Tag: Introspection

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.

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.

Clever Title

Back to school. This is (hopefully) my penultimate term in my masters program and what happens after that is not at all certain. I had hoped to have the basement done before I had to start school again but in spite of that I think I’m at a point where I’ll be able to manage.

Work has been interesting. There is an actual sick (in the previously discussed “sick or not-sick” sense) patient on the unit right now, one of the kind that I have spent the last 5-ish years specializing to take care of. The unit at my current place of employment has some very smart, very capable nurses and doctors but very few of them have a lot of experience caring for specifically this kind of patient. This is the kind of patient I would very much like to see more of on the unit and, I think, that is a goal that is shared by the Powers-That-Be at the hospital.

So there’s this sick patient and one of the assistant managers texted me to ask if I could come in to work tonight to help out. A couple more bits of relevant information; I worked last night, it was a pretty exhausting shift, and I didn’t get much sleep today for several different reasons. I’m really tired, is the point to all that. Even so, if this had been not that many years ago, I would have said yes without even pausing to think. I had told managers and physicians that I would live at the hospital 24/7 if that’s what was required to take care of the patient and I nearly did on more than one occasion.

I’m going to go on a little side-track here but we’ll get back to the main storyline in a moment. I have frequently thought that when I tell someone about the long hours and short sleep that I put myself through to take care of these complicated patients, they infer that this is due to some depth of character and dedication to the nursing profession that drives me to do these things. Nothing could be further from the truth.

The fact is, being a bedside nurse is kind of a shit job. All too often it is literally a shit job. Yes, it pays well, but really the only thing that makes all the, literal and figurative, shit worth it is if you’re doing something interesting. I pushed myself taking care of these patients because I wanted people to keep sending those kinds of patients to our unit. I wanted the admitting services to know that they could dump the sickest patient imaginable on us and we’d take it happily. Being a nurse is the only thing I know how to do that someone will actually pay me for so, if I need to keep working as a nurse, I need a good supply of crazy sick patients so I don’t get fed up with all the nonsense. This could potentially be a much longer tirade but I don’t want to lose focus.

The end of the story for today’s incident is that I did not go in to work. I really wanted to for all the above discussed reasons, but I also knew that it would really not be good for me and self-care won out.

Also, tomorrow we have our first D&D game in almost two months and I am not missing it.