Tag: Brain

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

Or maybe I don’t?

Bessel Van Der Kolk is a professor of Psychiatry at Boston University School of Medicine and president of the Trauma Research Foundation in Brookline, Massachusetts. He has been studying Trauma and PTSD for decades. His book The Body Keeps the Score was written pre-pandemic but has absolutely exploded in popularity since the whole thing started (I’m trying to wade through it myself right now).

Van Der Kolk was on All Things Considered on NPR this afternoon (his bit starts at around 6:18):

He makes a very compelling argument that, while the pandemic and it’s associated disruptions of every day life are deeply troubling and are, without question, causing an uptick in mental health complaints, those complaints most likely are not exactly “trauma” related. He takes the position that this is an important distinction to make because if you are treating people for pandemic related mental health complaints, and you treat them like they have PTSD or other trauma related issues when they don’t, they may not be receiving the best, most effective treatment for their condition.

I intend to discuss this with my therapist, and the psychiatrist I was referred to by Dr. Rando, but I think Van Der Kolk’s thinking is correct and it is much more likely that what I’m suffering from is garden variety stress and burnout rather than PTSD. I view this as good news because it means that, after my appropriately lengthy time away from work (it will be close to two months by the time I start my new job in February), and the addition of clonidine to my medication regimen, I should be able to get back to work without further issues.

I could be wrong but there is really only one way to find out: wait and see what happens.

In praise of 2-(2,6-dichlorophenylamino)-2-imidazoline hydrochloride

More commonly known as clonidine. Clonidine is an alpha-adrenergic agonist, and should not be confused with clonazepam (Klonopin) which is a benzodiazepine. As was previously mentioned, I had an appointment with Dr. Rando and among the things she recommended was adding a medication for anxiety to the antidepressant I’m already taking. Discussed options included benzodiazepines (which are not recommended for use in PTSD1), beta-blockers (which she was hesitant to put me on since I had been having issues with fatigue), prazosin (which is also an alpha blocker but is only indicated to treat nightmares associated with PTSD2), and clonidine.

TL; DR – I started on clonidine and I feel like it’s working really well. My baseline level of nervous system jangling has dropped noticeably. You are now safe to skip the rest of this post which consists of some rambling about how clonidine works, why I was positively enthusiastic to try it, and how irrational the distinction I have in my head between “psychiatric” medications and “physical” medications is.

My reaction to the suggestion of more medication highlights again my physical medicine bias. I resisted being on an antidepressant for a long time, and even after I started one initially my goal was to get off it as soon as possible (and then resisted going back on one when it looked like it was going to be required). However, when Dr. Rando suggested clonidine I was positively enthusiastic for a couple of different reasons. First, I am well familiar with clonidine. It was a mainstay medication for our ECMO program because it (at least theoretically) has beneficial effects on pain control, sedation, and blood pressure, it is available as a pill that can easily be crushed, dissolved, and put down a feeding tube if the patient can’t swallow, and, perhaps most importantly to the Powers-That-Be, it is dirt cheap. I understand how it works and, because I know how it works, I could see how it would help with the difficulties I have been having. The other reason I was enthusiastic to try it was the opportunity to see first hand if it really did work the way it was supposed to.

I want to talk a bit about exactly how irrational it is that I would resist adding, say, an SSRI to treat PTSD while not only accepting but being enthusiastic about trying clonidine. As I mentioned above, clonidine is an alpha-adrenergic agonist, which means that it inhibits some of the fight-flight-or-freeze response that our nervous system does when it feels threatened. In past times this response was a great adaptation because it allowed our progenitors to run away from saber-toothed tigers. In modern times it can be maladaptive because modern life is very good at creating stress that one can’t fight or run away from so the stimulation of our nervous system doesn’t turn off. Ever. The practical effect of using an alpha-blocker to moderate the activation of our nervous system is to reduce the hyper-alert state, resulting in improvement in tension and anxiety. Clonidine can do this by having the ability to cross the blood-brain barrier3 and by being structurally similar to norepinephrine, one of the main neurotransmitters in our nervous system. In terms of it’s mechanism of action, it is essentially indistinguishable from most medications that have primarily psychiatric indications.

Of course none of that matters to my brain. It’s a medication that I have used and am familiar with, and it has primarily physical indications which means it’s a real medication and not one of those woo-woo brain drugs (that work in extremely similar ways to achieve similar effects). Totally irrational.

This is one occasion on which I will not complain about my brain behaving irrationally. Whatever the reason I was able to persuade my brain that this was a necessity, I’m very pleased with how the medication is working so far. It has settled my nervous system sufficiently to make every day life a great deal less challenging.

There is more to catch up on but I am taking advantage of the reduction in mental clutter to enjoy doing things. What kind of things? Almost anything really. Even doing chores around the house is less troublesome when you aren’t spending an excessive amount of energy trying to keep from having a complete breakdown.

1 I’m not entirely sure why benzodiazepines aren’t indicated for PTSD. I suspect it has something to do with benzos having the potential to be disassociative which, based on my extremely limited understanding, is probably counterproductive.

2 I have no idea why one alpha blocker (prazosin) is only indicated to treat nightmares and another alpha blocker (clonidine) is indicated for general symptom treatment. Seriously, no clue.

3 I also don’t know enough about the blood-brain barrier to even attempt to explain it, so here’s Wikipedia.

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.

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

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.

Oh look!

Now that I’ve neglected this to the point that no one is reading anymore, it’s safe to post again.

The truth is there hasn’t been anything happening on the cancer treatment front, I’ve more or less settled into a routine with work, and my mental health is better overall than it’s been in quite a while. Of course that has meant I haven’t needed to whine about anything here. And I pretty much still don’t but there are definitely things on the horizon.

Looming largest in my mind right now is another covid surge. I’m sure any number of the none people reading this have heard me lamenting that I couldn’t do another year of covid and it’s looking like another year of covid is a good possibility. Having spent no small amount of time ruminating on this, right now, from a mental standpoint I think I actually could do another year of covid. I would certainly be happier to not have to but, strange as it may seem, having a couple months mostly away from the bedside may have allowed me to recharge my batteries a little bit. Well maybe not another year of covid, maybe six months. I don’t know. Anyway, the point is I could definitely do one day at a time which is more than I would have been willing to say a few weeks ago.

As an aside – there really isn’t enough information on the omicron variant to make any definitive statements about what the next year is going to look like. What is noteworthy is that in South Africa, where omicron was first identified, the delta variant was pretty much the exclusive strain being passed around and omicron is out-competing it and is on it’s way to becoming the new dominant strain. It is a deeply concerning variant and an excellent reason to get your vaccine booster ASAP if you haven’t already.

Anyway, this revelation that stopping to rest for a while can replenish one’s stores of mental and physical energy is the latest in a series of startling discoveries I have made recently now that my brain has had time to reboot.

The first of these came to me maybe two weeks ago. I believe I have lamented here before that I didn’t really know what to do with the advice to “make time for yourself”. The foundation of my difficulties was that I had more things to do than time to do them and it was impossible for me to make time for anything else. Short of actually making time (see any number of science-fiction stories to learn why that isn’t a good idea) I genuinely couldn’t comprehend how I was supposed to “make time for yourself”.

My revelation came while putting together a to-do list for the week. As was usual, I knew there wasn’t going to be time to get to everything so I was triaging and prioritizing what I really had to get done and what I could let slide and it occurred to me that I could just put myself on the to-do list and treat it the way I would any other project. And that the time-for-myself project didn’t always have to be the one that got dropped when it came down to prioritizing for time. If I had been on the road to Damascus I would have fallen to the ground. This was a revolutionary technique that I could use to try and…

…right… make time for yourself… like everyone has been telling you to…

Ahem.

Right. So I’ve been making time for myself and the world hasn’t ended yet.

Updates

Updates are called for;

  • House:
    • The basement floor project is still in a holding pattern. Last word was that everything should be in place to have it done by the end of the month
    • The new plumbing leak is also in a holding pattern. There is slightly better news than I expected here. Not good news, but not as bad as it could be. The leak was from the seal on the toilet in the bathroom upstairs. It was fast and (relatively) inexpensive to fix. We are waiting on hearing back from the people who are going to come and fix the floor and/or ceiling to find out exactly what is required there.
  • Work:
    • I’m going back to work on the unit starting next week. With the most recent covid surge settling down, Employee Health isn’t as busy as they have been and don’t need as much help. There are certainly other things I could do for light duty but the fact is I’m probably recovered enough to just go back to work. I’m never going to feel ready and the only way to find out if I can do it is to do it.
  • Health
    • Health is also in a holding pattern. No news has been good news.
    • Mental health is honestly as good as it can be under the circumstances. The previous post announcing the bathroom leak is typical of how I’ve been reacting to new difficulties recently. I’ve been feeling very brittle; when something hits I kind of break into a thousand little pieces and can’t see anything but crisis and my brain does everything it can to persuade me that things are as bad as they can possibly be and they will never be fixed. This is a known issue. I haven’t had much luck moderating my initial, disproportionately negative, response but I have been getting better at pulling myself together again.

The fact is, in spite of everything I, right now, today, I feel pretty good both physically and mentally. There is still a lot on my plate and I’ve been ready for all this shit to be done for about 6 months or so, but the struggle can continue.