“Perhaps the most concerning statistic regarding mental health problems relates to suicide. Those with mental illnesses have much higher suicide rates, and suicide is often considered a mental health disorder in its own right. Given this, recent statistics show that the rate of suicide in the U.S. exceeds 11 for every 100,000 people. This is so significant that suicide represents the 10th leading cause of death among all ages. Among those between 18 and 65, suicide is the fourth leading cause of death. In other words, suicide as a cause of death ranks higher than diabetes, stroke, homicide, and HIV infections. From every epidemiological perspective, mental illness represents a serious and devastating group of health disorders.”
Well, it’s been awhile, as they say. I’ve been away from the internet since March; although I do really wonder if we can ever fully get away. It wasn’t a happy vacation, mind you. The pandemic continues to loom large in my mind, and even though cases of covid19 have slowed (and nearly stopped) in my ICU doesn’t mean it hasn’t been busy. There is just as much normal heartbreak, death and disease to be found at my hospital as ever–if not more. And my colleagues are getting restless, wanting life to return to normal and travel the world again; they’re getting burnt out and in desperate need of whatever they call rest. The hospital is tallying it’s “losses” from last year and trying to squeeze the staffing and supplies to make up some deficit.
It has been a long few months of near hopelessness. What can be changed to make things better? What will normal look like? What is even the point?
But I’m back to try again, to think about this messy world I inhabit–on the edge of life and death, between the sick and the living. To make meaning out of this whole thing, healthcare, the pandemic, life, health, humanity. I’ll start again today in earnest.
I have gone back over a few “drafts” I’d saved while in hibernation and published them. I can’t claim quality. But, it is what it is. I’m sure I’ll be in this position again, so forgive me. And join me. Below are some links I’ve accumulated in the past week, and I knew that the urgency I felt when saving these links meant I was ready to start writing again…
Homelessness & Mental Illness Make a Deadly Combination
At about 8:20 a.m., 94-year-old Leo Hainzl, took what would be his last walk with his dog, Rip, to Glen Canyon. He crossed paths with a man who’d slept on the streets of the neighborhood for years and had often menaced passersby through a fog of mental illness. Police said Peter Rocha, now 54, attacked Hainzl with a stick, causing him to fall, hit his head and die within hours at a hospital.
Read more at SF Chronicle: “San Francisco’s Mental Healthcare System Fails Two Men”
Another instance when a homeless person, Rocha, who lived in Glen Canyon for reportedly more than a dozen years cannot be helped by police–because he can simply refuse medical care. And so he was left on the streets, where his mental illness deteriorated and left untreated led to the psychosis that caused him to kill someone. A very sad case.
Homelessness is a public health problem. Mental illness is a public health problem. If we don’t find systematic ways to treat these problems, we will never help the people suffering from these conditions.
Crisis Response Teams in SF: Are They Helping?
The crisis teams were created as part of Mental Health SF, a major initiative to reform the city’s care system, which is often understaffed and overwhelmed. But Mental Health SF has struggled to get off the ground during the pandemic.
Supervisor Hillary Ronen, one of the architects of Mental Health SF, said the crisis response teams look like “a promising program.” But to be successful, she said, the city must increase its long-term care options, from case managers to residential treatment programs.
According to city data, 9% of the street crisis teams’ encounters have ended in a 5150, an involuntary mental health hold for those who are a danger to themselves or others. Meanwhile, 18% were transported to a hospital and 18% to a program such as residential care or drug treatment.
The majority of the crises are resolved on scene, which means the person is left where found. But it is unclear what happens to people after the team leaves.
Read more at “S.F. finally has a new mental health team to respond to homeless people in distress. Is it helping?” on SF Chronicle
A Series of Mistakes That Should Never Be Made
Jeannette Shields, 70, broke her hip while she was at the Cumberland Infirmary in Carlisle, North West England, where she was being treated for gall stones, BBC News reported. While she was in the hospital she buzzed for help to go to the restroom, but went by herself when she got no answer, and she fell and broke her hip after she got dizzy, her husband, John Shields, told the broadcaster.
She then had surgery to fix her broken hip, and the hospital told her husband that the procedure had gone to plan but “unfortunately they dropped her off the operating [table] after the surgery.”
John Shields, 78, said: “She had a great big bump on the back of her head and she just deteriorated and then she just passed away, just died… I’m really shocked.”
Read more at Newsweek, “Woman Dies After Being ‘Dropped’ on Floor Following Surgery”
Is Medical Culture the Problem?
A plastic surgeon wants to go back to basics, the very culture that is built into medicine during training, to address our healthcare system’s problems:
“Many factors contribute to our nation’s soaring medical costs, flagging clinical quality and the rising dissatisfaction of both doctors and patients. The one problem we continually overlook with tragic consequences is the flawed culture of medicine.”
–Read more “Op-Ed: How doctor culture sinks U.S. healthcare” at LA Times
Work has been shit lately. Covid is still surging in my ICU, and we’re busy with other things too.
Last week was an especially difficult week for our heart failure service, as every patient on service was deemed “not a candidate” for advanced heart failure treatment. Bottom line: this is end-stage heart failure and hospice is the next step. For many patients, this means removing a piece of equipment that’s been helping their heart do it’s job (like an intra-aortic balloon pump, or an Impella). This can mean almost immediate death, but many patients do go home from the ICU to die there. It’s emotionally exhausting but incredibly important work.
And it’s so important to spend some quality time with these patients. Last week, I helped a gentleman who was just days away from getting his Impella out to go home on hospice. He was itchy from laying in bed. I washed his back with real soap and water and washcloths. The put on lotion with a little massage. 20 minutes including gathering supplies. And it made his day! We chatted about traveling and life’s simple pleasures. These are the important moments at the end of life, and I was so happy to be there for him.
But despite that part of my job being so meaningful, there are other parts that are nearly unbearable. There is a day shift charge nurse who is mad at me no matter what I do, and who demands a ridiculous amount of report on our patients. She wants a full head to toe but the 90 second version. Do you know how long it takes me to prepare a cohesive and comprehensive 90 second head to toe report that also includes the plan and updates from when she was last on shift??? It takes about 5 hours to do it for 30-36 patients. And when I don’t give her all the info she wants, she asks for it in aggressive tones. If I don’t know the answers, she will eye roll, sigh and slam turn the pages of her printout. Actually, she does that sometimes anyways if she’s annoyed by something, anything.
I find this to create a workplace so toxic that it gives me panic attacks. I dread giving her report. I get short of breath talking to her. I often cry after interactions with her.
So what do I do when I tell my managers about this and nothing changes? That is the million dollar question facing me right now.
Oh, I almost forgot my dream. I had a left ventricular assist device (LVAD) in my dream, but it became dislodged internally. FYI, I’ve never ever seen this happen in real life… I was bleeding to death, surrounded by work mates. They could do nothing. And finally, as I was about to die, one of the help pressure on the bleeding spot as the warm feeling spread through my chest and I lost consciousness.
This InStyle article captures perfectly, in the stories of healthcare workers ranging from psychiatrists to registered nurses, a feeling that I have also felt about Taylor Swift during this pandemic. One of awesome but quiet thankfulness. In a time when most of us are trapped alone in quarantine, driving to and from jobs that make us feel more isolated as we care for the sick and dying, “Folklore” came out to save us. It could bring together its listeners with a simple pensive mood, a reflective attitude towards life that seems more than fitting for the times. And one of the songs, “Epiphany,” although on one hand about Swift’s grandfather who fought at Guadalcanal is also a tribute to frontline healthcare workers during covid.
But Taylor Swift didn’t just come out with one album this year. Just as we were entering the darkest part of winter, the holiday season, and a part of the year when all of us that work in healthcare would see surges in covid bigger than our initial spring surges. For those of us who listen to music as a way to cope and who like Taylor Swift, the second album was like a surprise gift. And I am incredibly grateful for both albums.
Pondered your own mortality while rubbing the arm of a man who speaks a different language than you, who is tied to the bed with 2 different kind of restraints and is still trying to hit you, who has survived a brutal car accident that deformed his skull and has now lost more of his brain to cancer, who is on a medicine to make him sleepy and comfortable but still flops restlessly in bed, who somehow manages to fart right in your face as tears come to your eyes, thinking about how you’ll probably die alone.
Received the most vitriolic dressing down from an entitled white woman who no longer wants to be in the ICU but has unfortunately just had her 2nd brain surgery to remove a metastatic tumor. You try to set boundaries by saying “this is not a hotel; it is a hospital” to no avail.
Bonded with your colleagues about all the shitty stuff that’s happened in your night—assignments changed, 2 admits, charge nurse yelled at you, expecting to get yelled at by cardiac surgeon because you didn’t extubate your patient, massive transfusion, and so on. It’s true that working in an an ICU is like going to war. The trauma bonds you.
Although numbers are back up to pre-covid levels, Instagram (owned by Facebook) still struggles with automated vs. people-driven content moderation. Developing smart AI computer tools to detect self-harm and suicide content has been helping proactively.
Highlighting the burden that social media companies now bear in the fragile mental health of young people, this article really reinforces the notion that suicide is contagious and highlights just how large a role social media plays in that contagion these days.
Within 20 miles of where I live, Vallejo, California suffers under the most violent police force in the state. According to this fantastic long form analysis by Shane Bauer in The New Yorker, “[s]ince 2010, members of the Vallejo Police Department have killed nineteen people—a higher rate than that of any of America’s hundred largest police forces except St. Louis’s.” In those 10 years, the city has paid almost $16 million in legal settlements, had their insurance raised significantly, and are currently still facing 24 use-of-force legal cases expected to cost upwards of $50 million dollars.
“It can’t be awful if it’s lawful.”
Joseph Iacono, Vallejo Police Lead Force Options Instructor
This is a small city where many black and brown families have moved, often being squeezed out of the historically minority-centered but now rapidly-gentrifying Oakland and Richmond. The police force is staffed mainly by white men who don’t live in Vallejo but get paid top wages, often leaving forces in places like Oakland to find a job where their violence is acceptable.
And you know my refrain… Who suffers when the white man is in power? Always the black & the brown & the women. Also the mentally ill, the senior citizens, the homeless, and any other disenfranchised and powerless groups. Vallejo has gone bankrupt trying to pay the police officer’s increasing wages and benefits, often eliminating funding for roads and senior centers entirely in the process.
This is a city with a public health problem, and that problem is POLICE VIOLENCE. Defunding the police–perhaps even disbanding and restarting from the beginning seems to be the only situation in Vallejo.
All I can ask from you is that you know what’s happening in your area. Are people suffering like this? Can you help? Stand with your fellow citizens!
Again, I see an infuriating example of why defunding the police makes so much sense to me–or at least partially defunding. So many calls to 911 are for people causing a nuisance–in the wrong place (black man at a tennis court?), homeless, mentally ill, intoxicated in some way or just plain poor… And let’s be honest, someone is scared of something when they call 911 but these are people AND they are most likely suffering from a mental health issue, a substance use disorder, a severe medical condition, or ALL THREE. As a result, they may be lunging around “acting crazy” & not following commands. You know what happens when you don’t follow a police officer’s commands, right? Especially if you’re black, brown and/or a man? Well, quite simply, the chances that you’ll get arrested, thrown in jail or end up in the hospital (or worse, the morgue) go up astronomically.
“Law enforcement comes in and exerts a threatening posture,” Kimball says. “For most people, that causes them to be subdued. But if you’re experiencing a mental illness, that only escalates the situation.”
Angela Kimball, policy director of National Alliance on Mental Illness (NAMI) to Brett Sholtis, for NPR (link to article at end)
Police work and are trained mainly from a combat perspective. When you think about it, if they are fighting CRIME, they will most likely have to protect themselves. But here’s the kicker. Police are not always or even usually really fighting crime, per se. They’re fighting HOMELESSNESS, DRUG ABUSE, ALCOHOL ABUSE, POVERTY, DOMESTIC ABUSE. Do you think they need combat techniques to fight these things? Hell no. They need non-violent de-escalation training, communication training, training on substance use disorders, medical triage & first aid, mental health triage, psychology, racism, economics, etc etc etc. So basically, they need psychologists & social workers, homeless resources & outreach, domestic violence outreach & resources, food/shelter/medical treatment/basic human dignity.
We should take money from the police if we have to in order to fund these alternative programs, especially considering that developing these alternative services would lead to less need for police in general–and would also provide for less opportunities for fatal “accidents.”
You know what I’d rather have than police on the streets? Nurses! Shit, we’d get so much shit done. We’re already really good at hassling “the man” until we get what we need for our patients. We’re organized, clean, know what the resources are already. We probably even get paid less too. I see a plan coming together.
Would you believe if I told you that I haven’t posted in (insert # of days/weeks like I even bothered to look) forever because I’ve been busy? Well, I’d be lying. I have been working 3 or 4 days a week then having 3 or 4 days off and repeat. I like to think I’ve been busy but to be honest, no.
On the 3 days in a row when I work, there is literally no time for anything else though. I wake up between 4:30 and 5pm. Get ready for work, including make lunch (praying there’s food in the house since pandemic grocery shopping is the worst), and leave at 6pm. I get to work usually around 6:35-6:45 depending on traffic and take a few minutes to “print my list,” which is my giant tree-killing summary of each patient in the ICU and their one-liner H&P, chief compliant, and major events. This one-liner of course is more like a one-paragrapher…
We start each shift with a huddle at 18:55 and then I’m off to the races for the next 12 hours. I spend my shift breaking nurses, admitting patients, communicating with family members & doctors, in rounds, putting out fires, wiping butts, assisting in procedures, and getting report for the next shift. Whatever the night may need. After giving charge nurse report on an average of 26-32 patients, I only hope to leave before 8:30 when the parking garage will charge me $8 to get out. If I’m leaving this late, something bad happened. And it happens about once every two weeks.
I get home on average at 9am and try desperately to fall asleep by 10. Sometimes the adrenaline is still rushing through me from an end-of-shift emergency, or I have to eat because I simply didn’t have time to all shift–and I will not be able to sleep on a stomach that has likely been empty since a protein bar inhaled on the way to work at 6pm yesterday. Days like this, I hope not to be checking the time on my phone, which is shoved under a pillow next to me as I sleep.
And I get up and do it all again.
Every time I use the phrase “crazy busy,” I think of this quote–am I so busy just to protect myself?
For those 3 days, I am, yes, “crazy busy” but then comes my three or four days off in a row… These frequent days off are the reason some people joke “how can you be tired; you only work three days a week?” Oh hell, I think there’s probably even a meme for that…
Oddly enough, this is exactly what my hair looks on my day off. Disheveled bedhead.
So then, those days off? What are they if not busy? The answer is complicated, especially since I work night shift. When I get home from my third shift, I go to sleep by 10 like normal. But I let myself sleep until whenever I wake up– usually until 6 or 7. I wake up like a zombie, stumbling to the kitchen for coffee and food. I’m pretty useless at this point, still tired from the work week. I stay up to watch some tv, maybe do some laundry– although as I type this, I’ll admit that is unlikely. And I’m back in bed by 10pm. My first day off, spent entirely sleeping…
There are weeks where no matter how much I sleep, I don’t feel rested. Days when co-workers are restlessly texting me about this problem or that, and I feel a weight of responsibility as I take their confessions
But as this pandemic and its necessary quarantine continue into its sixth month, my colleagues and I cling to each other. We are bound by what we’ve seen and done. We are a “quarantine family” of essential workers–and though we wear our masks, we cannot control how close we get to each other. Some days, we work shoulder to shoulder–arms crossed–to turn and lift patients, to hold pressure on bleeding wounds, to change dressings.
Now that we’re doing elective surgeries and the first three months of strict shelter-at-home orders, the ICU is busier than ever. Way too many cases of pancreatitis from months of heavy drinking, severe heart failure from heart attacks overlooked when people were too scared to go to the hospital. Kidney, liver, and heart transplants. Drug overdoses, and cardiac arrests–sometimes it seems like 5 homeless or near-homeless people found down and resuscitated every day. Their u-tox reports telling the story of despair and mental illness and drug addiction that plague our cities: meth, opiates, sky-high alcohol levels.
I spend my days off thinking about these patients. That first CT scan showed a lack of grey/white matter differentiation, a very poor prognosis and likely anoxic brain injury for our Joe Doe cardiac arrest patient. What had happened to him? Did they find out his name? Did the police have to come fingerprint him? And what about the woman whose chest we opened at the bedside? We all watched as the cardio-thoracic surgeon retracted the ribs, suctioning out & washing away blood and clots from around the heart. Then he searched for whatever might be bleeding, suturing tiny blood vessels and covering with small pieces of dissolvable clotting material.
The OR rolled in a sterile table filled with so many instruments when we opened our patient’s chest at the bedside. I had clamp envy.
