Health – Barrelhaven

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

²How’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!

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.

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

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!

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.