Saturday 28 July 2007

Liaison Psychiatry

A routine liaison referral

I was asked to see a widowed elderly lady who has almost certainly has had an anterolateral myocardial infarction (a heart attack). She's on the medical wards and, thankfully, is doing well. I know her reasonably well from prior home visits.

A few weeks before this . . .

Prior to this miserable event she enjoyed good health but had become depressed. A mixture of social isolation, loneliness, loss of friends (many passing away), loss of fitness (no longer able to potter and enjoy her garden as she used to), increasing frailty and the bitter loss of her close husband all contributed to a pretty low mood.

Some of her low mood is understandable. Anyone in her situation would feel pretty despondent. As such, that's normal human emotion, that's sadness and upset, that's not an illness. Unpleasant, yes. Psychological disturbance, yes. Unwanted, yes. Psychiatric illness, no.

But her mood became more than just sadness, it started affecting her well being. Appetite faded away, weight started to fall off her already slight frame. She couldn't get to sleep (and no pain or other problem stops her). She'd awake early, with feels of disquiet, then sadly couldn't find solace in sleep again. The mornings were hard; she had thoughts of a full day to fill, to endure. When awake she'd not feel refreshed, she was still exhausted (but not sleepy). She had ideas of doing things (sorting bills, writing to a friend she used to go to the theatre with) but isn't quite motivated enough to do so. She no longer wore lipstick, she always used to.

She had other features that were sufficient for a very sensible GP To start an antidepressant, which didn't work, so she then referred the lady on to me. Trying an SSRI antidepressant then reviewing this and supporting the patient with frequent contact . . . I am blessed with many excellent GP colleagues in my area.

I swapped her to a new antidepressant which rather pleasingly for all of us has been successful. The medication is venlafaxine XL, easily taken once a day, it helped her feelings of ill ease and anxiety as well as her low mood. Things started to improve.


She has written to her friend. She is making plans for the future, reading through the programme that's still posted to her each season and suggesting they go to the theatre this Summer. She's eating better. She remembers her medication. She's able to tell me what she's been watching on television and reading in her novels and how family are faring (since she is once again interested enough to 'phone them up).

Medical care

She was admitted under the care of the medics at our local District General Hospital. She has, it seems, received good care. They rightly are worried. Use of venlafaxine is cautioned in heart disease and contraindicated in conditions with a high risk of abnormal heart rythms. Review of the use of venlafaxine is indeed a sensible request. The medical team faxed a request to me from their hospital which I received in the morning, asking me to liaise with them in her care. A sensible liaison referral.

I drove on over at lunchtime to see the lady and review the risks, benefits and alternatives around her medication.

Liaison psychiatry

20 minutes driving there. 15 minutes driving around the district general hospital site looking for somewhere to park. 10 minutes kerb crawling around the nearby streets seeking somewhere to park. No success. 20 minutes driving back to my base hospital.

A plea

I am sorry that, yesterday, I could not review this lady's care. I did try. Hearing Jeremy Vine on Radio 2 was a pleasing way to spend an hour or so but I'm sure it's neither what I'm being paid for nor what I've been trained to do.

We have no Service Level Agreement with the hospital, I'm foolishly providing my time to them for free. And attempting to see patients promptly. Despite this, they still can't put things in place enabling me to see their patients for them.

Surely, surely, there has to be a better way of doing this.


Dr Andrew Brown said...

Ha ha! There you are at last! I'm very pleased to see you now have a blog up and running.

I have much the same problem when asked to do a "section" at our local hospital. I can usually find a parking spot about ten minutes walk away. Of course, the doctor who desperately wants you to attend and assess the patient has no power to grant a car parking space, and the hospital administration don't give a fig.

The Shrink said...

Ah, you found me! Indeed, I seem to have sufficient time to dabble :-)

And it is a shame that clinicians just want to see their patients but hospital systems aren't sympathetic to letting us just crack on and do that.

Calavera said...

That's ridiculous. I thought they might have reserved parking for you docs? ...No? How strange.

The Shrink said...

Ridiculous, yes.

Tragic how, oft times, medics are now a source of ridicule ;-)