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Addictions, Acute Psychiatry
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CASTLEGATES has 27 years experience and specializes in Addictions, Acute Psychiatry.

CASTLEGATES's Latest Activity


    Wilmington University RN-BSN ONLINE! wgu opted out

    Last Master's rotation that led to FNP's had not one but 2 instructors sleeping, instead of instructing graduate students. These were not the easy classes, but the infamous P's classes you really need for you career, and the boards. Classmates took it upon themselves to try to figure out the requirements (amidst snoring instructors) out of the syllabus themselves, since instruction was esentially nonexistent (despite complaints to the dean). After everyone graduated, they received letters offering them audits to retake these 2 classes. After passing the boards, who would want to go back and audit a class that should have been there, in the first place? Even more importantly, who wants to be treated by an NP who made it through the boards, lacking in critical areas because of sleeping instructors? It's unfair all the way around (since it wasn't just one, this signifies more global quality program concerns). Just a caution before you choose this option.
  2. Unfortunately the AANP wasn't even present during the DATA 2000 act that allowed only MD's to prescribe buprenorphine (nevermind NP's and PA's can prescribe potent opiates they can become addicted to). Due to the absence of NP's at that legislation, they were left out of the act altogether--even allowing the AMA to refer to NP's as "paraprofessionals" unanswered (paraprofessional=uneducated assistant of a professional). Subsequent efforts for legislation have failed, and something like 80% of providers who have the ability, still don't prescribe buprenorphine for addiction. They want this epidemic treated, but the AMA's got them by the toes and meanwhile, patients aren't being treated for the safest treatment for opiate addiction since abstinence. Since my specialty is addiction, I'm interested in any way to get legislation revisited, using the statistics of other countries (and our own failure to adequately treat the heroin epidemic). Even states like Maine have requested other providers be allowed to help, but the response was nothing but crickets. I'm currently in school (with the goal of opening an addictions treatment clinic). It looks like I'll be required to have a physician, if I want to treat them adequately (I was hoping for an all NP practice, like many have been emerging lately). There used to be a lot of internet chatter about this topic, but it faded off more recently. I'm interested in continuing to bark, until legislation is changed allowing NP's to treat opiate addiction with buprenorphine monotherapy and duotherapy. It WILL eventually happen, (just as NP's will continue increasing in numbers in acute settings despite AMA protests). It's just a matter of when. It would be nice if the when was sooner (to save more lives). France has impressive statistics, even with diverted drugs saving lives. Fascinating to see how we're just catching up to other countries as far as health care (since we're not even in the top couple dozen for neither health care, or life expectancy).

    Having kids & working 12hr nights??

    If my wife didn't stay home, we'd have a serious issue. It's complicated, but if she ends up being deported for any reason (still may happen-I don't want to get into detail at the moment), then I'll be in dire straits. I do 12hr nights. I've almost always done nights, since I'm nocturnal anyway. I researched nannies, babysitter, etc. It's bad 'cause you need someone to stay the night (just in case), then stay the day, while you're sleeping.

    Lateral violence. How did you handle it?

    For me, I know they cannot fire me, since I follow the rules and do exactly as directed. If they're breaking the law, I'll say something and run it up the pole (if that's what needs to happen). My only issues are unfair treatment and lateral violence, for which I have zero tolerance. If someone is targeting me, they'll pay and I won't let it go until something permanent has been done about it. It's just that simple. I cannot comment because I cannot see you in person to sense your demeanor, how you carry yourself, etc. I do sense the vibes another astute nurse observed, though. It reminds me of a comedy where the bad guy jumps into the window of a hotel, and the woman inside started yelling, saying "don't touch, me, don't touch me" (but her body was following him as she was disrobing)!! Two completely different things if you had either your eyes closed, or the sound off. It's very possible body language is saying one thing, words are saying another and I would also venture to assume this has been a pattern in other jobs and environments, before. Never is the victim to blame (don't get me wrong), but if I were you, I'd go for the kill (never maim). There is a process for formal complaints, and if it's not handled appropriately, they will owe you some money when you take them to court. You're there to work, not to make buddies. If they're making this impossible, there are plenty of ways to hold others accountable and if higher admin supports this, then you've got a slam dunk suit. Just that simple. Don't tolerate a second of it. Not a second. If they're not in the line of decisions that affect the jobs, or get things done, don't complain to them (collaborating physician, etc). Go to HR, tell HR you want to pursue and send certified letters.

    Doctors vs. Nurses

    People go to hospitals because they need nurses. Nurses are revenue producers, not just costs. When a patient is admitted, it is for nursing care. Labs and tests can be scheduled in, or outpatient, but it's the nursing care that gets them back to health. I keep hearing that physicians are revenue producers, nurses are costs (seems kinda ridiculous). We work as a team to get patients out of the door, and retain some income for their stay. Physicians will check outpatient to see how they are, and if they need 24/7 nurses again, they'll readmit them and we start again.

    First NP Job and unhappy...What to do?

    I echo what was just said.Take your clinicals, what you learned and apply to the best of your ability. Easy to say that (knowing you can't go back in time), but perhaps that may help those in clinicals now (see yourself handling all this on your own). Part may be confidence, and going to the other providers, busy or not, and asking them anyway. You've got to be a little aggressive, if it means sink or swim. Those are only my naive thoughts :-)

    Passing cut offs

    Mine was 80%+, as well. 96-100 for an A, 90-96 for a B and most were 85 (we dropped to #5 in the state and they changed everything).
  8. Their first impression will be when you walk into their office, and it's nursing not HR you need to impress to get hired (unless you're new to the field and can't read people terribly well). Rather than doing all the things suggested by a brand new nurse, change your name on your social media accounts to a nickname. Case closed. No HR at any hospitals Ive worked at have made any hiring decisions based on a FB account. (it was a new nurse that wrote the article, most likely reading articles online versus interviewing the hiring deciders themselves--none of it mentions anything about actual hiring decisions, so I don't see any real valid points).

    Too Young..Rejected from Graduate School

    When I completed my initial education, some schools wanted 5yrs to get an MSN (min). Now, some schools are letting nurses with fewer in, but that depends on the applicant numbers (where they can afford to be picky). I know earlier in my career, grades were more difficult to max. The more experience, each time I took a class, they got easier and easier. I'm now doing my MSN DNP and I have no doubts I'll nail it (because I'm old as dirt now) ha, ha! It's OK. I was 23 and looked 15 when I was new, needing at least 5 solid years before I knew what was happening (I was good at my SICU specialty, just not as well rounded as I could have been, especially for advanced stuff, I suppose). Meaning more to do with work experience (but age helped as well). Military considers 1-education 2-experience and 3-age when determining promotions.
  10. Post acute withdrawal syndrome can mimic schizophrenia, bipolar, PTSD, explosive d/o and others. This is why it's not recommended for addictionologists to stamp any new diagnoses on patients until they're finished wit PAWS. It can last anywhere from 2mos to 2yrs. Addiction is a disease, just like cancer. What do we do with a cancer patient who breaks his leg in an accident? We tend to place them in the unit where the most acute need determines where they go. This is the same with addictions at the psychiatric campus where I work. It's not fair to place addicts in a locked ward with people hallucinating, etc. Actually we had to learn this. A patient pursued this the legal route (when we did detox in a locked unit with psych) and the findings were--this was, in fact unreasonable and unjust to lock detox with acute psych (who can get violent), so no more detox patients into the locked units where I am (unless mental illness is the primary need). This is how triage, care, anything works (squeaky diagnosis gets oiled first) :) ha ha! Regarding the previous comments above: "The rest of them I couldn't care less what happens to them. They are generally, from my exp, ungrateful, needy, selfish, and just aholes?":madface: Whoa Nelly! Did I just read an professional RN calling a diagnosis group aholes ??? If you read no further; three letters E.A.P.! I don't feel it's remotely appropriate, or acceptable to name-call any diagnosis group. I had to do a double-take. If a patient is doing something where I feel I'm going to react emotionally, or negatively, I've completely lost my ability to help that person (and I need to move out of that area to a different specialty ASAP). My self actualization, nor does my career depend on patient gratitude (they're not on our units to please US)! My job is focused on saving lives from a continuous, progressive and fatal disease. It's not a moral character disorder where patients are (enter negative name here). Again, it's an AMA AANP ASAM diagnosed disease. Has anyone called diabetics idiots, or aholes because they did xyz to further their illness, became obese, cheated, etc. I take care of them, because they come to me asking (asking) for help. Withdrawals (acute and post-acute) make patients insane. Some are more difficult than others (psychiatry 101 for anger, manipulative redirection, anger management, safe handling, etc). It's my job to come to them armed with all this information, so they understand what's happening to them. I always tell them, "Although you feel like you're completely losing your mind, YOU"RE NOT." When they act manipulative, panic, angry, etc. I calmly let them know "It will get better, trust me, it will." In nearly all cases, once in recovery after PAWS, many can decrease or stop psych meds (obviously supervised, but these are the outcomes of recovery). It's nice to see the majority of professionals here taking it upon themselves to learn the most they can, ask legitimate questions and enjoy learning about a rapidly progressing specialty. Wouldn't it be great if we had staff who liked working with the most challenging patients, as well? I love my "druggies and drunks." The more manipulative, the better (because we have something to talk about, and I have an inroad to help them). I don't need any thank you's (my ego isn't fragile, and I already get paid as a thank you; never mind I'd do it for free). Last of my soap box chat...patients and other staff see, and react to body language, facial expressions and word choices that exude the feelings one harbors against addiction, races, religion, orientation, etc. People can see, feel and sense that, whereby the practitioner becomes therapeutically ineffective (and creates a toxic environment of the unit, as this behavior can be contagious).

    Favorite cheat sheets, tools, references, resources

    I thoroughly agree with the others. I have no references for addiction (pocket sized), since it's more of an "on your feet, using your wit" sort of job. After being manipulated several times, I learn not to allow it to happen again. School of hard knocks (or how many times can they play me)? It's commendable you're motivated. If you're not familiar with the 12-steps, find anything in your life and get thine rear quarters to some meetings . There's a wrench to fit every nut, and I can apply the 12-steps to any stressor in my life. Knowing that will mean you'll speak the same language of most of the patients (since most will have been familiar with it, and it's the track your job will ask you to set them back upon). AA and NA books. Read them back to back. Staying Sober and anything by Terrence Gorsky (he's the relapse ranger). Read all that, and you'll be far ahead of others (depending on where you work). At my hospital, about 1500 nurses and only 1 certified in addictions (none on the addictions , detox or treatment units).

    Saying hello..newbi

    Welcome! My two cents would be to focus on the psychological signs and symptoms. I would find a pirated copy of "the brain, hijacked" by Bill Moyers. It explains addiction in the simplest sense. You might be able to get your work to buy a $500 copy, though. I would also attend at least 20 AA or NA meetings, so you understand the lingo, what it is they're facing and what you can do to help. Addicts are not bad, so don't buy into that popular attitude that it's not a diagnosis. It is a diagnosis. They don't throw diabetics into jail for eating a sugar cookie, so addicts who get arrested because of their using is just plain wrong. Our country is decades behind others (who have reduced deaths by as much as 87%)! Keep telling yourself they're sick, not stupid. It's a serious, fatal brain disorder if it's not paused at some point. It's deadly, so work on making a real difference. Don't focus on that one or two pills you can keep from them to "cure" them. It will only anger them and tell them not to return. Real countries treat addiction as a social disorder (and refer appropriately). These are not bad people. Those with the gene will drink or use. That's what they do well. We can only direct them over and over to hit community support meetings with the same fervor they used. Your hospital should have you pretty safe regarding ETOH and benzo withdrawals (stay wayyyy ahead of the CIWA score or you'll lose chasing it). You shouldn't have any DT's if you're doing your job well. Open your senses to all forms of withdrawal and read EROWID for the latest drugs and symptoms for the latest concoctions to hit the streets (in case your area is heavy on the new stuff). It's a good place to read addicts writing about their experiences, deaths of friends and determination to get high. Getting high has been happening since the dawn of man. It's nothing new. Our society doesn't support it, so we have to get them to conform best we can. It's deadly, so make it your business to know everything you can. They are depending on YOU, because the reason patients go to hospitals, is for nursing care. Welcome! It's a dream job for many!

    Advice for dealing with addicts?

    I agree. If she felt it right to withhold, then that's her professional judgement at the time. Education is another thing; judgement from knowledge-base, where the RN was at the time, with the tools she had at her disposal, is the key (and the quality the hospital expects via training). It's not her fault...I like it when they put the onus on us (personally); it forces me to make it my business to learn my specialty. After all, patients come to hospitals 'cause they need nurses (not MD's). This is our time--things are changing. Not so long ago, there were no specialty certs. Mark my words, APRN's will be doing surgery within the next 20 years or so. Remember when Doctorate's were PhD's, now they're practice DNP's? We're moving into the fast lane, so buckle up! I worked in an ICU that leaned heavily on RN's...We did all Hosp codes w or w/o MD's; tons of things other hospitals (I later learn) wouldn't fathom leaving up to RN's. I do understand places can vary, just like experience. Acute withdrawals {which I was assuming they were in--(again assuming also they were in a hospital type setting)} for me, isn't the time to wean. I try to keep 'em there, keep em comfy, so once they're out of acute withdrawal, we can deal with the PAWS and really "talk." It's not easy understanding addiction, what makes a difference (a real difference), and what's just a treatment nuisance. It's hard not buying into the "bad addict" thinking. I stick to acts that will make the difference, allowing meds they want because after all, it is THEY who need to make the decision. I can't force 'em (it will never work, anyway). My one or two petty things won't "fix" an addict. It's deep within, where they change. I try to connect with that part, soon as I can. I love the manipulative one's (especially when I'm suckered) Every once in a while they get me & I've got a big S on my forehead keeps it fun & interesting! I can't understand how phenothiazines could be (physically) addictive...I wouldn't know those withdrawal symptoms (or treatment thereof), if I was hit in the face with 'em:specs: Anything, including ibuprophen is psychologically addictive, however.

    certified addictions nurse question

    I got my guide used from fleaBay. Sometimes you can find good deals there.

    RN counseling guidelines

    I would let the counselor know she needs to work on acceptance of what is (versus life as she would like it to be). We make referrals and advise patients what to do in order to promote health. What a catty thing to do by reporting you to your supervisor. I assume that counselor was going through a divorce or her husband just left (something of the sort). Don't stop what you're doing. I'd give the counselor the phone number of your state board, telling her in the future to spend her extra energy on helping patients rather than turning on coworkers.

    CIWA: OK to reassess in less than 4 hours?

    I give meds, then reassess in one hour to determine my plans for the next several hours. Good question; better to ask than wonder )