I Want to Be a Doctor

Dr. Robin: Welcome back to I Want to Be a Doctor or Something. I'm Dr. Robin, and I'm here with my friend, Nurse Jill, who's a registered nurse.

Jill: Hi, friends.

Dr. Robin: We're two healthcare besties sharing the real, wild, and funny side of medicine for anyone who's thought about a career in healthcare. Ready? Let's go.

Dr. Robin: All right, you ready for another Never Have I Ever?

Jill: Yeah, I think it's my turn this time, right?

Dr. Robin: It is. Okay, so here's my question—or my Never Have I Ever. Never have I ever had a patient with psychosis threaten me.

Jill: Ooh, I have.

Dr. Robin: Have you?

Jill: Yes, yes.

Dr. Robin: I figured, because you said you worked in geriatric psych. I figured you probably had.

Jill: I did about 10 years in geriatric psych, so I've had a few instances, but there's one that really stands out to me.

The patient was in a really bad situation mentally. He had not been treated or taking his meds like he was supposed to, and so he had landed on my hall. We were treating him there, but he was mobile, so he was ambulating and walking and things like that.

He came up to me at my med cart while I was doing med pass and started just yelling, cursing at me, making physical threats. And I'm like, "Oh, okay, what did I do? Hold on a minute." Then he started trying to take the meds off my med cart.

But I could tell definitely that he was having some hallucinations and delusions. It was still kind of scary, though, because it was night. We were pretty short-staffed. I didn't have a CNA or another nurse on that hall, so I'm by myself, and I'm just thinking, okay, what's the best thing to do?

So I just kind of stood there until I knew help was coming. I let him talk and tried to talk in a calming voice and things like that, and then mainly just kind of listened.

But he did end up getting a shot that helped him calm down and helped him rest. Later he got treatment and everything, and he didn't even remember the episode. It was a little bit scary just because I was on the hall alone, but it happens with patients. We always knew as well that the patient was just in a bad situation and just needed help and treatment. Thankfully, we have lots of tools for that.

Dr. Robin: Oh boy, do we ever. Well, and the fact that you never held it against him—he didn't remember it. That's one of the things about being a healthcare caregiver: you know people do things they don't mean.

Jill: Yeah, yeah. You just don't take it personally. You hope that you can help them through the situation.

And something that we were always taught—and I know you were too—is keep yourself safe. If I knew that he had a means to really harm me or something like that, then I might have handled it a little bit differently. But I could tell that, in his condition, he was just going through a really, really difficult breakdown.

He did get better, and he changed. He was totally a different person within maybe, I don't know, two or three weeks. He was very pleasant, very calm, and went back to his normal baseline, thankfully.

Dr. Robin: Oh, I'm so glad he went back to that normal baseline. It sounds like he didn't even remember what it was like, which is one of those things where I'm like, having them not remember is a blessing.

Jill: Yes, it is. For sure. It is, you're right.

Dr. Robin: And being nighttime, was he sundowning too at all?

Jill: Yeah, I wondered that because, you know, I think he did. Looking back—it's been a while—but I think he did have a diagnosis of maybe dementia or something.

And also another thing with our geriatric patients, too: when they get UTIs, things like that can really, really affect them. I'm pretty sure that he was also tested for health conditions like that, and he would have been treated with antibiotics for that as well, because sometimes just something underlying like that can make someone act differently.

That was usually the first sign that we saw in our patients—agitation, irritability, things like that start increasing. We would always check for a UTI, and most of the time it would be positive.

Dr. Robin: Yeah, because older people often can't feel that they have a UTI, or they can't tell you, depending on the situation. I've seen that happen with older people too. It can just kind of take them to a different place mentally, for sure.

Jill: I was just thinking, if any of our viewers take care of older people or loved ones, or they're working in that environment—and you probably already know—but if anyone's personality just starts to change and they are older, that's always a good place to look. It may not be a UTI, but a lot of times it could be something related to that, or dehydration. You would see some changes. Simple things.

Dr. Robin: I remember both of those happened with my grandpa, who had dementia: dehydration and UTIs.

And then also, we should probably define sundowning. Sundowning is when, at nighttime, people who are more stable during the day—sometimes people who are totally fine when they're at home—are in this strange environment of the hospital or a facility where they aren't oriented to where they are, they don't know what's going on, it's nighttime, and then they get confused.

So sundowning is kind of the name given to what happens at night. Which is not like Las Vegas, where what happens at night stays at night, but a little bit different.

I remember one patient—this was in a nursing home. In residency, we all had our nursing-home responsibilities, basically. At this one facility, there was this older woman, and she was so sweet. She was a nurse her entire life. She'd been a nurse for like 40 years. Now she was in a facility and she had dementia.

During the day, she was just normal, sweet, pretty aware of what was going on, a little bit confused. But then at night she would think that she was a nurse going to work, and she would go from room to room checking on all the patients and waking them up. Which, of course, imagine a nursing home in memory care, waking all these people up. It did not go well.

They tried to stop her, and then finally one of the nurses had the best idea. Every time she'd get up, the nurse would say, "Betty, what are you even doing here? It's your night off. I'm here tonight. I'm working. Go home. Go watch some TV."

And so then she'd go back to her room, thinking that was her night off. I thought that was a great solution to that problem.

Jill: Great. That's really sweet.

Dr. Robin: So yeah, once you're in healthcare, it probably stays with you the rest of your life. Certainly she'd been doing it for that long as well.

Jill: Yeah, and she'd worked night shifts the whole time.

Dr. Robin: Which is not good for your brain, to work night shifts all that time.

Jill: I found that out.

Dr. Robin: Yeah, probably contributed to her dementia. I don't know.

Jill: Yeah, probably so.

Dr. Robin: But also, she was used to going in and waking people up. And so that's why she kept doing it.

Jill: That is funny. That's really sweet. Well, it sounds like the nurse who was taking care of her handled that very, very well—very therapeutically.

Dr. Robin: That was in the past when they would still argue with people and try to bring them back to reality. And I really appreciate that she was so patient-centered: what does this person need? Instead of, let me convince you—because you're not going to convince someone with dementia of anything.

Jill: Exactly right. Yeah. People did mistake that for the appropriate way to talk with someone—to try to bring them back to reality. And you're exactly right. It just causes more stress. It makes the patient react more. They can't comprehend it if they're in that type of state.

Dr. Robin: No. For me personally, if I were ever in that state, I would much rather people just go with it. Work with me where I'm at. Don't argue with me. That just sounds stressful. I'd rather just not know.

Jill: Very true. And that reminds me of another patient that I had. It was also in geriatric psych, but he was a retired firefighter.

He would get in his wheelchair and roll down the halls yelling, "Fire!" And it would scare all of the patients in there. It was really, really funny because he was like, "Fire! Fire!"

So it was hard to get him to calm down because he was reliving those moments. And it did seem to happen around sundown time as well.

Sundowning is really interesting. I've always found that very fascinating. It's sad for the person experiencing it and the people who are caring for them sometimes, but it happens like clockwork.

Dr. Robin: Yeah. One of the facilities I worked in, they were really working on addressing it. I remember one of the things they did was really work on the lighting, because the hospital lights—or nursing-home lights—are so bright.

What they would do is, in the morning, they started basically bright-light therapy, like you would for someone with seasonal affective disorder. They'd wheel people out to the patio and get everyone outside first thing in the morning.

Then in the evening, they would dim all the lights. You have to be careful because you don't want them to fall, so they'd dim the overhead lights and go more with lamps and more normal indoor house lighting, and do more bedtime-routine type stuff like you would at home.

It really made a difference. They saw a huge decrease in sundowning.

It's interesting. I think about how disoriented I was in the hospital, and I was in my 20s. I can only imagine how disorienting it would be for someone who had not worked in a hospital and just was suddenly in this weird environment.

Jill: Oh yeah. It would be very, very difficult. So they were decreasing stimuli. That's very important to do for patients who are in distress.

We would do things like that—turn the lights down, turn the noise down, TV, things like that as well—and just let the patients get more relaxed in the evenings too. It really does decrease their stress, it seems like.

Dr. Robin: Yeah, hospitals are so chaotic. I think back—I was pregnant with Charlie when I was in residency—and sometimes I'd be sitting there in the ICU with all the dinging and alarms.

I'm like, he can hear all that to some extent. It's muffled, right? But I wonder how that's affecting a developing brain. He doesn't associate it with an alarm the way I do, but at the same time it's constant chaos and noise compared to this picture I had in my mind of what I should be doing, which is resting.

I was like, I wonder how this is affecting him, being in there hearing all these dinging alarms and things like that. I don't even know if they've studied that at all. But it just seems—certainly as a patient, it can't be good for recovery to hear the chaos. I know for myself, as someone who was exhausted and stressed, it was not helpful.

Jill: No, of course not. Maybe some of our viewers know if they have studied that or not. But I do recall, a long time ago, hearing about a study with classical music that they played for babies in utero and how it affected brain development, and it was positive or something. I don't remember all the statistics on that, but it was a cool study.

Dr. Robin: The Mozart effect. People actually made money off of that one.

Jill: Wow. Okay.

Dr. Robin: They sold Mozart CDs and little headphones to put around your belly.

Jill: Do you think it really makes that much of a difference, or was it a gimmick?

Dr. Robin: I can't remember. I think it does make a difference—not a huge difference. I mean, all these differences they look at, how do you even control for it too?

But my favorite pregnancy study was moms who read Dr. Seuss to their kids. You know, like One Fish Two Fish Red Fish Blue Fish, or Green Eggs and Ham. They have that rhythm to them.

So they had moms read Dr. Seuss to their babies before they were born. Then after they were born, they had the moms read different books, and the babies would react when they heard the Dr. Seuss, like, "I've heard this before." So I thought that was cool.

Jill: That's so cool. That is really sweet.

Dr. Robin: Yeah. So we do know they're doing some things. And I don't know about you, but I remember my babies following the flashlight. We'd shine it around my belly and they'd be kicking at it. So there's new stuff going on in there.

Jill: Yeah, definitely. My mom's told me for years that after I was born, I heard my dad's voice and I turned my head.

Dr. Robin: Uh-huh. You're like, "Oh."

Jill: And hearing is fully developed at birth, right? A lot of senses are. So long as they go full term, that last trimester they're just kind of completing everything.

Dr. Robin: Part of completing brain development is actually getting all your senses in line. Your brain develops first, and then you kind of send out all these feelers toward the senses of taste and smell and seeing and hearing. All of that is developing at the end.

Early in pregnancy, first trimester, they're not feeling—if you touch them, there's nothing. You have to have that brain development first. But toward the end, they actually react to different foods the mom eats because they can taste them in the amniotic fluid.

Think about bitter foods—if you've ever seen a breastfed baby who's like, "What did you do?" They've seen similar reactions in utero, which they can't prove. They can just look at whether they're grimacing or not.

But I have a cat here.

Jill: Oh, we have a visitor.

Dr. Robin: Puffin's like, "What is this?" So this is not my normal—normally you see Mazzy. This one is Puffin. Puffin's like, "What? What is going on here?" Good girl.

Jill: You have so many sweet companions there. So cute. I'm surprised I don't have a cat running around here somewhere. I have my daughter in my lap, but she's off today, I guess.

Dr. Robin: Some other time you'll have to bring her in so we can admire her.

Jill: Definitely, yeah. We definitely love our pets here at Dr. Robin's School, for sure.

Dr. Robin: For sure.

And I think that's all we have time for today. So that's it for today. If you want to be a doctor or something else healthcare-related, head over to docrobinschool.com/podcast. That's D-O-C, Robin-like-the-bird, school.com.

Jill: Yeah, and don't forget to subscribe so you don't miss the next episode. Thanks so much for watching. Bye.

Dr. Robin: Bye, friends.