Saturday 12 July 2008

Physical illness

Dr Crippen got me thinking.

"One of the most dangerous places to get a serious physical illness is in a mental hospital."

No no no, surely not. Our hospital has had no MRSA and no significant hospital aquired infection for years and years. Patients are cared for better than the New York USA model, i.e. staff review and intervene. We've had no assaults on my (old age psychiatry) wards causing physical harm to patients that I can recollect, ever.

Okay, I trained as a GP then did physiciany whatnots and am appointed as a Consultant psychogeriatrician but am also appointed and employed as a Consultant doing physiciany work too. And I work in old age psychiatry, where physical comorbidity is routine and addressing physical health problems is a daily part of my work. So I concede I'm more medical than most psychiatric colleagues.

But even so, aren't all patients having biopsychosocial elements of their presentation addressed? Aren't all elements of physical comorbidity being considered, not simply as good medical care but also as a necessary intervention to address neuropsychiatric sequelae to the physical presentations?

Sadly not.

On reflection, Dr Crippen is quite correct.

I actively look for physical illnesses. I speak with patients and their GP and seek informant history. I find illness. I investigate. I formulate and diagnose. Often, I treat. But, not infrequently, I find something I can't or shouldn't manage myself.

One patient recently had hyperthyroidism. In GP training I worked on an endocrine firm but that was rather some time ago, the world's moved on, I'm not the best placed person to orchestrate optimal care of thyroid dysfunction. Although clinically and biochemically hyperthyroid, our local endocrinologist did not attend the ward, did not see the patient and did not review care. Hmmm.

A lot of drugs I use can affect the heart. It's common to find heart murmurs (i.e. it's not silent between the heart sounds), but most are innocent flow murmurs of no clinical significance. Many years ago I worked on a coronary care unit, fiddled with clever chronotropes and inotropes, but there's no way I'm competent let alone expert at the management of complex cardiac disease nowadays. On finding a murmur and pulse that I thought was significant, then getting appropriate investigations, then referring on to a cardiologist, the patient on my ward wasn't seen. Two weeks through her admission on my ward she went in to high output cardiac failure, my junior doctor 'phoned the Consultant cardiologist, a diuretic was suggested and still my patient wasn't seen. Hmmm.

Dr Crippen has a point.

Even with the best will in the world, with mental health teams having awareness and interest in physical illness, looking for it and treating it, hospital in-patients on mental health wards still get suboptimal care.

Much badness.


Milk and Two Sugars said...

Much. There are some of us who consider that mental health patients deserve medical care equal to that of patients on any other ward of the hospital. I have occasionally gone to review a patient "on behalf" of a disinterested registrar, only to talk the patient up to convince them to see the patient themself. It disgusts me at time that deception or convincing is even needed.

Anonymous said...

When on the phone for one of our psych patients with a medical problem talking to the med reg tor equest a review; I love asking the med reg - who just tells me they're too busy to come see them today - how to spell their name properly for when I call the consultant to come see them they know why.
They tend to show up then.

As I posted on Crippens - I find the general health care of psych patients IN general health care frequently to be left wanting. However, current placement is very good and they even take direction from the nursing escorts as to how best to approach the patient (and not for fear of mad violence either).

In mental health facilities I have found the general care to be good. Our psych reg's push to fast track paranoid people for hearing work - it's made significant difference to their presentation in several cases where physiological issues have existed.

In fact we get pretty good service for all our in-patients - but that's the bonus to having a nurse as your booking agent as opposed to a GP or registrar ;-)

We do have a lot of cardiology input - but that's Clozapine for ya.

The Shrink said...

". . . but that's Clozapine for ya."
Even when a clozapine patient had a Red result and crashing agranulocytosis we still couldn't get a Consultant Haematologist to step in and give advice.

cellar_door said...

We have had a nightmare getting ambulances out for some of our patients. As soon as they hear that we a are psych 'hospital' we are given low priority. Whilst I can understand the reasoning, it doesn't mean we are any better equipped to deal with a patient who has just slashed an artery...even if we were 'proper' nurses, we just don't have the equipment!

Milk and Two Sugars said...

Badness from the haematologist.

What is a Red result?

Anonymous said...

'red' result :
white cells< 3.0 X 109/L and/or neutrophils< 1.5 X 109/L

I'm posting on here and Crippen so trying not to overdo the same points - but I do think medical and paramedical hospital staff think a 'psych ward' is like any other hospital ward and the doctors like any other doctor.

Now psych docs may have the generic training and will understand what the med reg is talking about - but what of the reciprocal debate?
How many med reg's would manage a medically unwell patient who also presents as acutely psychotic without consulting a psych reg/consultant?
Heck, when it comes to psych patients on a medical ward - I find their docs consult the escorting psych nurses when it goes to chit and I frequently have bailed them out on acute management issues (with or without prescriptions).

Ms-Ellisa said...

What milk'n'2 said:

"There are some of us who consider that mental health patients deserve medical care equal to that of patients on any other ward of the hospital."

There and Back said...

This is a hot topic for me at the moment as, currently being on an acute psychiatric ward, and having a kidney infection simultaneously = total nightmare. It's not exactly rocket science - but to the ward it is. I've had to resort to seeing my GP while on day leave from the ward for her to take over the treatment of it while in the meantime I'm suffering pretty horrible symptoms. Just a total nightmare.

Unknown said...

Are the consultants slow to show up on your ward because they assume that your team can already handle everything and so they don't really need to, or is it a persistent stigma that the mentally ill don't really deserve the same care as everyone else and so aren't important?

The Shrink said...

DeeDee, probably a mix of both.

We deal with everything we can deal with and only ask for help when we're out of our depth, so there's an assumption (and experience) of us dealing with most stuff pretty well.

Equally, our patients' care simply isn't an issue to the acute Trust so their staff aren't enthusiastic about popping over and helping out since it's seen as, "not their business," in any sense.

Unknown said...
This comment has been removed by the author.
Unknown said...

This is an age old problem. I work as a Liaison Psych (dedicated to providing psychiatric care to patients within the medical/surgical setting). We have a clearly defined role - to help our medical colleagues manage 'psychiatric' issues that arise during their stay. It is my job and has my full attention. Most of my med/surg colleagues provide a similar service for each other on a more ad hoc basis. I suspect the rum deal for patients in more general psychiatric wards is secondary to the logistics of their being in a different geographical location and the absence of a discrete funded 'Medical Liaison'service. Perhaps most importantly the lack of personal connection between individual physicians and psychiatrists is at the root of the problem. I find one always gets a prompt response when you have a deeper relationship than just phoning for advice.