Category: Blog

Yeah, so I have PTSD

And generalized anxiety disorder as well, just for good measure (F43. 12 and F41. 1 for those tracking ICD-10 codes). I’ve probably had PTSD for a while now just based on the most common reaction I’ve had when I tell people this, which has been some variation of “Wait… you didn’t know?”

One of the funny1 thing about how my brain works is how it managed to have virtually every symptom of PTSD but somehow rationalize each and every one of them as being not only unrelated to PTSD, but as being completely separate issues that are unrelated to each other. Haven’t been sleeping well? I never sleep well. Been really irritable? Totally understandable, I’ve been busy and under a lot of pressure. Hyper-alert and anxious? I’ve been an ICU nurse for 20 years, being alert is part of the job and I’m just having trouble turning it off. Haven’t been able to make it through a whole shift at work because of overwhelming angst? Fatigue from cancer treatment combined with baseline laziness.

There were a few incidents which really made me think there was something more going on and my increasing dysfunction at work (documented in other posts on this site) was becoming unsustainable. I talked to my therapist, I talked to my primary care provider (actually I talked to Dr. Rando, MD because my regular PCP was booked out until the end of the month) and I got a referral to a psychiatrist. I’m off work until the middle of next month and when I go back to work I will not be returning to bedside nursing. As of the third week of February I will be a nursing supervisor at Swedish.

I’ll probably talk more about this new job later. I have a month to, as my father says, get my nervous system pulled back inside my body and then we get to find out if I can keep working as a nurse in any capacity or if I really have managed to blow out all my circuits.

1 Not like “ha ha” funny, more like “what’s that smell” funny.

I can’t even

“I think it’s hard to process what’s actually happening right now,” said Janet Woodcock, acting commissioner of the Food and Drug Administration, “which is most people are going to get covid.”

Woodcock pitched this as being a necessary acknowledgment when it comes to charting the path forward — recognizing that the focus now needs to be on averting the worst that widespread infections could bring in the near term.

“What we need to do is make sure the hospitals can still function, transportation, you know, other essential services are not disrupted while this happens,” she said. “I think after that will be a good time to reassess how we’re approaching this pandemic.”

Woodcock pitched this as being a necessary acknowledgment when it comes to charting the path forward — recognizing that the focus now needs to be on averting the worst that widespread infections could bring in the near term.

The Washington Post January 11, 2022 at 3:52 p.m. EST

As the Omicron variant spreads like wildfire across the United States, it’s likely just about everybody will be exposed to the strain, but vaccinated people will still fare better, the nation’s leading infectious disease expert said Tuesday.”Omicron, with its extraordinary, unprecedented degree of efficiency of transmissibility, will ultimately find just about everybody,” Dr. Anthony Fauci told J. Stephen Morrison, senior vice president of the Center for Strategic and International Studies. “Those who have been vaccinated … and boosted would get exposed. Some, maybe a lot of them, will get infected

CNN 9:04 AM ET, Wed January 12, 2022

We appear to have surrendered to the virus.

Just as a little thought experiment, imagine if omicron kills 1% of the people it infects (actually it’s higher than that). If, as the experts now seem to think, everyone in the country is going to get infected that’s an additional 3,000,000 plus deaths in the U.S. alone and that’s just from the virus. Add in the number of deaths from delays in receiving care for other non-covid health issues and who knows what kind of numbers we can put up.

Humans have lost, the virus has won, and it was almost entirely avoidable.

Maybe we deserve it.

Fair warning

Those among the none people visiting this site who do so exclusively for all the cancer talk may be in for a bit of disappointment in the next weeks to months. Cancer is still a thing, I will still be getting treatments, and I will still be writing about them here but what is top of mind right now, as odd as it seems, is not cancer. If me droning on about mental and emotional health is not of interest, you may want to check back later.

I have a blind spot when it comes to mental health1. This has come up before but I want to highlight one manifestation of this blind spot in particular. I touched on the thought process that my brain went through regarding my ability (or inability) to work briefly in a previous post and the same pattern applies more generally as well. In order to explain the behaviors I see in myself while avoiding the conclusion that those behaviors are the result of mental health factors I may not have complete control over requires some quite startling twists of logic, and accepting, without question, the assumptions necessary to make those twists is, I think, a large part of the problem.

What the fuck am I talking about? Let me offer an example;

I’ve been irritable recently1. Things of little to no consequence have been getting under my skin to an exceedingly disproportionate degree. I like to think I’m a rational person who doesn’t let emotion influence my decision making. Let’s run through the thought process I used to make all of those things be true and a little bit of the consequences of the necessary assumptions:

  • I am a rational person
  • I am getting irritated over trivial things, which isn’t rational
  • I must be consciously choosing to get irritated because I don’t let emotion influence what I do
  • Wait, isn’t choosing to be irritated even more irrational? There must be a reason I’m doing this
  • I must be trying to manipulate people in to thinking I’m getting irritated so they’ll think the pressure and stress are getting to me and I’ll have an excuse to not work
  • Why do I need an excuse to not work? I like my job, I enjoy being a nurse, and since I’m immune to the physical and mental consequences of stress, it must just be that I’m lazy and don’t want to work
  • Wow. So I’m feigning mental illness just to get out of work? I must be a really terrible person. I really need to stop doing that
  • I’ve tried but I can’t seem to stop pretending I’m disproportionately irritable, therefore I am both lazier and more of a terrible person than I even realized.

For comparison, the process I’ve been working with more recently is as follows:

  • I haven’t been able to stop being a terrible person and drop the pretense that I have some sort of incipient mental health issue because I actually have an incipient mental health issue and all the things I’ve been “pretending” to do are actual symptoms
  • Also, it isn’t so much “incipient” as it is “fully armed and operational”

Upon reflection, what this reminds me of most is a well known headline from The Onion:

Or in my case, why can’t I stop pretending to have PTSD?

Anyway, excluding any other analysis, Occam’s Razor would lead one to suspect that the latter chain of reasoning was correct over the former, and it also has the benefit of not requiring me to be a totally shit human being in order to be true.

Which is, of course, why my brain keeps telling me it can’t possibly be true. It seems I’m just trying to let myself off the hook and rationalize my ongoing terrible behavior. After all, if I believe it’s a genuine mental health issue I won’t have to give it up, stop being a lazy-ass, and go back to work. My brain, as has been mentioned, is not terribly helpful sometimes.

If one accepts the unlikely premise that spending the last two years working in an ICU during the worst pandemic in a century may have had an impact on my mental health, comfort can be taken in the knowledge that I am far from alone. Caillet et al. (2020)2 found the incidence of anxiety and depression among ICU caregivers were 48% and 16%, respectively, and PTSD symptoms were present in 27% of respondents. That was as of September and I suspect those numbers have not improved3.

I can’t say how this is all going to play out in the larger context but brought down to the level of one individual (if that individual happens to be me) I can make what I think are some very accurate short-term predictions.

But that is a story for another day.

1 This is the equivalent of saying the Pacific Ocean gets quite deep in some bits.

2 Caillet, A., Coste, C., Sanchez, R., & Allaouchiche, B. (2020). Psychological Impact of COVID-19 on ICU Caregivers. Anaesthesia, critical care & pain medicine, 39(6), 717–722. https://doi.org/10.1016/j.accpm.2020.08.006

This in-line citation is really problematic. What kind of maniac has both in-line citations and endnotes? This is exactly the kind of societal collapse I’ve been warning about. My only excuse is that my school uses APA format (in-line citations) and virtually all the journals and whatnot I read use AMA (endnotes). That said, no excuse can justify this. I’m a monster.

3 The only reason I’m even a little uncertain about the current rates of depression, anxiety, and PTSD being worse or better is I can’t exclude the possibility that all the people predisposed to those conditions have already washed out which would make the percentages look better in spite of the overall situation being worse.

I feel like I should put this here

I stumbled across this kind of randomly while wandering around the internets and, for a couple different reasons, thought I should share it.

As mentioned previously, I’ve had the pandemic right up in my face pretty much since the beginning. I’ve watched it spread, wax, wane, wax again and, most significantly I think, I’ve dealt with essentially nothing else in my professional life. My therapist pointed out to me recently that when you’re that close to something, it tends to look very large. Sometimes disproportionately so.

I am by no means downplaying what’s going on. We’re still really not in a good place when in comes to case numbers, rate of spread, and available hospital resources. Models are predicting that the omicron surge will peak in 2-3 weeks with close to 1,000,000 new cases per day in the United States. Keep in mind, too, that the official counts are still, very likely, drastically undercounting. This graph is wastewater analysis from Boston showing the increase in viral DNA in sewage. The spike from omicron completely obliterates the spikes from all the other surges we’ve seen so far suggesting that there are likely significantly more cases than have been recognized;

All that said, we have come a long way from the beginning and there is still hope that we can survive this with something that looks more or less like modern society relatively intact.

Now we come to what brought me here today;

“Your Local Epidemiologist (YLE)” is written by Dr. Katelyn Jetelina, MPH PhD—an epidemiologist, biostatistician, professor, researcher, wife, and mom of two little girls. During the day she has a research lab and teaches graduate-level courses, but at night she writes this newsletter. Her main goal is to “translate” the ever-evolving public health science so that people will be well equipped to make evidence-based decisions, rather than decisions based in fear. 

The most recent newsletter is entitled “There is good news” and is worth a read. Things are bad but they could be worse and they will get better. Eventually.

Anyway, read it and feel some momentary relief from the doom that I’ve been spouting.

https://yourlocalepidemiologist.substack.com/p/there-is-good-news

Another day, another surge

As has been noted previously, I have been putting in some hours doing contact tracing with employee health. This has been good in that it has given something to do that I can get paid for while I’m not at peak performance. This has been bad because it is a naked, unblinking look at the waxing and waning of the pandemic.

Over the last two days I was covering the afternoons on the covid symptom line, responding to people who have left voicemails reporting exposures or to get set up for testing when they have symptoms. I started at 4pm yesterday and found that there were “more than twenty messages”, according to the unjustifiably cheerful automated voice on the voicemail box. I spent four hours responding to messages, cleared 15 or 20 of them, and when I was done there were still “more than twenty messages” and I hadn’t gotten past messages left at 10:00 that morning. I did another four hours today, cleared another 10-15 messages, still had “more than twenty messages” in the queue and didn’t get past messages left at 11:30 yesterday morning.

The good news is that all the people I talked to that were positive for covid were vaccinated nd not terribly sick. The bad news is that there were maybe two or three that said they had been exposed at work and all the rest had a story that was some variation of “I got together with my family over Christmas and my [aunt/uncle/cousin/sister/brother/whatever] tested positive [the next day/a couple days later] and now I’m feeling sick”.

STAY THE FUCK HOME!

Christmas movies

Rational people who discuss the relative quality of Christmas movies (a rather small subset of people) almost universally1 agree that the two main candidates for the greatest Christmas movie of all time are Lethal Weapon and Die Hard. I acknowledge the argument for making a distinction between Christmas Movies and movies that take place during Christmas but that is a debate for another day.

What I want to talk about today is the inclusion of a third candidate for greatest Christmas movie of all time; The Lion in Winter (1968).

Based on the play of the same name by James Goldman, and adapted by him as well, the movie tells the story of Henry II of England’s Christmas court in 1183, and the interpersonal and political dramas among Henry, Eleanor of Aquitaine, their children, and their guests.

The script runs the whole emotional spectrum over the course of the movie and is full of sharply funny and poignant dialogue. The cast is full of enough heavyweight actors that it bends light2 and even the soundtrack is extraordinarily good.

It is not a perfect film by any stretch. The directing and cinematography are not great, by modern standards at least, but it is still a towering achievement that easily deserves consideration as a Christmas classic.

—-

1 I would argue that disagreeing with the idea of those two movies being among, if not at the top of the list could almost certainly be used as evidence that would exclude someone from the “rational” category.

2One of the more enjoyable parts of the movie for me is Katharine Hepburn’s performance. She plays Eleanor of Aquitaine, who was notoriously French, but not only does she makes absolutely no attempt at a French accent, she doesn’t even make any attempt to conceal her own, quite broad, East Coast/New England accent (in her first scene she mentions that she’ll be attending a “Christmas co-aaht”). In spite of that she gives a performance so compelling that it almost pulls you into the screen.

Apparently, mental health is a real thing

There is a possibility that I’m overgeneralizing somewhat with this, and I may also be doing some post-hoc revisions of my internal dialogue. That said, what follows feels true to me and has allowed me to resolve some very perplexing things that my brain has been doing.

For some time now I have been having a harder time than usual with work. I’ve been finding it increasingly difficult to go to work in the first place and once I’m there I have a really hard time staying. This is not an entirely new phenomenon, and is also not unique to me. Who looks forward to going to work and who is happy to be there once they arrive? Almost no one, that’s who. That said, this has felt very different than the usual vague malaise of dissatisfaction that comes from having to put down Animal Crossing and leave the house.

“Well of course you’re having problems,” you might say, “you’ve been in cancer treatment and dealing with fatigue from that. No one expects you to be at the top of your form!”

This is true. I have a very real physical medical condition and I have unquestionably been experiencing some physical side effects from my treatment. However, at this point there really isn’t any reason that these side effects should be as limiting as they appear to be and, if I’m completely honest, they probably aren’t as limiting as I have been allowing them to be.

As I have discussed here previously, my brain constantly tells me that I am malingering or exploiting the system somehow because, in terms of physical health, I likely could be working without any restrictions right now. The slow realization that there might not be an actual physical problem sapping my willpower and energy has kicked the “you’re just a lazy bastard” message from my brain into overdrive in the last few weeks

Again, though, I genuinely have been feeling like I’m incapable of working, and the worst scolding from my brain hasn’t made it any easier to keep pushing and just do the work, so WTF?

At this juncture it is important for the narrative that I mention my longstanding prejudice when it comes to mental health. My poor opinion results from long years of dealing with the healthcare consuming public, which certainly has no shortage of people with genuine, serious issues, but also no shortage of people just trying to game the system. The way my mind works, it comes down to Sick or Not-Sick. You can’t objectively measure depression, anxiety, and trauma so they probably aren’t real. Intellectually I know this is nonsense and when it comes to patients I try hard to stay aware of this bias and to not let it affect the care I provide.

When it comes to myself, though, it is something of a blind spot. Deep down, I don’t completely accept the notion that my mental health is a real thing that can actually affect how I approach the world. Again, intellectually I know this is nonsense but that seems to be how my brain wants to see things.

Keeping all that in mind, my thought process has been something like the following;

Stage 1

  • The only valid reasons for me being unable to work are physical ones.
  • I’ve been feeling very limited in my ability to work.
  • Therefore, something must be physically wrong with me.

 Stage 2

  • The only valid reasons for me being unable to work are physical ones.
  • I don’t physically feel all that bad, really.
  • I still appear to be limited in my ability to work.
  • Therefore, I must be faking it. 

Stage 3

  • The only valid reasons for me being unable to work are physical ones.
  • I still don’t physically feel all that bad, really
  • I still appear to be limited in my ability to work.
  • This doesn’t feel at all like I’m faking it.
  • ???

The explanation, of course, is that my first assumption is faulty. I really am limited in my ability to work but at this point it’s for mostly psychological and emotional reasons, not physical. 

In February of 2020, an emergency room doctor at Evergreen Medical Center in Kirkland was infected with Covid. His condition deteriorated quickly and he was transferred out of the ICU at Evergreen to Swedish Cherry Hill so he could be put on ECMO. He was the first Covid patient on the west coast, probably in the whole United States, to be put on ECMO. That was my unit and I was one of the lead ECMO specialists.

I lost count of how many more Covid patients we put on before I left Cherry Hill. They all were insanely sick1, insanely complex to care for and most of them died, as did most of the Covid patients we had that weren’t on ECMO.

This went on non-stop.

For months.

And it still hasn’t exactly stopped yet.

There was a lot of non-Covid unrest at Swedish at the time as well, of course, so I had plenty of reason to be discontent before I left. Given that mental health isn’t real, I attributed my angst to the external situation and didn’t think about it past that.

Since then I have changed jobs two more times for a total of three job changes in the last 18 months or so. Each of the jobs ended up feeling unsatisfactory for one reason or another and, like I had at Swedish, I felt compelled to leave. True, the working conditions weren’t (and aren’t) ideal but I’m also starting to think that there is an underlying current of mental disfunction that is making it nearly impossible to get comfortable and settle in.

The point is that it has been a difficult couple of years and perhaps there could be some lingering trauma that I’ll probably need to deal with at some point.

For all my airs of professionally detached objectivity, I may be merely human after all.

Looking after my mental health has never been one of my strong suits but entertaining the idea that I could be mentally fatigued enough to impact my job performance has been something of an eye-opener. It explains a great deal of what I’ve been experiencing and it has already helped me to get the asshole part of my brain to shut up every now and then. Beyond that, I’m not sure if this shift in thinking will make any difference or not.

This post was very long and has an unsatisfying conclusion. It also may not matter because, hopefully, I will be changing jobs again in the near future.

But that is a story for another day.

————

1 I’ve talked about this before too, although I can’t remember if it was here. I don’t think it’s possible to convey the actual reality of how sick these patients were/are to normal (non-medical) people. Even most medical people, I think, fail to grasp how sick they are. The best analogy I’ve come up with is that caring for these patients is like trying to keep someone who is on fire alive but you have to do it without being able to extinguish them. I love doing that kind of work but it is exhausting under the best of circumstances.