Psychiatric emergency room holding cells

Did you know that patients with psychiatric emergencies have to wait the longest to receive care? At my local hospital the average daily census in the “psych ER” is 60 patients. That is, 60 patients a day are triaged and waiting for a bed to become available so they can get treatment. Not just a bed on the psychiatric unit at that particular hospital — I’m talking about a bed on a psychiatric inpatient unit anywhere in the western part of the state. Patients can wait for days, weeks, and even months to be transferred out of the ER and into a hospital for treatment by psychiatric medical professionals.

One particular ER at a large hospital in the southeast has psychiatric patients wait for days in small, dark rooms, 4-6 per “pod”, with nothing to do except look at old magazines or DVDs. There are no windows, and there are no clocks. The only way to mark the passing of time is during shift change and by what meal is being served. Some of the pods don’t have beds — just recliners. There is no counseling or therapy. Some patients are allowed to journal in composition books, the closest form of treatment until they are admitted. Medication is adjusted by staff covering the ER; it’s often cursory at best and is just a temporary measure. But the staff are kind and caring and patients try to support one another. Everyone is trying to make the best of an awful situation.

So the next time you find yourself in the ER, whether it’s for yourself or a friend, count your lucky stars if it’s not for mental health reasons. As you wait to be treated for your medical emergency, try not to complain that it’s been 3 hours and you’re getting uncomfortable on your hard gurney, and you’re cold and need another blanket from the warmer.

person holding hour glass

Photo by samer daboul on


Holistic options for psychiatric NPs in long-term care



As a psych NP new to working in LTC settings I’m finding scant research on what to prescribe that has the fewest side effects. How can I incorporate holistic care into my practice? I prescribed chamomile for the first time but didn’t get the chance to evaluate it because the patient was discharged from the short-term rehab she was on. Aromatherapy is not being used enough, at least not in the facilities where I practice; how can I bring it to my practice in an easily delivered manner? I read where one psych NPs provided boxes of Lorna Doones for nurses to keep on the med carts and actually wrote orders for them to be used PRN. As long as diabetes isn’t an issue that might work but I haven’t found the nerve to use them yet!

If you have suggestions I’d love to hear them. If you know of resources, websites, articles, anything — please share.


For All Time

Music has such power to heal. Thank you to outofagreatneed for this post from June 23rd that I’m reblogging here on NurseGrit.

Out of a Great Need

This song…

pulls me back to the darkest days, during our younger daughter’s adolescence, when long drives helped her racing mind in the midst of the overwhelming symptoms of her severe brain illness.

We took long drives every single day for several…yes…several years.

We listened to music.  This is a song from one of the CDs she would bring along.

But this song does not upset me.

It reminds me that all of the quiet patience made a difference.

It reminds me of a bond that cannot be broken by a severe brain illness.

This song reminds me of the power of love.

It reminds me to NEVER give up.

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7 Step Diet and Lifestyle changes for Alzheimer’s Prevention


The topic of Alzheimer’s disease treatment has been a topic of conversation multiple times in the past few days so this is my blog topic today. While we wait for a cure for AD, there are steps we can take to hopefully better position ourselves from a prevention standpoint.

At the International Conference on Nutrition and the Brain, Washington, DC, July 19–20, 2013, multiple recommendations were brought forth with respect to diet and lifestyle changes for prevention of Alzheimer’s disease (Barnard et al., 2013). Below is their list of 7 steps to take.

  • 40 minutes of aerobic exercise three times a week
  • Eat a plant based diet
  • Minimize intake of trans and saturated fats. Trans fats are often found in snack foods (especially pastries and fried foods). Saturated fats mostly are in meats and dairy.
  • 15 mg of Vitamin E every day, coming from plants and not vitamin supplements. Vitamin E rich foods: Seeds, nuts, green leafy vegetables, whole grains.
  • B-12 supplement of minimum RDA (2.4 micrograms daily for adults). Age can lower B-12 so be sure you get levels checked. Your primary care provider can do this for you easily.
  • If you take vitamins/supplements choose those those without copper and iron.
  • Avoid aluminum products. Jury still out but it’s linked to Alzheimer’s (as well as cancer). Aluminum is in many products we often use: deoderant, cake mix, dyes, processed cheese, antacids, baking soda/powder, foil, cookware.


Barnard, N. D., Bush, A. I., Ceccarelli, A., Cooper, J., de Jager, C. A., Erickson, K. I., et al. (2014). Dietary and lifestyle guidelines for the prevention of Alzheimer’s disease. Neurobiology of Aging, Volume 35 , S74 – S78.

Image: Physicians Committee for Responsible Medicine


NC #1 in naloxone distribution

The Guardian  published an article today (Timothy Pratt, June 10, 2016) about naloxone rescue kit distribution efforts in NC. The state claims national leadership status in the number of lives saved with naloxone in the shortest period of time (not by police, ERs, or other medical first responders). Key to that effort has been getting the rescue kits into the hands of opiate users and their peersThe NC Harm Reduction Coalition (NCHRC) is the organization responsible for this monumental undertaking. Most states are making similar efforts but some advocates have expressed frustration about the lack of cohesive plans to reach those in need.

Peter Davidson, a professor at the UC San Diego School of Medicine who has studied opioid deaths said it’s “frustrating” to see that other states haven’t yet adopted North Carolina’s methods, which he believes should be a national model.

“We have a really good … public health response that works, and seeing it not being done more comprehensively is infuriating,” he said. “You’re watching the death reports come in, and you know they don’t need to be that high.”

Let’s all learn from each other with the common goal of not just saving lives but treating addiction adequately in the first place.



How one NJ hospital’s ER is combating opiate addiction: no routine opioids for chronic pain

New Jersey ER bypasses opiates for chronic pain

Timely for APNA 14th CPI — NY Times 2016 article describes how this ER is using alternatives to opioids for managing many types of pain.

As psychiatric nurse practitioners our clients often have chronic pain. Knowing about alternatives to meds for treatment of pain can be helpful info to share with them and/or could reinforce what they might be told by their PCP or pain medicine clinic, in terms of alternates to opioids.

Thursday 5/9/16 APNA CPI preconference discussion on benzo pitfalls: notes from the lecture

Benzo discussion Dr. Limandri:

My impression: great info, so much material to cover though so she mostly skimmed the surface. Lots of the info seemed to come from her own experience. Some material came from the UK — Ashton Manual which I refer to often and it’s full of good info.

Below are my mostly unedited notes from this session along with some lyrics from a famous Rolling Stones song relevant to subject.

  1. Women use this class of med more than men. 25-50 yr age range is highest; multitasking requirements for women in that age bracket; middle aged, white, wealthier higher utilizers of benzos. The Rolling Stones wrote a famous song about women using Valium, “Mother’s Little Helper” in the 1960s — here are the lyrics:

What a drag it is getting old
“Kids are different today, ”
I hear ev’ry mother say
Mother needs something today to calm her down
And though she’s not really ill
There’s a little yellow pill
She goes running for the shelter of a mother’s little helper
And it helps her on her way, gets her through her busy day

“Things are different today, ”
I hear ev’ry mother say
Cooking fresh food for a husband’s just a drag
So she buys an instant cake and she burns her frozen steak
And goes running for the shelter of a mother’s little helper
And two help her on her way, get her through her busy day

Doctor please, some more of these
Outside the door, she took four more
What a drag it is getting old

“Men just aren’t the same today”
I hear ev’ry mother say
They just don’t appreciate that you get tired
They’re so hard to satisfy, You can tranquilize your mind
So go running for the shelter of a mother’s little helper
And four help you through the night, help to minimize your plight

Doctor please, some more of these
Outside the door, she took four more
What a drag it is getting old

“Life’s just much too hard today, ”
I hear ev’ry mother say
The pusuit of happiness just seems a bore
And if you take more of those, you will get an overdose
No more running for the shelter of a mother’s little helper
They just helped you on your way, through your busy dying day

Notes con’t:

2. More deaths for those who were regular daily users v the infrequent.

3. 3 weeks is the longest time they should be prescribed, per the speaker. Most long term users stay at same dosages, but they have rebound anxiety and end up raising the dose over time. When your patient c/o anxiety while on a benzo — and you choose to up the dose — you’ve done opposite of what you were supposed to do.

4. Primary care providers are the bigger offenders, that is, prescribe benzos the most, possibly because they feel pressured to solve all the problems of their patients.

5. Studies are reporting on stats by psychiatrists and not NPs. Add the NPs and the stats would be different.  For many providers it’s much quicker to write the script than it is to  do MI or other counseling in an effort to back off the dose or taper off. There are providers out there that will write for benzos with no intent to stop because it’s lucrative work, sad to say.

6. GAD has so many somatic c/o so they end up in primary care and while there they end of getting a rx for benzo.

7. Best anxiolytics are SSRIs. Take a bz to bridge until they kick in, for 2-3 weeks, and then stop without taper.

8. DSM5: MDD with anxious distress… emphasize the last part and that it’s linked to the first, as say of encouraging someone to try and SSRI.

9. Why do many people with trauma dislike taking bzd? They feel a loss of control when on them, less reactive, less fight/flight.

10. Dementia and increased falls.

11. It’s expensive to treat all the collateral damage, eg, falls, car accidents, etc.

12. 2.5 x higher rate of suicide attempts: from a big study in Taiwan she mentioned (I don’t have the reference).

13. Anterograde amnesia (use midazolam in your teaching and why it’s used in medical procedures), dissociation, cognitive impairment, paradoxical anxiety that is proven in PET scans. It makes you not care about the anxiety, not care about possible risks. hinders fight/flight — exactly what trauma survivors don’t want.

14. Cognitive impairment makes it hard to learn the skills needed to curb anxiety.


16. CBT to get people off benzos: question why you think it’s helping your anxiety.

Questions from the audience:

State hospitals and volatile patients and common use of bzd’s: increases impulsivity but they’re slower and we can catch them. Use a different gaba med that’s not the benzo receptor: lamictal and gabapentin. both slow the firing and allow staff time to think. State hospitals may want to use benzo cause it’s cheaper.

Alternative anxiolytics: Effexor — more adrenergic at higher doses. 75mg is antidepressant. Fetzima more adrenergic at lower doses so better tolerated. Buspar helpful; others: lamitical and gabapentin. alpha and betas blockers: trauma clients do better on these and feel it right away.

Schizophrenia and benzos: no indication but had been used for akathisia.

APNA 14th Annual Clinical Psychopharm Conference

Yes! It’s conference time in Baltimore! I’m excited to be here at the 14th Annual CPI. The program this year includes many important topics and I’m going to try my best to write a little about the sessions at the end of the day. Conference registration is downstairs in 29 minutes so I better get ready to head down there.



Recovering From Rotator Cuff Surgery

Yesterday was my last follow-up visit with my surgeon. He told me that PT was now optional, and that over the next month or so I could ease into regular life with a new shoulder.

That came as a surprise because I’m still going to PT and am only on 1 or 2 lb weights for strength training. He said I could resume mountain biking (only gravel roads for the next month). When I asked him what would happen to my shoulder if I fell while biking, his answer was that the operative shoulder is now the stronger of the two, even at this stage of recovery, so if I fell no worries! That was hard to believe.

I still have pain but it’s not constant. I still only take prn nsaids plus prn Tylenol and that’s plenty sufficient. I’m able to get through an entire workday of hand writing all my notes (no EMR) — something I couldn’t do in the days leading up to surgery.


GET THE BEST SURGEON YOU CAN, that is, the one with the most rotator cuff repairs completed with success. Ask local physical therapists which ones they recommend if possible.

GET THE BEST RECLINER YOU CAN AFFORD —  I opted for a lesser model with the thinking that I wouldn’t be using it for too long. That was wrong — I’ve used this recliner so much that it’s starting to lose it’s comfy luster of newness.

DON’T BELIEVE EVERYTHING YOU READ ONLINE ABOUT HOW PAINFUL IT IS. Yes, it hurts, but not like I was led to believe from almost every post I read.

THE WORST PART WAS NOT BEING ABLE TO SLEEP WELL DUE TO POSITIONAL CONSTRAINTS and subsequently being sleep-deprived. Caution: DO NOT USE AMBIEN or similar products for sleep. You could accidentally do something in your sleep that could damage your shoulder (I took off my brace in the middle of the night and didn’t know it until I woke up in the morning — brace was supposed to be on 24/7).

That’s it. Contact me if you have questions about RC surgery. I am happy to try and answer.

Be well!