Crisis Clinician

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There probably has been a thread describing people's jobs, but I am feeling ornery and upset that I have to stay late so I am describing my job here.
I am a psychiatric crisis clinician. I evaluate people in crisis to help determine how they can resolve their crisis. As the money for this type of service goes away, the service becomes more about whether or not someone needs what is called a higher level of care. In my state there are other options besides hospital admission.
Today I came in to find out that I was needed to help in the ER at one of two hospitals we work in. The other ER had called as well, but because the people didn't want to wait, they simply walked out. There was no involvement on our part so the hospital will have to evaluate whether there was an issue of risk (on the surface it did not seem so).
The larger ER had 4 cases pending by the time I got there (I had to do the paperwork at the office first). I saw two people, oddly coincidental: one was a mother who had fought with her daughter and then taken an overdose, and the other was a daughter who had a fight with her mother and then took an overdose. No, they weren't related.

Both had no or limited history of mental health issues, and the mother clearly did hers to get attention (she took 6 pills, and made moo cow eyes at me whenever I asked a difficult question). The daughter was very depressed; all I had to do was say that she seemed very sad and she started crying. I was more worried about her so I asked her to come in for another meeting tomorrow and to consider going to a crisis stabilization unit - like a hospital, but not locked and voluntary - people have a lot more freedom to go to appointments and even to work.

After seeing them I consulted with the supervisor and now I am in the lengthy process of finishing the paperwork. Easy to get overloaded except now the phones get answered by another crisis team and I am the only one here. The room is a big room with 9 desks and a table in the middle. During the day it is very noisy and hard for me to be here. But weekends and evenings are quieter.

I will write a summary of my evaluation (actually taking a break from that right now), organize all the authorizations related to insurance and talking to other providers about the case, and log the information in a couple of places. Almost everything is on the computer so it is much faster than in the past.

Once upon a time I did seven evaluations in one eight and a half hour shift. It has never been that busy again. I find the job easy because I don't get tangled in the emotional turmoil that occurs with the clients, their families, their therapists and doctors and sometimes the doctors in the emergency department. In fact, the only person who bothers me is a Spanish interpreter who thinks very highly of her Castillian Spanish, but works with Latinos who are almost never from Spain. She doesn't know that I speak Spanish so she doesn't get that I understand what she is saying. She protests that she did accurately translate what I said even when I confront her. Someday I think I will doctor her and see if she shapes up.

When I doctor someone I use the prefix Dr. in front of my name - I'm allowed to because I have a PhD. It helps with arrogant people; otherwise I don't use it.

I suppose I should move on and become a psychologist, but this job is a lot easier. I never take work home with me, and I don't have to remember anyone. I am planning on moving on because I have outlived people's ability to accomodate my strangeness, but I don't know what I want to do. My only goal is not to have to move on because people no longer can accomodate my strangeness...

Back to work.

Finally got out of work at 1:30 am. Not too bad. I have another shift at 11pm today. I have a lot of running around to do so I probably will be a little tired. Right now I am a little wired from the drive home - the nice part was not too many cars on the road.
Tomorrow I will be stationed in the Emergency Department (they don't like it when you say Emergency Room) at the largest hospital in the area. The ED has more than 30 beds with five types - there are a few stations for nebulizer treatments, a pediatric section which is the size of some other hospitals' EDs, an intensive care section called the bubble, the regular ED which has at least 28 beds, and the psychiatric section which has 3. I work in an office in the pscyh section. It's rare not to do any evaluations on the overnight.
My coworker is a woman who does not know how to modulate her voice, the office is small and poorly ventilated, and people just walk in and out without warning. I spend most of the time either focused on the computer screen or walking around.
I have two more shifts to work with this woman and then I am not going to do it anymore.
At my full time job I have my own office which has some disadvantages, but is very good for controlling sensory input. Also they are less tolerant of difference which has resulted in my being away from there for three months now.
I am not so wired anymore so I'll browse and then go to bed. I have to get up early tomorrow to do the recycling and the trash. At some point I'll redo my meal which I didn't get to eat because I was so busy. Hopefully tomorrow night I'll have time to eat. It was supposed to be soup and hash browns, but I left my lunch in the office when I went to the ED to help my coworker. This particular one is supportive and knows I have asperger's and it doesn't seem to matter. She was profusely grateful for my help but not mushily so. She's cool. I stayed there so long I got hypoglycemic so I bought a salad at Friendly's which is located in the hospital and open all night. They make great root beer floats!
Rambling because I'm tired. Better stop.
I turned this into a day in the life of because I thought folks might find it interesting....

Woke up,
Got outa bed,
dragged a comb across my head.
achinga, chinga, Chinese.
went down stairs
and had a cup
looking up, i noticed i was late
ah, aaeeah, a-ah-aaahhh

Here is a mental status report that I wrote just a few minutes ago (details changed to protect the innocent):
Background: Clt was sent via ambulance to the ED because he was hallucinating, not eating and talking about driving his car into other people's cars. His parents found out today that had been on a 7 day mushroom binge until Friday, when he became alarmed and began smoking cannabis to alleviate the symptoms. Instead, the symptoms became worse. He arrived home last night from work and was incoherent, so his parents called an ambulance.

18 y.o. European American male, gaunt, clothes falling off and ragged, unshaven, avoidant of eye contact. Clt was minimally cooperative and increasingly less cooperative as he began to realize the probability of admission. Attention and concentration were impaired: clt had difficulty following the conversation and at times appeared to be distracted by some internal process. Unable to assess memory functioning; some impairment was evident but difficult to distinguish from from clt's confusion. The confusion was displayed in response to questions regarding recent behavior and history. Mood appeared depressed with some underlying anxiety at times. Affect was flat. Clt reports he sleeps too much now, and he has not eaten in 3 days because food "didn't feel right." Clt unable to elaborate on this other than to deny that it was the smell or taste of the food that was not right. He denies SI/HI but reports ideation to drive his car into cars he sees along the side of the road, with the knowledge that he would die. Some limited insight into the fact that this behavior might put others at risk stopped him from acting on his ideation this morning. Insight and judgement are impaired, impulse control questionable.

Lots of psychobabble to you, but this is actually helpful shorthand when I am reading a case. Most of us skip to the mental status and then go back and read the rest of a report. This information makes up about a tenth of the information contained in a report. Most people can generate one in about an hour; mine vary from 15 minutes to 90 minutes for a particularly difficult report. The one in which I wrote this mental status report took about an half hour to write.

Thanks for posting that, Neuroman... I think it's fascinating to see what gets written in reports like this. Not something I have a lot of experience with.

It is nice to know what people put in those things. When I was a kid I always wondered what they were writing in their reports.
The psychological assessments are really dry and repetetive. I hate reading that stuff which is one reason I don't do testing. My mental status reports tend to have more colorful vocabulary in them because I wouldn't want to read a lot of the ones I see on a regular basis.

Is it possible to know, whether his mental state was a direct causal effect of the drugs or were the drugs a direct causal effect of his mental state.

Is he a drug abuser because of his demons?

or

does he have demons because of his drug abuse?

I am working in the ED again today. My mother bought me a car (I can't do salesmen) and I had to go pick it up so I drove here from her house, which is 2 hours away. I arrived in a bad mood because the traffic was bad and because she forgot that I am allergic to cigarette smoke and she got me a smoker's car. The worst part is having to pay for something that is making me sick.
I had two co-workers today; the second one is nice to everyone and I wish I knew how she does it. One part is that she sits outside the office and talks to people. I don't understand their conversations; they are all about sports and gossip and no way to verify anything said.
I had two evaluations to do today; the first three hours I did nothing so part time surfed and part time wrote a letter to my lawyer who doesn't understand the concept of limited energy for social tasks.
The nicest part of this job is the high degree of structure. Everything can be made into a checklist; in fact that is how I learned the job. Then within the structure I am free to be creative. I am most creative in the part they call the Impressions/Formulation; this is where I get to be speculative and say what I really think is going on. The parts of a crisis evaluation are pretty standard, even with different crisis teams. Here are the parts common to most of them:

Presenting problem: why the person came to the crisis service. some places ask for this in the client's own words.
Precipitants: what precipitated the crisis
History: past history that may have contributed to the current crisis.
Medical information: any chronic illness or condition
Substance abuse history: includes what legal or illegal substances a person used recently or in the recent past. The DSM IV has an algorithm for figuring out whether the person is in remission or not.
Living situation: includes whee the person lives, who they live with and who supports them. sometimes a person's job is included here.
Resources: this includes any treaters such as counselors, psychiatrists, whether family or other folks are supportive, if they have sufficient physical reources, etc.
Mental status: includes current mental state as well as a forecast of whether the person is at risk of harming self or others.
Impressions/Formulation: what I think is going on, including what I think would help.
Recommendations: what I think should be the next step; what level of care would be most helpful.
Diagnosis: five "axes" which address chronic conditions, personality issues, medical issues which might impact the problem, what caused the problem/is making it worse, and finally something called global assessment of functioning which is a subjective impression of the person's ability to stay safe. In general a GAF of 100 is probably whoever made God, 75 to 90 is most of the rest of us. 65 is someone who needs some kind of intervention, 45 is someone with a lot of distress but limited danger to self or others. 35 is someone who is close to acting out some self-harm or other-harm scenario, 25 is someone who probably has already tried something. I have given out very few 10s, this is someone who if they are not restrained in some way, is definitely going to hurt someone or themselves.

This kind of report sometimes takes a couple of hours to generate. mine usually take 15 minutes to an hour.
Perhaps next time, for the brave of heart, I will tell you about some of the "gallows humor" that happens here. Not sure its appropriate so I will wait to see if anyone has a problem with it.

I have been here since 12:30 and it is almost 11 pm and I am ready to go home. We'll see if I am wired when I get home. If so, you'll hear from me again.

Can't speak for the other mods, but I highly doubt I'd have a problem with it.

I see a lot of overlap between ASCs and borderlines with one extreme distinction. ASCs are at best ambivalent about attention while borderlines are ambivalent about the fact that they crave attention.
I saw two borderline style people tonight. I will see if I can give a description. The most prominent factor in their presentation was the lack of an acute crisis and the time of year they are showing up.
The holidays are stressful for all of us, but I think moreso for people who have issues with attention. The attention tends to be on children and in families, diffused among many relatives so someone who wants or is used to more attention may feel they are getting less.
All of the people who showed up seemed to have no remorse that their behavior might affect other people's holiday.

I find it interesting that people there would have problem with strangeness in a PhD. I mean no offense when I say this but every PhD I've known has been quirky, strange, whatever you want to call it. Just figured that was par, ya know? Doesn't have to be a bad thing. Maybe it would help to play up the doctor, go with the stereotype to your favor - dunno. Kinda like how we all assume M.D.s have bad handwriting so you excuse it in the ones that do.

This account of your work is fascinating.

And this is the coworker rant.
first the one who is abusive toward/about clients and hurts my ears with his yelling and swearing. every time someone comes in to refer a client he goes on about how they don't need to be seen.

he goes away and the next one needs attention so badly that she has to bang things around in the office on the pretext of cleaning. She puts things on top of my work and tries to move my stuff around. She empties all the wastebaskets claiming they smell (there is nothing in them but empty sugar packets). Then she insists on talking non-stop and complains when I leave to use the WC. She complains about the previous guy who left early without leaving her the list of clients waiting to be seen. She apologizes for complaining and then continues to complain. I have my DVD player on when she comes in and she tries to drown it out with the sound of cleaning and talking.

yet this is not as bad as the one who takes everything personally and makes clinical decisions based on if the person has pushed her buttons.

and i wade through all this trying to do the right thing and looking like the bad guy because i am not doing what somebody wants. and the somebody is always more powerful than i am which is why they are right even when they are not right.