Who knew you could ever find joy again... I was required to post a final reflective discussion for Adult II Practicum for FNP program. Now I am sharing my submission here, and yes, this really happened!
The Experience
Background
My preceptor (Randi) and I saw a 63-yo female for an initial visit to establish care because her primary care provider moved out of state. She had just completed an annual physical last month with labs, and we had quite a lot of medical information available to us. We decided that a quick physical assessment to would suffice for this visit as she was on quite a few medications for mental health. We decided to focus more on her mental health, sleep, nutrition, and home stressors during this initial visit. It seems that Randi was using this visit to establish a relationship, and that she would take the medically driven approach during a follow up in 2 weeks. This patient was on more than a handful of psych medications, including antidepressants, stimulants, anxiolytics, sleep aids, nerve pain meds, and meds to address the extrapyramidal symptoms that all of these meds were causing!
Findings
As she was telling us briefly about her childhood (ACE score was 7), and that she had 4 prior attempts at suicide, and a little about her mom and her daughter - both whom she loves dearly, she had a flat affect. Was it her? or was it the meds? A review of when-she-takes-what for her meds revealed she is taking things that bring her down, in the morning, and some meds that stimulate, she was taking at night! It seemed like her flat affect was a direct result of the many meds she was taking. Randi and I agreed that a strong improvement could be achieved by a shift in timing - when she takes her meds could start the ball rolling on an improved quality of life. This should also help with her current sleep patterns and overall abilities to cope with stressors and to perform daily activities with greater success and maybe even joy. We decided that making med changes would be high priority for this patient.
The Heart of the matter
After building a rapport, we were able to get into a discussion about her current feelings, any suicidal ideations, and her goals. She said she thinks about killing herself every day. This is just a part of her life, she said. These thoughts are daily - that she should just die, or that she just wants to die. "I won't do it though. I made a solemn promise to my mom and my daughter. I just won't do that to them," she professed.
Again, her affect was flat, and she was not complaining as she was reporting these symptoms. She was very matter of fact about the thoughts and the refusal to act. She was almost accepting of the fact she has these daily thoughts; they are a regular part of her life because “that’s just the way it has always been” or something along those lines.
During this time the anxiety-wrought patient began to relax; her tense, nervous body language slowly loosening. Randi and I both started this patient's visit by sitting in chairs close-by. Really, I think, it was a proximity that you would expect among a caring group of three friends; close enough to reach out and touch a hand or shoulder if needed, but far enough to allow for personal space.
The Beauty
This part of the interaction is where the beauty lies... deeper into the patient interview...
Randi asked, “so you think about it every day...tell me what you see? ...how are you doing it?”
The patient said “pills - ya, I guess pills.”
(pause)
(pause)
...
She then said, “But I guess the last time, it was the car.”
(pause)
“You know how, now, cars have a catalytic converter?”
Randi and I glanced at each other, and back to the patient. The patient was looking up in the corner of the room as if in thought, remembering the time she is talking about, reliving it...not expecting a response about catalytic converters...
I said, “Ya, the catalytic converters. Aren’t those for the exhaust or something?”
She said, “Yep. Ya, that’s right.”
(pause)
(pause)
(silence)
And then, “Well the last time, I sat in my car for about three hours. I sat, and I waited.”
...
(pause)
(pause)
(pause)
(another almost an awkward pause length)
“...and after three hours, all I had was a sore throat.”
It was just so unexpected. She did not say any of this to be funny, she didn’t crack a smile, she was still reliving the moment, almost... but it couldn’t be helped.
A stifled, abrupt chortle flew out of my throat,
before I had any chance to stop it!!
This is the moment when everything
proceeded in slow motion for me...
Randi looked at me, I looked at her, my hand was covering my mouth to hold back any further assault-by-chortle... and then we both looked at the patient...and the patient looked at me and then looked at Randi.... this - all - in a matter of milliseconds... yet time stood still, and it was an eternity of awkwardness for me...
...and then... the magic.
We all started to giggle.
Which then turned into unshrinking laughter...
...and grew into hold-your-belly, throw-your-head-back-laughter!
Some of it was the patient laughing at her own situation, her story; some of it was each of us laughing at how she worded it, and the unexpected visual that went along with it; and some was probably because it felt so inappropriate to be laughing at all... and some of it a tension release...but here we were.
I couldn't stop picturing how this patient's story had just unfolded...her, sitting in a garage with the car running, for 3 hours...in an effort to die... but with the new catalytic converters, the exhaust isn't what it used to be so it only gave her a sore throat...
Asisde: Think of the tshirts: "I sat in my car for 3 hours and all I got was a stupid sore throat"
Thoughts and Feelings
We had taken a journey together, and arrived at a place that broke down the barriers, opening the doors to what ended up being a very meaningful experience for our patient. This shared moment led to trust and hope for the patient, and she openly shared that with us just before leaving. We know it is true, and we have all heard it so many times before, but humor really is the best medicine. Humor, when used in the right way, can be a healing power all on its own.
Evaluation of Strengths and Challenges
This experience validated (to me) my strength in connecting with patients, my ability to offer support, encouragement, and even hope, when available. The challenge is that I don’t always get it right. And I won’t always get it right. The challenge is learning to distinguish between the receptive patient and the patient who is a sycophant because of the perceived or inferred power dynamics in the provider-patient relationship. The challenge is discernment, a skill to be honed.
Analysis and Self Reflection
It was a meaningful experience for me, as well. The patient is not the only one who came away from the meeting with hope and trust. This experience, this interaction with the patient, was my expression of deep caring and compassion for someone who has been utterly rocked by trauma in her life. I quickly grew to care about this patient’s outcome – her quality of life – her future.
I can only say how relieved I am that this interaction had such a positive outcome, despite a terrible mistake. Laughing at something that is not humorous to the patient can destroy the relationship, and the potential for honest interaction. Laughing at the wrong thing, or at the wrong time, or sometimes even laughing at all can result in the complete opposite of “doing no harm.”
Action Plan
I have not had any experiences like this before – where my emotions betrayed me in front of a patient. Although this all worked out and turned into the best-ever patient reaction, it could have gone differently. Much differently. I plan to continue just as I had up to this point – managing my emotions when engaging with patients – to provide them with respectful, supportive, professional care.
Addendum:
No comments:
Post a Comment