*Frustrated keyboard-pounding noises*

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A couple of things I don’t think I’ve mentioned here have cropped up again today. Among the reasons I took the job I currently have was the medical benefits kicked in on my hire date. None of this “the first of the month after your first full month of employment” nonsense, sign to accept the job; get benefits. At least that’s what I was told and, to be fair, that was probably the intention of my employer. Unfortunately it didn’t exactly work out that way.

I’ll spare the reader the blow-by-blow details of what happened but the short version is, for reasons that no one can adequately explain, Shannon did not get added to my medical and dental coverage. It took three weeks of fighting with the benefits people and me turning in my resignation for it to get fixed. I did withdraw my resignation after being promised the insurance would be fixed (by sheer coincidence this promise came almost immediately after me submitting my resignation). Anyway, as of yesterday it was supposed to be all fixed.

Imagine my surprise, then, when we got a message from our pharmacy saying there was a problem with the insurance, which is exactly what they said when we found out about the problem in the first place. Fortunately it turned out to be a relatively common and easily corrected SNAFU with the pharmacy’s records but the situation still put me very much on edge again, which is what I really came to talk about.

I have previously talked a fair amount of shit about trigger warnings. It isn’t that I object to their use, nor do I have any doubt that trauma-related disorders can result in certain otherwise normal everyday events and topics to be distressing for people. What I object to is the use they have commonly been put to in discussion forums and the like, which is to put responsibility for one person’s mental health on to someone else – “OMG I am so triggered right now! How dare you not put trigger warnings on your completely ordinary and generally uncontroversial content? Now my triggers have been triggered and its your fault for triggering me because you didn’t use trigger warnings which has resulted in me being very triggered by the triggers you failed to warn me about“.

So this is the difficulty I’m running into. It is hard to talk about the things that escalate my stress and anxiety, “triggers” if you will, without sounding like a complete choad. This gets right back to my baseline difficulty with mental health in general; the overwhelming majority of my professional experience with mental health has been with people ostentatiously using a, usually self-diagnosed, mental health condition as an excuse to behave like a raging asshole. This is a particularly sensitive topic for me right now because my own mental health condition has resulted in me behaving kind of like a raging asshole over the past few weeks.

I don’t know what the solution to this is. My worst fear… among my worst fears is becoming one of those people who may as well have their diagnosis tattooed on their forehead and who use it as a central piece of their personality and all their social interactions. Meeting someone for the first time? Better make sure you work the fact that you’re neurodivergent into the conversation in the first few sentences, no matter how tangential it may be to the topic at hand, to make sure everyone knows you’re different and interesting. On the other hand, if simple things are going to elevate my stress and anxiety it might be a good idea to let people know.

It’s a conundrum.

My very own To Err is Human

In 2000 the Institute of Medicine published To Err is Human: Building a Safer Health System, a landmark work that shone the light, really for the first time, on the incidence and severity of medical errors. Why do I mention this? Because I’m pretty sure I had one.

As seen in the previous post, for the last few weeks I’ve still been having panic attacks and was quite symptomatic with depression and anxiety which prompted Dr. Primary Care to start me on sertraline. While I was seeing Dr. Primary Care I also got a refill on my bupropion since I was nearly out. I started the newly refilled prescription yesterday and noticed something kind of odd.

I want to take a moment here to mention I am aware of the difficulties and pitfalls of identifying pills by sight. Pills from different manufacturers will look different even if they are the same drug and the same dose. That said, I’ve seen quite a few pills in my day and I can generally spot things that are different because of manufacturer and things that are genuinely off.

So I started my newly refilled prescription and noticed that the new pills were markedly larger than the ones I had previously been taking, in spite of appearing to be from the same manufacturer. By chance I have access to examples of 150 mg XL tablets in addition to the 300 mg XL tablets that I am supposed to be taking and I am as certain as I can be without any physical evidence that the pharmacy filled my last prescription for 300 mg XL with 150 mg XL.

Two additional pieces of evidence that could add weight to the theory; once I started taking my new 300 mg XL tablets I immediately started feeling better. My mind has not been this calm in weeks and my overall mood has improved a great deal. Also when I started taking my new 300 mg XL tablets, I was struck with a serious case of insomnia which is a common side effect of bupropion. It hasn’t really been a problem for me1 except for a couple of days after a dose increase.

There are potentially confounding factors to consider however. As mentioned above, I don’t have any physical evidence. All I have is an empty bottle that says 300 mg XL, and a comparison of my mental image of the pills I was taking to known samples of 150mg and 300mg tablets that appear to be, but can’t be said for certain to have, come from the same manufacturer. There is also the addition of sertraline to my regimen. I’ve been on it for a week and, while usually SSRIs take a bit longer to really take full effect, the possibility that I’m just feeling the benefit of the sertraline cannot be ruled out. Finally, the insomnia could very easily have resulted from me working my first full week on night shift after being on a “sleep when you want, wake up when you want” schedule for a couple months.

Pretty sure but not certain.

The thought of the difficulties I’ve been having with my mood over the past few weeks being the result of a medication error is actually reassuring to me. I was feeling distraught because I thought I’d been making all this progress in therapy and introspection and self-analysis and all, but here I was feeling like shit most of the time again. Additionally, if this was a medication error, any doubt about the benefit of being on medication that I may have had is gone. Being on a half-dose was all kinds of no fun so I don’t even want to think what being off it entirely would be like at this point.

1 I know, I know. But there is my baseline insomnia and then extra insomnia gets piled on top of it. Insomniaception. A couple of days after my last increase in dosage I was back to my baseline insomnia.

Back on the SSRI

Those sertraline girls really knock me out1

As previously mentioned, I had a cast on my dominant hand for the last few weeks. This condition didn’t make typing or writing impossible but it did make both activities more frustrating than was tolerable for anything less than absolute necessity. Astute readers will doubtless have reached the conclusion that, since this post was typed out by me, and nothing I do here is even in the same neighborhood as anything even remotely necessary, I must be out of the cast now. This is, in fact, the case. Dr. Ortho-Hand was satisfied enough with how the fracture had healed that he didn’t even feel the need to put my in a removable splint. I have an entirely bare naked hand and, in spite of my wrist feeling like it tried to fuse solid and is now only grudgingly moving again, I could not be happier with the situation.

On the topic of not being happier2, astute readers may also have reached the conclusion that, based on the title of this post, my prescribing provider and I have been messing around with the medications again. My PHQ-9 and GAD-7 scores3 have been getting uncomfortably high again and I have still been having panic attacks multiple times per week4. Fortunately my health insurance situation has stabilized and I was able to go back to the primary care provider I had been seeing for several years prior to starting my whirlwind tour of employers. Given the degree to which I have been symptomatic, Dr. Primary Care felt that adding a serotonergic antidepressant would be beneficial. I have been on sertraline twice previously and we’re at 50/50 in terms of it being effective. I did, however, tolerate it well as far as side effects go so that’s where Dr. Primary Care felt we should start5.

One of the complaints I have with antidepressants is they can take a ridiculously long time to really take effect, weeks in some cases, so it may be difficult to tell if any improvement is from the medication or from me just settling back into a work/school routine with a lower baseline stress level.

On the topic of work6, I have started my new, non-patient care job and I feel like it will be okay once my nervous system adjust to the idea of me going to work in a hospital but NOT going to work in an ICU filled with people dying from a pandemic respiratory virus. I’ll talk more about work later (probably) but for now I’m going to go eat some tylenol and rest my wrist.

1 Apologies to Lennon/McCartney

2 How’s that for a transition!

3 Patient Health Questionnaire and Generalized Anxiety Disorder scales for assessing depression and anxiety symptoms. These are a desperate attempt to put an objective measure on the extremely subjective experience of emotional distress. They’ve been validated in peer-reviewed studies and people more knowledgeable on the topic than myself rely on them, so ¯\_(ツ)_/¯

4 I don’t want to leave people with the impression that I’m getting worse. I still think I’m improving in general but “better” is not the same as “well” unfortunately.

5 For those keeping score at home, this brings the total number of prescription psych meds I’m taking to three.

6 I am just killing it with these transitions!

What progress feels like

I spent most of the time between Tuesday morning and Thursday night last week having what felt like one, very long panic attack. Of course I didn’t recognize it as a panic attack until it was over. I seem to have two flavors of panic attack but neither of them have the precise textbook presentation I learned in school; a feeling of impending doom or a fear of death, frequently physical symptom similar to a heart attack, etc. What I seem to get are a sense that everything in the world in general and my life in particular is broken and nothing will ever be able to fix it, or a sense that everyone in my life either hates me or is angry with me about something. The one under discussion was the former and I spammed several friends, family members, and my therapist with texts and emails about how it wasn’t fair how badly my life sucked and now we’re going to have World War III thanks to Putin.

The thing is, at the time I did not feel irrational and, in my defense, it really has been a few pretty rough years and the nature of my reaction wasn’t completely unjustified. The problem started when my (perfectly justified) dissatisfaction with the state of the world turned into an out of control semi barreling downhill with no breaks. On some level I knew something was wrong. I knew I didn’t feel like myself, I couldn’t think clearly. It felt like my brain just wasn’t working right.

At this point I would like to pause for a moment and talk about brain anatomy. In broad terms, the human brain can be divided into three sections, the brainstem, the limbic system, and the cortex.

what a brain might look like

Generally, the brainstem tells you that you’re hungry and need food, the limbic systems tells you to go find food, and the cortex decides whether you want Thai or Mexican. Or, more importantly, tells you that you can’t go look for food right now because other things are more important.

That inhibitory function of the cortex is the key. The brainstem starts shouting about how there’s a big problem here (whatever it might be, probably a saber-tooth tiger), the limbic system agrees that this is a big problem (whatever it is and we certainly can’t rule out the tiger theory) and we’d better do something about it right fucking now. It is at this point where the cortex is supposed to step in and remind everyone that saber-tooth tigers have been extinct for a really long time now and all that happened was some jerk cut us off in traffic.

Problems start because under enough stress, either intensity or duration, the limbic system kind of stops talking to the cortex. It decides that the big problem (whatever it is) is important enough that we have to deal with it and we don’t have time for the guys at headquarters to get back to us. This effectively removes the filter between thought and action which frequently results in people doing stupid things like spamming their friends with apocalyptic text messages.

Or punching a wall.

What I’m learning is it’s impossible to think yourself out of a panic attack because the thinking part of your brain is quite literally not at the controls anymore. Of course the goal would be to not have panic attacks in the first place which is why I’m also trying very hard to learn the warning signs so I can do something to change the situation before the lunatics take over the asylum as it were. Unfortunately I am really bad at recognizing the warning signs, partly because I’ve spent the overwhelming majority of my life not just ignoring them but desperately pretending they didn’t exist at all. Since nothing my limbic system could do would get the attention of my cortex to have it fix the problem, my limbic system decided it needed to turn things up to a point where they couldn’t be ignored anymore.

The point to all this is I will almost certainly have more panic attacks in the future and people may very well see me behaving somewhat erratically. Be assured that in a matter of hours, or a couple days at most, I’ll be fine so just strap in and hang on.

Hey… didn’t I have cancer?

Remember how I was going to start a blog to keep everyone up to date on how my cancer treatment was going? What ever happened with that?

I started the second round of BCG yesterday. I had completely forgotten about it until about 5 pm Monday evening so it was a nice surprise. As always the procedure went smoothly. Pretty much as soon as I got home, though, I was right back to the frequency and urgency with urination. It was like the treatment never stopped. I’m feeling a little fatigued today but there are plenty of non-cancer treatment related reasons for that as well.

The plan was for three more doses but that is going to get really complicated. After my second dose, I am going to be changing insurance and my current urologist won’t take my new insurance. Just out of morbid curiosity I asked the billing people at the clinic how much getting a dose would cost and the answer was somewhere on the order of $10,000. For one dose.

Yeah. I’m just going to finish this post later. Or not.

The benchmark for stupidity

Back in the early 2000s (by which I mean 2000-2001) I worked as a nurse in the emergency department at our local university hospital. Among the injuries we saw on a semi-regular basis were adult men (and it was always men) presenting with a fracture of either the fourth or fifth metacarpal bones (sometimes both) and no other injuries.

what the fourth and fifth metacarpal bones might look like

This particular injury is known as a boxer’s fracture and results from, as one might guess, punching a hard, unyielding surface such as a human skull or, much more frequently, a wall.

In my mind it did not get much dumber than punching a wall. You start off with a bunch of problems, something makes you lose your temper and you punch a wall. Now you have all the same problems you had originally plus a fractured hand (and it was almost always their dominant hand because that’s the one people tend to throw the first punch with) and a bill for an ER visit on top of it.

With that all said, this is how I spent my Thursday evening:

ulnar impaction syndrome is a degenerative joint disease similar to arthritis

I knew what I’d done as soon as I did it, although I did spend a couple of hours trying to pretend I didn’t.

So, as the man said, how did it come to this? The short(-ish) answer is that I am having an increasingly difficult time arguing that the PTSD-like symptoms that I’ve been having aren’t actually real1. The longer answer is that I really can’t point to anything specific. I’d been feeling off since the Tuesday of that week; more irritable, harder time concentrating, more than usual sleep disturbances, etc. and by Thursday afternoon I was moderately dysfunctional. I really can’t remember what I was doing right before. I was upstairs actively falling to pieces and went downstairs to try and get somewhere quiet. I went back to my office and then I was back out in the hall with a fractured hand.

I have to revise my opinion of at least some of the boxer’s fractures that came through the ER. This is, I think, a perfect example of that “toxic masculinity” you hear about these days. Men in America, certainly men around my age, were still acculturated into fairly traditional gender roles, especially when it comes to emotional intelligence. There comes a point where the only way one knows how to express and attempt to manage the intensity of emotions that one is experiencing is through violent rage because men have traditionally been actively discouraged from experiencing negative emotions in any other way.

I hope that others can maybe avoid these self-destructive patterns and learn a lesson from my experience.

And that lesson is: punch something softer than a wall.

1 This is not to say that my brain isn’t trying to tell me this is just an example of how serious I am about sloth and malingering; that I would go so far as to injure myself just so I could better fake mental health issues shows real dedication

This will definitely make me a better nurse

Probably a better teacher too when it comes to that. This is the kind of insightful critiques that really help me to build the skills I’m going to require to be successful.

I suppose I should clarify; I had a paper returned for revision and among the reasons it was kicked back are:

Missing sentence case for article title – The titles of work appear in title case, with most words capitalized, instead of sentence case. 

Missing italics of journal title – APA style requires the use of italicized font for periodical volumes. 

Separate the single author and the publication date with a comma in-text. 

The abbreviated version of the word ‘volume’ is improperly included. 

All text should be double-spaced

Some rando evaluator

What I’d really like to get from an evaluation is maybe some indication of whether or not I understood the material from the class well enough to put together a coherent argument. What I get is ”MISSING COMMAS, IMPROPER ABBREVIATION FOR ’VOLUME’!”

Which would make sense if I was working on my masters in copy editing.

But I’m not.

Who could have predicted?

To be fair, I don’t really know what ThedaCare was paying the employees that quit, nor do I know how much they were asking for to stay.

Even without knowing exactly what the anount is, I’d be perfectly happy to bet that amount and more on the guess that what the employees were asking for is less than half, and probably much closer to one third, of what ThedaCare is offering to pay travelers to replace them.

Update on indentured servitude

After Monday’s testimony, Judge McGinnis said ThedaCare did not meet all four of the required prongs to keep the temporary injunction in place.

“Could or should ThedaCare and Ascension get together and work in this transition period? I was hoping so over the weekend and I will continue to hope so. But I’m not able to craft any type of injunction that would require or limit Ascension without, I think, creating more issues or more friction, or taking away the ability that they have to provide healthcare services,” the judge said.

The decision means the seven medical workers can start work immediately at Ascension.

Thank goodness for that. Just knowing the judge thought it was reasonable to do this in the first place is plenty bad, at least he had the sense to realize it and put the whole thing…

The lawsuit itself continues.

Well shit…