Moving

I didn't blog as much as I thought I was going to in 2011.  I'd like to keep posting, but I obviously can't keep using a 2011 blog.  So I'm renaming my blog and moving.  In case you're following me, I can't promise that I'll post more often, but I'll try.  My new blog is called Dave's Side of the Story, and can be found here:

http://davessideofthestory.blogspot.com/

Thoughts on the Therapeutic Relationship

I believe that one of the core elements of effective nursing practice in any setting is the interpersonal relationship the nurse forms with a person responding to a change in health status. 

The goal of nursing intervention is to benefit the client by meeting needs.  When the nurse-client relationship is beneficial, the client need can be met more effectively.  The client can be an individual with a health need (patient), the friend or family member(s) of the patient, or a broader population (community, class, group of patients, etc.)

The term “therapeutic” is synonymous with “beneficial.”  The nurse-client relationship is a “therapeutic relationship” when the nurse uses interpersonal skill and expertise to help the client.

The skill and expertise that the nurse uses to create a therapeutic relationship are called therapeutic communication techniques. 

The concept of communication includes a two-way process involving the sending and receiving of messages.  Therapeutic communication techniques include saying the right things (sending) as well as listening effectively (receiving).  Additionally, the nurse must recognize that the majority of communication is unspoken (nonverbal and paraverbal).

Therapeutic communication skill includes awareness of the unspoken communication that the nurse both sends and receives throughout the relationship, and awareness of personal effectiveness, personal challenges, and a desire to improve based on this self-awareness.

Skill at using unspoken elements of communication is essential when the nurse cares for a client who is unable to communicate verbally.

The concept of relationship means that the communication occurs over time.  This may be time-limited to one conversation or even one interaction, but there is still a time element.  Each message builds upon previously sent and received messages, strengthening the trust and confidence the client feels about the nurse and the care being delivered. 

There are substantial differences between a therapeutic relationship and a social relationship.  In the following chart I use the word client to describe the person in need of nursing intervention in response to a change in health status.  However, the “client” could also be a family member, a group, or a community.

Therapeutic Relationship	Social Relationship
Primary focus is on the client.  The goal or purpose of the relationship is to benefit the client.	Mutual focus.
Client and nurse perceive the nurse as helper and the client as in need of help.	Friends give and receive help and perceive each other in both roles.
More defined limits of time, space, place, and type of relationship.  The nurse has the responsibility to establish and maintain these limits.	Fewer limits on the relationship.  Limits are set mutually.
The nurse must maintain a balance between intimacy and detachment.  Intimacy means forming a close relationship with the client.  Detachment means not becoming friends with the client and not taking client behavior personally.  Simply stated, the nurse must be friendly with, but not be a friend with the client.	Detachment skills are not crucial to communication in a social relationship.
The nurse has professional responsibility to communicate therapeutically. Two keys to this: 1.  Nurse should get social needs met outside the therapeutic relationship. 2.  Nurse must increase self-awareness through self-assessment to improve therapeutic communication skill.	Friends may communicate therapeutically, but may not consider this a responsibility.
The nurse is professionally bound to honor confidentiality.	Confidentiality is important but not an obligation.

I'd be interested in hearing comments from my nurse friends.  What do you think about the concept of the therapeutic relationship?  Do you see yourself using relationship and communication skills in your practice?

Reflections on Nursing: The Therapeutic Relationship

I have been thinking about writing some essays about key concepts in mental health nursing, maybe with the idea of publishing something.  Here's something I wrote about the therapeutic relationship a while back.  I really like how I was able to describe what is often times so difficult for me to put into words.  While this is a core concept in mental health nursing, I believe that nurses in any area need to recognize that we may not be able to accomplish much alone.  

That's enough of an introduction.  

A few years ago one of my students wrote about her experiences with people with mental illness.  She wrote about someone close to her who was struggling with depression:

She could not escape from telling herself horrible things in her mind like “You’re not good enough, you’re never good enough,” “You’re so ugly, who could love you?” “You brought all this down on yourself by not being the wife he wanted you to be” – just awful things that were not true! Her mentality was breaking her and holding her down.  But she could not conquer the thoughts.

All through school I was always the friend that tried to fix everyone’s problems.  I was good at it.  I always had the “mature” answer, apparently. I have tried to give people my opinion but also offer them tools that have proven successful for me in order to allow them to solve problems themselves.  But I cannot always save people from doom.  I have to let that go sometimes.  People, just like me, have to learn lessons on their own.  I need to listen more and talk less.

I circled three sentences on her paper (underlined above) and wrote the following comments to her:

Both the “could not escape” and “could not conquer” comments paint a grim picture of almost inevitable despair as a result of mental illness.  Note also the last comment that I circled.  You (we, anyone) cannot always save people…another grim picture.

Yet I firmly believe that there is hope.  Even though we cannot always “save” people, we CAN help them.  We CAN interrupt the slide into madness and despair as moods shift or thoughts torment.  We can brighten a minute or an hour of a bleak day.  A person may not be able to “escape” or “conquer” illness alone.  We may not be able to save anyone alone.  But we can accomplish things by working TOGETHER.  This is the power of the therapeutic relationship.  Neither the client nor the nurse may be capable of achieving much by working alone, but a partnership between client and nurse gives both of them the chance to make a difference.

Pain Part 2

If you talk to a pain specialist she or he will tell you that there are a number of different types of pain.  (Bone, muscle, nerve, acute, chronic, etc.)

If you live with pain for a while it doesn't matter what type it is.  Oh sure, you need to be able to use the right sort of therapy (heat vs. cold, for example), but the bottom line for the person in pain is simply that you're in pain.  Period.

When you're in pain for a while it is always with you.  It's like a close friend, in a really weird sort of way.  You become so intimately familiar with the pain that you're closer to it than you are to your lover.  You are acutely aware of how this intimate friend will react to whatever you do.  However you move. Where you put your foot when you're walking.  Which hand you'll use to open a door.

Another intimate relationship develops at the same time.  This is the relationship that the person in pain for a while develops with the treatment for their pain.  This relationship becomes an essential part of your ability to function, just like the relationship you have with pain influences your ability to function.

I'm currently juggling a delicate balance of seven different medications to manage the flare up of pain I'm dealing with.  So now in addition to the intimate relationship I have with thinking about how moving, breathing, thinking, stepping, turning, eating, and any other functioning will influence my new friend, I also have to think about how which of the seven medications I can take when, how they'll interact, how my eyesight will be affected so I can drive, and how I can remember not to mix up my timing so I don't accidentally kill my liver or some other important organ.  Plus I have to try to stay awake, and try to stay asleep.

Sometimes the medication is worse than the pain.

And there are other things I'm doing for this.  Exercises to restore muscle balance.  Heat and cold therapy.  Meditation and prayer.  Reaching out for support from friends and family.  Each of these both help and hurt.  Each of these at some point or another becomes a vital function just to live.  To live with pain.

Thankfully I can feel progress.  My pain is starting to diminish.  It's still there, but it's less.  The medications and treatments are working.  Soon I'll be pain free again.  For a while.  Until my old friend (enemy?)  comes back and takes over my life again for however long it is next time.

I will be back to golfing, hiking, walking, sitting with friends playing games, and living without having my world dominated by pain and treatment schedules.  I will not sink into despair, even if this goes on far longer than expected.  Because I have other intimate friendships that I can rely on to help me live.

Pain

I had curvature of the spine when I was a teenager.  The technical term is kyphosis, which means a front to back curve.  Usually people with curvature of the spine is scoliosis, a sideways tilt.  The treatment for curvature is to take the spine apart and fuse the vertebrae together.  Then the surgeons install a steel rod on either side of the backbone to help hold the fused section.  Because I had kyphosis, my fusion needed to focus on both the front and back of the vertebrae, instead of the sides.  This required two surgeries, two weeks apart.  The first surgery addressed the front of my spine.  To reach the front, the incision started about an inch or so below my navel, then went diagonally up to my left side, vertical to my armpit, and around my back to a spot to the inside below my shoulder blade.  To get at my back, they cut through all the ribs and basically opened me up like a clam.

They harvested bone chips from my left hip bone.  These chips were placed between the vertebrae to rebuild them to the right thickness to correct the curvature.  I spent two weeks in halo traction after this surgery, then had a second surgery fusing the back of my vertebrae and installing the steel rods.

After another two weeks in the hospital, they sent me home in a plaster body cast.  I spent nine months in a body cast, spending about half of my senior year of high school popping Tyelnol 3 like candy.  The part that hurt almost more than anything else was the hip.  After all, the plaster cast pretty much rode on the where they took the bone chips.

After I got out of the cast they said I was fine, I could do anything except play football or go on a trampoline.  And for the most part, I was fine.  I rarely had any back pain, and if I did I simply took tylenol or ibuprofen.  I went to nursing school, worked the floor lifting and moving patients (always being careful about body mechanics), backpacked, water skied (that was a mistake...), and built and roofed a garage, drywalled two houses, and pretty much anything else I wanted to do.

Then in September of 2007 everything changed.  One of the things that happens when a spine is fused is the removal of the disks between the vertebrae.  One of the functions of the disks is to absorb shock.  I had about 14-16 inches of solid bone in the middle of my back, which meant no shock absorption for my lower vertebrae.  In August of 2007 I hiked 11 miles through Glacier National Park.  No problem.  But in September, 2007, I hurt my lower back at work, despite using the "right" lifting techniques.

On Labor Day I woke up unable to walk.  My legs simply quit working.  I had to crawl to get out of bed and to the bathroom.  My boys and wife had to carry me to the van so I could get to the ER.  The ER doctor initially accused me of being drug seeking (Are most people with bad backs druggies?)  He later apologized when the x-ray showed that I had broken one of the steel rods that was supposed to be holding my fusion together.

I ended up going home and had a wheelchair delivered.  I went to an orthopedic specialist on Wednesday (first day I could get in) who described the problem.  The front of my fusion was collapsing, the vertebrae under my fusion were turning into powder, and I had compression on all the nerve roots causing my weakness.  I got a brace, oxycontin, an order for physical therapy, and a probable surgery date.

I was out of the wheelchair by the end of September, but by November it was clear that the predicted surgery was unavoidable.  By the way, oxycontin is pretty incredible stuff.  Theresa thinks it made me crazy, but I was able to work half time and when I look at some of the stuff I wrote during that time it's pretty lucid, so I doubt it was that bad.

My surgery was early in December.  The orthopedic surgeon and a neurosurgeon worked together to basically take my back apart and rebuild it, from the joint where the first sacral vertebra joins the hips up to about the middle of my chest.  They cut all the muscles away from my back, straightened everything, including notching the front to straighten things up, reattached all the muscles, and then woke me up.  While the incision was still open.  They wanted to make sure that before they finished they hadn't left me paralyzed.  Once they were sure, they put me back to sleep and then finished.  They probably carved their initials in one of my bones, I wouldn't know the difference (that was supposed to be a joke).

I've got a handful of screws, clips, and broken rods from my 1978 surgery sitting in a bowl on the mantle in my living room that my surgeon gave me.  My back is now held together by a combination of screws (ranging from 70mm to 35mm in length), plastic mesh, titanium, clips, hooks, and probably some other stuff.  I've seen the x-rays, it sort of looks like I could open a True Value hardware store.

So now we get to the point of this post.  Pain.

While I was in the hospital the worst of my pain was caused by muscle spasms.  You have to realize that the surgery straightened me out, and added almost three inches to my height.  That's how much my back was collapsing by collapsing vertebrae and forward tipping.  So when my muscles got reattached, they got stretched three inches or so.  Which causes spasms.  And those hurt.

They called in the Palliative Care Specialists to develop a pain management plan for me.  The Palliative Care people usually deal with advanced cancer patients, hospice cases, and the like.  After tinkering with a number of different muscle relaxants, they found a mix that worked.

I took myself off oxycontin in December, a few weeks ahead of the plan.  I was back to work in February, a month ahead of time.  I had very few episodes of pain over the next couple of years.  The two worst were at the Gathering of Friends in 2010, which I'm blaming on the bed, and in the spring of 2011 when I hiked on steep hills.

Until now.  I have been dealing with intense, excruciating pain since last Thursday.  I thought it might be related to backpacking two weekends ago.  Except I got back from that trip on Sunday and would have golfed Monday night if I didn't have a staff meeting.  My back didn't start hurting until Wednesday.  The most likely explanation is stress, coupled with carrying a few relatively bulky (but not too heavy) things at work.

Stress?  I can blame work and my daughter's wedding coming up this Friday.

So how am I managing?  First off, I had a supply of muscle relaxants left over so I started in on them Thursday.  On Friday I got a few refills to make it through the weekend.  Then I got in to see my orthopedic surgeon Wednesday to make sure I hadn't broken anything.  Most of the pain has been high up, so I was worried about maybe some loose hardware or a broken rig.  Thankfully, nothing is wrong.  He also gave me prescriptions for some of the things that the Palliative Care specialists had put together but I no longer had refills available.  And he told me this is probably going to take three or four weeks to go away.

My life for the last week or so has been centered on the list of meds I have taken so far today, and shorting out when I can take the next.  The pain is slowly going away, but I'm still on schedule.  But I'm not looking forward to four weeks of this schedule, but since it worked before, I'm confident it will work again.

North Country-Manistee River Trail Loop June 2011

My seventeen-year old son Nick and I have been planning this trip since February...

Friday

Inevitable delays: needed new moleskin, stopped at Rite Aid.  Realized on the way that we had forgotten the water bottles, so had to stop at Family Dollar in Baldwin.   Had to take a detour of several miles off M-37 because there’s a bridge out just south of M-55.

Made our last stop at the gas station on the corner of M-37 and M-55.  Filled the quart water bottles we bought in Baldwin and bought a couple of 1 liter bottles of Aqua Fina.  I figured we’d do the North Country Trail side of the river first, so we needed plenty of water.

We reached the Upper River Road trail head at 4:30.  I wanted to park here instead of Red Bridge simply because it saved us 0.8 miles of hiking on Friday.  Since I had no idea where we were going to find a spot to camp, I figured the sooner we were on the trail, the better.

There were quite a few mosquitoes circling the van as we changed in the parking lot before hitting the trail, but they didn’t seem hungry.  I didn’t even bother putting any repellant on and they ignored me.  The weather was about perfect: mid 60s, not too humid, almost no wind.  No hint of rain yet, but the 70% chance of overnight rain was another reason I wanted to get going sooner.  We hit the trail at 4:50 PM.

The woods were amazing!  It was sunny, and breathtakingly gorgeous!  The woods were filled with steep hills with views partially obscured by thick foliage.  Speaking of steep, the trail itself was steep.  It started out steep, and got steeper, as the trail generally ran north along a north-south ridge.  Also, there were many steep climbs followed by steep descents.  This is about the steepest hiking I have ever done in Michigan.  Some of the hills were as bad as some of the Adirondack high peak trails.  I had to take frequent rest breaks, even though I was carrying only 18 pounds.  My back surgery has changed the way my body reacts to hills.  I put more strain on my hips than ever before, and they were aching.

We reached Forest Road 8060 at 6:50 PM.  This is a little over 2 miles from where we started.  Considering the frequent rest stops we were taking and the trail condition, a mile per hour was a reasonable pace, I think.  The topo map suggested some flat areas about a half mile past the road, but it also showed a steep climb to get there.  By 7:20 we had climbed back up the ridge from the road, and had found a perfect campsite about where the map suggested things leveled out.

It took less than 15 minutes to set up camp and get the stove lit.  Supper was Minute Rice with spices added.  In addition to the minute rice I added dehydrated green beans to the boiling water to sit while the rice cooked.  When it was done I opened three salmon steak packages and added the entire contents to the pot, then simmered everything for a few minutes to heat the salmon and steam off the extra water.  It was incredibly good.  I’ll be doing this again, it’s a lightweight meal that’s simple to fix.

Saturday

The rain hit at 4:40 AM.  It rained very hard but nothing seemed to be leaking, so I fell back to sleep.  We were awakened about 6:30 in the morning to the sound of people running on the trail.  Seems there was a 75 mile, six person relay race going on, and our trail was one of the legs of the relay.  Later in the morning I found a paper dropped by one of the runners, describing the terrain of this trail as “gut busting” and “visually orgasmic.”  Both descriptions seemed pretty accurate.

It had stopped raining by the time we got up, so we didn’t have a lot of wet gear to pack.  The tent kept us almost 100% dry.  The Tyvek ground sheet worked great, and the packs were dry under the large vestibule.  We hit the trail at 8:30, after a breakfast of granola bars and trail mix.

The terrain continued to be quite rugged, and remained gorgeous.   There was a steady upgrade for a while (long but not steep), and at one point a beautiful grove of tall red pine trees (that smelled great!)  We left the North Country Trail and connected to the Manistee River Trail at 10:50.  We reached the suspension bridge a half hour later, at 11:20.

We stopped for a 15 minute lunch break, enjoying the view and talking to a few people who were on their way both directions.  We talked for a while to a group of boy scouts from Lansing who spent the night at Seaton Creek Campground (1.25 miles east).  They were hoping to do the entire Manistee River trail today and the North Country Trail tomorrow.  Ambitious!

It doesn’t seem to be as densely wooded on the east side of the river, and the frequent views of the river added something to the scenery that made for a very different kind of beauty. Also, it seemed like the trail was less steep for the most part. 

Most of the time the trail is 100 to 150 feet above the river, and it’s too steep to climb down to the river.  I was getting worried about finding water to filter, until we crossed a small bridge over a fast-flowing stream.  I filled some empty water bottles so we could filter when we stopped for the night.  And I worried about where we were going to camp.  I wanted to stay ahead of the boy scouts, so that we could get the site I wanted before they ran out of steam (I didn’t think they would make it the entire nine miles to Red Bridge in one afternoon).  But they were ten and I’m fifty, so they got past us within about a half hour. 

Camping is only allowed on designated sites on the east side of the river.  As we reached each of these sites we found they were already taken.  It would work to be there with someone else, I suppose, but I wanted to be alone if possible.  As we passed people heading north I asked if the next campsites were taken yet or not.  Campsite 3?  Yes.  4?  Yes.  5?  Someone was just setting up there when we passed.  6?  Not yet.  So campsite 6 became my goal, even though it meant we would probably end up going almost 9 miles today (and I thought I was sore after 2.5 miles yesterday!).

 

We reached campsite 6 at 2:15.  It was empty, so we claimed it for our own.  What a beautiful spot!  The river here flows straight south, bends sharply to the east, then sharply back to the west, sort of like a flat question mark.  There is a fire pit on the bank next to the trail, just a few yards from the cliff above the river.  The view from the site is straight north.  Two hundred yards or so to the east, along the sharp bend to the west, is a cliff filled with swallows, who entertained us by swooping, darting, and flying over the water while keeping the mosquito population down.  Looking to the northwest in the distance we could see the hill we camped on the night before on the North Country Trail side of the river.

I took a half hour nap, then filtered water.  As I was finishing this, the boy scouts who had passed us a few hours earlier passed us again.  They had taken a wrong turn, and some of the kids were almost in tears as we talked with their leaders.  They still had five miles to go to get to Red Bridge, and it was after 3:00 already.  I felt sorry for them, and wondered how they would make it through the more rugged North Country side tomorrow.

Supper was dehydrated chicken fettuccini, which was very tasty.  We were so tired that we ended up going to bed at 7:30.  

Sunday

We were up at 7:00 (slept over 11 hours, wow!).  There was no rain through the night, but our campsite was windy and cold (down to the low 40s).  Our food bag was soaked from dew in the morning.  Even though I had packed the instant oatmeal inside a plastic bag inside the food bag, the packages were wet and the oatmeal was pretty much inedible.  So it was another breakfast of granola bars and trail mix.

We packed quickly and were on the trail at 7:45.  The trail south of our campsite continued to be beautiful, but there were fewer views of the river.  Some of the smaller creeks we crossed were very pretty, and tasty, once we filtered them.  About two miles south of our site, at the top of a large bend in the trail above the river, we ran into the boy scouts who were hoping to reach Red Bridge yesterday afternoon.  We passed them about 9:30, while they were cleaning up from breakfast.  I hope they didn’t try to make it to Red Bridge, up the North Country Trail, and back to Seaton Creek campground with that late of a start.  At their pace they wouldn't make it back to Seaton Creek until dark!

We finished the five miles to Red Bridge at 11:00.  Some of the views at the south end of the trail are amazing.  After a 10 minute break, we headed out on the final .8 mile trail to get to the parking lot, covering that in about 20 minutes. 

Total distance: about 16.5 miles

Gulf Games: The Games

I don't track which games I play any more.  It got to be more effort than it was worth, and it also ended up being a meta game of sorts.  I'd check to see what I "had" to play because I hadn't played it in an while.  So basically I'm not sure exactly what I played at Gulf Games.  I'll comment on a few things.

7 Wonders
Build an ancient wonder of the world using a hand of cards that you pass to your neighbor after choosing one card.  Competition with your neighbors means you sometimes want to keep them from having a card you would otherwise pass.  I like games that present you with a dilemma like this.  Unfortunately, this game is "temporarily out of print" so impossible to find.  I will buy it ASAP (have reserved a copy from Game Surplus).

F something
New 2F game.  Breweries want your goods (water, hops, barley).  You produce some to start, your production changes as you add cards to your 2x3 board.  Supply and demand sort of happens at the breweries.  Turn order favors those who made the least money.  Boring.  I'm not sure if I played it or if it played me.    I won't give it another chance.

Zombie Dice
Fun push-your-luck dice game that I wish had a slightly different theme, but I'll be buying it anyway.

Auf Achse
Of course I played this.

Knot Five
Outstanding deduction game designed by James Miller as the "game of the day" at the Gathering a few years ago.  Won't ever be published, but someone had done a nice ArtsCow version.  If I was any better at this type of game I'd consider doing the same thing.

Tichu
I played two or three games of this, and won each time.  One incredible steamroller win that lasted five hands and included a 1-2 Tichu on two separate occasions.  Plus a blown Grand on the second-to-last hand that would have worked if I hadn't passed my partner a 6...which created a bomb.

Lemming Mafia
Really fun game where you're the mafia attempting to get some lemmings to go in the water first, even if you have to put concrete boots on them, drive them in cars toward the water, etc.  Plus you are betting on who you think will be last alive, and asking the Don for favors (discarding special objective cards that are no longer possible because some other mafioso at your table sent the "wrong" lemming to sleep with the fishes).  Lots of laughs.  My first pick from the prize table, to the delight of my son.

What else?
I know I played more than this.  I was something like fourth place on the friendliest person chart so I must have played more than this.  Even though I can't remember everything right now, I had a blast, so I'm not worried about it.  I won't start logging games again.