When I worked in residential, I had a patient who was the sweetest, caring girl and for the longest time, I wondered why she was even in residential. She was depressed and had anxiety. She had experimented with some drugs, but she never struck me as our usual residential patient.
When I was still teaching dance club at residential, she came up to me one day and said, “I can’t dance good, but I think I want to come and watch.” I told her that I’m sure she would be great and to come and watch if she wanted to.
She was nervous and she went on to tell me why.
Let’s call her Tami.
Tami had dwarfism as well as multiple joint abnormalities. While she had a lot of pain while walking in her knees and hips, she was very mobile and was able to get around without a wheelchair. While many of her joint abnormalities were visible and at times you could see she was in physical pain, she was always smiling. Every time I talked to her, she was bubbly and laughing. And after coming to dance class for a few weeks just to watch, she finally decided to participate. She even participated in one of our talent shows and did absolutely amazing. I was so proud of her!
She wasn’t in residential for long. When she discharged from our care, I did not plan to see her again as she seemed so stable when she left.
Much to my surprise, after working inpatient for a few months, I turn the corner into the activity room and there she was.
She was sitting at the table beside the door, alone. She had her head hanging down and looked like a completely different person.
Her once smiling face that I was so use to seeing every day was empty; blunted. She had lost that spark in her eye that always made me smile.
What happened? What changed in the past year that lead her to an inpatient stay?
“Tami! Hi!” I said to her, in my typical outgoing, upbeat voice. The one that usually drove the kids crazy bright and early at 7am! One of the other kids in the activity room said, “why are you always so happy in the mornings!?” Little did they know, I HATE mornings and still do. But anything to try to make their mornings a little brighter!
“Hello,” Tami replied to me without looking up from the table. I sat down in the chair beside her.
“It’s been so long! What’s been going on?” I asked her. She continued to keep her head down.
After what seemed like a lifetime, she finally lifted her head up. And when she did, I thought I was going to cry.
She looked so sad; so confused. I had never seen her like this before. She didn’t say anything, just stared at me with blank, empty eyes.
“Tami, do you remember me?” I asked her.
“No,” she said in a monotone, not her previously usual happy voice.
“I was your nurse in residential.”
“Why are you poisoning me?” She asked me as the tears started falling down her cheeks. It was then that I knew something was very, very wrong.
Unfortunately, this interaction caused her to become very agitated. She was able to walk out of the activity room and into her room without having to be restrained, but she took a very long time to calm down enough to be willing to talk to anyone.
She was convinced that everyone in the hospital was poisoning her food. She wouldn’t eat. After talking with the doctor and the nurse who admitted her the previous day, they informed me that she was having her first psychotic episode. That she was at her foster home when she started to become paranoid that everyone was putting poison, bugs, and poop in all of her food. She started thinking that everyone around her were fake people and that nothing was real. She was scared. She was confused. She was breaking my heart.
How did this happen so quickly? She was just fine last year. How did we get here?
Her foster mom said that once she was discharged from residential, everything was going great. She said that Tami was going to school and doing really well. She was about to graduate high school. Foster mom said that Tami had had clean urine drug screens consistently since being in her care. She said she was pleasant, sweet, patient with the other foster children. She said that Tami’s depression and anxiety were almost always in the background, but that she was able to continue pushing through and succeeding. Foster mom said that it was “out of nowhere” that Tami started becoming paranoid, and it took off from there. Foster mom said it had been three days where Tami would not eat, drink, or take her medication because she thought it was poison. She was then brought to the ER and admitted to inpatient.
I was shook by this.
Now, psychosis is complicated and it can happen this way; come out of nowhere with no indicators previously that this was among the horizon. Other times, it is gradual, more predictable. Every case is different.
What can make providing care to a patient experiencing psychosis difficult is that they are often scared, paranoid, and untrusting of others. Because of this, it can take a long time to build a rapport and make good progress.
After 48 hours of Tami refusing her medication, she had to be restrained and administered her anti-psychotic medication via injection.
And of course, I was her nurse that day.
Going from teaching this sweet, smiling girl how to do four-count-turns to restraining her and giving her an injection, was really breaking my heart.
“Why are you doing this to me?” She screamed at me as myself and another nurse administered the injection. “You want to poison me? You want me to die?!” She screamed.
The other nurse I was working with knew that I had been working with Tami in residential and that this was really difficult for me to do. She was so supportive and understanding when I had to take a break to wipe the tears off my cheeks.
I was so grateful that I had the next day off. I needed it. And when I came back to work the day after my day off, Tami was smiling in the activity room, eating her breakfast!
What a huge relief. The medication was working.
While having to restrain her and administer the injections can sometimes feel so controversial, I have to remind myself that while in a psychotic state, these patients are unable to make sound decisions for themselves. Because of this, they rely on us as providers to make those decisions for them. I never take those decisions lightly.
In the last post, we discussed emergency medication administration. This is different in the sense that this was a long-term medication that was going to be bringing her back into reality, not a medication that was just going to calm her down or make her sleep.
As the rest of the week went on, I slowly saw the light come back into Tami. She was even taking the medication on her own, willingly and we were able to switch to pills instead of injections. She was eating her food without fear of someone poisoning her. She was participating in group. She was talking to me about how we previously knew each other in residential and about how much she enjoyed being in dance club.
When she discharged back to her foster mom, I felt mixed emotions. I was glad she was leaving the hospital a completely different person that she was when she was admitted. I could only hope that it would stay that way. Sometimes I find myself wondering if she is still taking her medication, because unfortunately, she is going to need it for the rest of her life. The good news is, as long as she did take it, she could live a great and successful life. That’s always my hope; that’s what I make myself believe. That she is doing great and is stable, wherever she may be.