all the kids get lunch

• find things

• repair broken toys

• clean up little “accidents”

• greet guests, and ensure they’re fed and comfortable

• make sure everyone keeps the place tidy

• assign chores

• deal with the unpleasant relatives upstairs

The one thing I don’t do is enforce discipline. No spankings or time outs. I have a Manager Mommy for that.

Treat the Patient Not the Disease

Abscesses and wounds, and especially abscesses and wounds which are infected, suppurative, purulent, and generally awful, are embarrassing for patients and difficult for nurses. Embarrassing for patients because they are disfiguring and smell badly, and difficult for nurses for really the same reasons. Personally I don’t mind caring for and treating wounds and abscesses, but I know plenty of nurses who would rather throw live kittens on a hot barbecue than go anywhere near a draining carbuncle.

Jennifer Olin over at RNCentral has an excellent blog post on caring for wounds. The first part of her post deals a little with the pathophysiology of wounds, the second on the providing good care to patients with wounds. Olin writes:

Well, we are likely the healthcare providers who will first notice the problem. It will be during a dressing change, or just when you enter the patient’s room—you know. The scientific side of nursing will to clean the wound, inspect it, chart it, and if it is bad enough, inform the wound care team or physician. But remember, I said you are likely the first healthcare provider to notice. Trust me, the patient already knows.

This is where the nurturing side, the compassionate side of nursing is brought into play. And, it’s not for the weak of stomach or, particularly, the weak of heart. Bad smells carry a social stigma along with the health hazards inherent in the wound itself. Wet, sticky, bandages are a sign for all to see that there is a problem. People with wounds in this state often suffer inhibited work, social, and sex lives and frequently have feelings of shame and depression.

[SNIP]

You learn little tricks to help you not react (breath through your mouth, use a minty lip balm).  Keeping the patient engaged is the key. Many of them won’t look at their wounds, won’t acknowledge there is a problem, or want to discuss it. You can teach them how to clean and dress their wounds, give them pamphlets and supplies, and help them plan future appointments but it is the emotional part of nursing that will often make the biggest impact on their healing and wellness.

Something we (remember?) were all taught in nursing school was the holistic care of the patient, that is, caring not only for the physical complaint of the patient, but also for the emotional, spiritual, social and even economic needs of the patient. Good wound care exemplifies nursing care in a microcosm. So when nurses see a patient with a decubitus ulcer, what do they see, the wound or the patient? Our inclination, of course, is to see the wound, somehow detached from the person bearing it, a way of thinking exacerbated by seeing nursing as a series of tasks to be completed rather than a holistic process involving critical thinking. Olin’s article, in this context, is a good reminder that in the end, we should be treating the patient, not the disease.

A Note about Alan Sullivan

Nearly two years ago, the poet and blogger Alan Sullivan died. His final project, a new translation of the Book of Psalms, has been published. The translation can be ordered here. His collaborator and advisor on this translation, Seree Zohar, was kind enough to send me a note to tell me this, and to gently correct my impression — as I wrote in my post about his death — that the work remained unfinished. Sullivan, in fact, completed the translation in the very last days of his life, and I am glad to make that correction.

More on Alan Sullivan as poet is found in this brilliant tribute here.

How Nurses Practice

Working on a PowerPoint presentation, and did up this (yet to be formatted) slide:

Which column do you think represents the current state of nursing practice?

 

We Get No Respect

From Ian Miller at ImpactedNurse.com, a few thoughts on under-utilized and under-recognized senior nurses who are leaking out of the profession:

Nursing has few opportunities for promotion and recognition of senior expertise within the clinical setting. How often have you watched senior (and I’m talking about years of experience here) nurses move on to non-clinical management positions, or drift off into non-nursing jobs where their specialised skills are snapped up, or just stagnate on the floor (feeling little respect from the system) with nowhere to go and little exploration of the stuff they might teach.

What we are sadly lacking is a health system that gives the nursing ‘elders’ opportunity, support and recognition to pass on their profession, their experiences, their corporate knowledge and their craft to the next generations. This huge collective of nursing elders have so much to offer both the healthcare policy planning process in general and the future of nursing in particular.

As many of them are now approaching retirement the opportunity to pass on the craft will be lost forever. Skills that could be used to improve quality healthcare delivery, departmental operations and mentor-ship of other nurses. Believe me, those skills are out there in many of these people. They should be consulted not insulted.

Such a waste.

This seems to me about exactly right, and very nicely describes the  position — and present frustration —  of many nurses, including myself. The career path for the vast majority of nurses is pretty flat. The conventional nursing career path looks like this:

Graduation

35 years service on ward(s)

Retirement

Death

I am not exaggerating — not much anyway. Any movement, to be sure,  is usually in a lateral motion, e.g. from ED to ICU to PACU etc., but always as front line staff. Moving upwards almost always means a move away from your specialty. And that’s a waste too.

And there’s also this elephant in the room: would we be talking about things like wasted skills and staff retention if front line nurses were truly respected, and recognized as being the centre of what we do as a profession? Or to put it another way, if front line, bedside nursing was considered valuable in itself, would so many nurses be itching to get out?

Protect Your Love

Via Osocio, a very likeable ad for HIV prevention and awareness from the Toronto-based Alliance for South Asian AIDS Prevention. Osocio notes the ad is less about sex than and more about love, and in this way, I think, it manages to get its message across effectively, without being preachy or didactic.

(Incidentally, the short scene filmed in the Scarborough RT is very funny.)

Favourite Poems LVII: Death

The first two lines — “Because I could not stop for Death,/He kindly stopped for me” — must be among the greatest opening lines of any poem.

Death

Because I could not stop for Death,
He kindly stopped for me;
The carriage held but just ourselves
And Immortality.

We slowly drove, he knew no haste,
And I had put away
My labor, and my leisure too,
For his civility.

We passed the school, where children strove
At recess, in the ring;
We passed the fields of gazing grain,
We passed the setting sun.

Or rather, he passed us;
The dews grew quivering and chill,
For only gossamer my gown,
My tippet only tulle.

We paused before a house that seemed
A swelling of the ground;
The roof was scarcely visible,
The cornice but a mound.

Since then ’tis centuries, and yet each
Feels shorter than the day
I first surmised the horses’ heads
Were toward eternity.

— Emily Dickenson

When the Police Come Calling

The police are more-or-less a permanent fixture in every Emergency department. They bring in the drunks, the suicidal, the psychotic, the homeless and yes, the criminal, who have either sustained injuries as a result of their activities, or else have developed sudden (and convenient) cardiac symptoms upon their arrest. Most of us in Acme Regional’s ED will cooperate with the police to the point of expediting whatever they need us to do, which usually means filling out the Form 1 or medically clearing the patient. At the same time, most of are pretty clear that ED nurses and physicians are not an extension of the Police Service: police objectives and those of health care, to state the obvious,  are not the same.

It isn’t exactly mistrust. It’s more a wariness. There are ethical and legal issues involved. We cannot, for example, divulge patient information, so there is the constant dance of the police asking for information they know we won’t give them.  Come back with a subpoena, we tell them. They try anyway.

Then there is this: what do when the police bring in someone who, well, they’ve been beating on. It isn’t common, I should emphasize, but it isn’t so rare that it excites comment either. The police will say (nudge, nudge) the patient fell on the pavement while being arrested. Or banged his head while getting into the cruiser. Or the wall hit his face. Which may even be partly true. The patient usually says nothing at all.

So what do we do about it? Approximately nothing. We might document the injuries, in case there are  legal problems down the road. Or not. We are definitely not going to make any allegations about misuse of force. Who wants to travel that road, full of traps and pitfalls and paper by the mile plus, of course, the undying enmity of the local cops? I have seen a few pretty egregious cases, and we did exactly that — nothing. As well, I suppose many of us don’t want to second guess the police: I mean, who knows how things really go down, right? And we say, didn’t he deserve it anyway?

But how does this make anyone accountable? Including ourselves? And don’t we have a legal system in place to adjudicate innocence and guilt, and administer punishment?

It’s a moral swamp. And having thought about it long and hard, I’m not clear what, if anything, that can be done about it in practical terms. ED staff are not the guardians of the guardians. So we document. Poor excuse, I know.

Friday Night Flicks: Pigeon Impossible

No pigeons were harmed in the making of this short film.