I recently saw a gentleman, who has dementia of moderate severity, who was low in mood. His GP had reasonably started an antidepressant. Things were no better. I stopped the antidepressant. I reviewed him. Things were no different.
I recently saw a lady who was tearful all the time, felt hopeless and wasn't doing sociable things with friends at the local tea room and Tuesday evening bingo. Her GP had sensibly started an antidepressant, reviewed her, changed it then referred to me. I stopped the antidepressant, reviewed the lady, things were no different.
It's not easy work. In both cases I saw the patient in their home with a CPN colleague, it took over an hour doing an initial assessment then time following up and reviewing them.
The gentleman's scans showed widespread vascular damage. His limbic system was shot to pieces. If the bits of your brain that regulate your mood no longer exist/are damaged, it's unsurprising that peoples' mood is less than perfect.
The lady had low mood because she'd recently been widowed, her sister had also died this year and she had a blood disorder (which slowly is getting worse) meaning she's knackered all the time. Her mood is low because life's grim. She's not mentally ill, there's no psychiatric disease.
If there's no chemical depression, with no chemical solution, answers aren't in a tablet. This makes it harder. Patients and carers need to do something to get better, to change something if they want things to be different. Professionals can't just gift an FP10 and be done. And, invariably, things can be improved, but they can't be "cured" and less than perfect mood needs to be accepted/endured/dealt with rather than "fixed" or changed.
Management of clinical depression is, to my mind, pretty easy. But management of other low mood is grim.
Tuesday, 24 August 2010
Wednesday, 4 August 2010
Consultant Time
A couple days a week I start at 8.30am which I still reckon's an ungodly hour. Although I'm often in at this time, on just 2 days do I start work at 8.30am, on all other days clinical activity (like an out-patient clinic) starts at 9.30am. A much more civilised hour.
Why the early starts, why just some days?
It suits the nurses. It makes no odds to me really when I start, I can organise time as I wish. Home visits, MDT meetings, writing reports, care home reviews and such can all be juggled around and don't have to be at a specific hour.
Nurses though have a lot to do. Too much. They've so much clinical activity to do, now, more than 5 years ago. It's good and interesting and they're very good at it, but it means they're genuinely busier. Audit evidences this increase in direct patient care and increase in complexity of work. It's been formally looked at since it's resulted in job matching and regrading under A4C through nurses' roles shifting. As well as being more involved with more patients doing more work more of the time, they've also got to do more nonsense. Falls and nutritional and other risk assessments. A form for every patient on risks to children/childrens' needs. Screening tools. Repeats of carer assessments. Suicide assessment tools that don't apply to older adults but still must be done. They have to collect lots of demographic data that already exists (ethnicity, marital status, occupation/retired, where they live etc) and enter it into the computer system. They have stupid, stupid amounts of paperwork. The paperwork is only the start, since as well as ward/community paper notes, psychiatric medical notes, letters to GPs/referrers, social work/other referrals, there's also electronic stuff. Our "paperless" notes on the computer with squillions of fields to fill in. Some are always left empty and months later nurses are bullied/harrassed to complete the data set. Assessment forms. Diagnostic/clustering tools. CPA fields. Care plans (plural, since every intervention has to be entered as a separate care plan, with lots of fields on each one). Safeguarding referrals and meetings. Mental Capacity Act assessments, best interest meetings. Doing what only an RMN can do (such as administering oily depot medication). Generating statistics, results, activity levels, outcomes or other information that managers, commissioners, service leads or other parties want (usually straight away). Attending more management meetings than I care to count as more and more is added in without anything being reviewed and stopped. Attending mandatory training, often in things of dubiuous relevance. Carer support (a quarter of their clinical time is spent with carers, not patients). Coordinating multiagency working so patient care actually happens, and happens right. De-escalating challenging behaviour (such as stopping them battering folk). Feeding them. And then there's the direct therapeutic work undertaken with patients, effecting change.
Sometimes, just sometimes, they also need to work with doctors.
It's for this reason that I work when I work. My ward round is on a day and time when no other Consultant is on the ward, my team meetings start at 8.30am since it suits the nurses to do it then, so they can crack on and do everything else from 9.30am onwards when everything kicks off.
I've huge sympathy for poor Militant Medical Nurse who seems to work with medical colleagues who instead of adding helpfully to their process are seen to be unhelpful. I appreciate that in psychiatry Consultants can have much more latitude to shift clinical activity around and generate flexibility, whilst a surgeon has to operate when they've theatre time and that's that, so it's not possible to be as flexible in other disciplines. Yet somehow Militant Medical Nurse's account leaves me frowning and feeling a little ashamed at how my medical colleagues are felt to be adding to, rather than helping with, the stresses that nursing colleagues are grappling with.
Why the early starts, why just some days?
It suits the nurses. It makes no odds to me really when I start, I can organise time as I wish. Home visits, MDT meetings, writing reports, care home reviews and such can all be juggled around and don't have to be at a specific hour.
Nurses though have a lot to do. Too much. They've so much clinical activity to do, now, more than 5 years ago. It's good and interesting and they're very good at it, but it means they're genuinely busier. Audit evidences this increase in direct patient care and increase in complexity of work. It's been formally looked at since it's resulted in job matching and regrading under A4C through nurses' roles shifting. As well as being more involved with more patients doing more work more of the time, they've also got to do more nonsense. Falls and nutritional and other risk assessments. A form for every patient on risks to children/childrens' needs. Screening tools. Repeats of carer assessments. Suicide assessment tools that don't apply to older adults but still must be done. They have to collect lots of demographic data that already exists (ethnicity, marital status, occupation/retired, where they live etc) and enter it into the computer system. They have stupid, stupid amounts of paperwork. The paperwork is only the start, since as well as ward/community paper notes, psychiatric medical notes, letters to GPs/referrers, social work/other referrals, there's also electronic stuff. Our "paperless" notes on the computer with squillions of fields to fill in. Some are always left empty and months later nurses are bullied/harrassed to complete the data set. Assessment forms. Diagnostic/clustering tools. CPA fields. Care plans (plural, since every intervention has to be entered as a separate care plan, with lots of fields on each one). Safeguarding referrals and meetings. Mental Capacity Act assessments, best interest meetings. Doing what only an RMN can do (such as administering oily depot medication). Generating statistics, results, activity levels, outcomes or other information that managers, commissioners, service leads or other parties want (usually straight away). Attending more management meetings than I care to count as more and more is added in without anything being reviewed and stopped. Attending mandatory training, often in things of dubiuous relevance. Carer support (a quarter of their clinical time is spent with carers, not patients). Coordinating multiagency working so patient care actually happens, and happens right. De-escalating challenging behaviour (such as stopping them battering folk). Feeding them. And then there's the direct therapeutic work undertaken with patients, effecting change.
Sometimes, just sometimes, they also need to work with doctors.
It's for this reason that I work when I work. My ward round is on a day and time when no other Consultant is on the ward, my team meetings start at 8.30am since it suits the nurses to do it then, so they can crack on and do everything else from 9.30am onwards when everything kicks off.
I've huge sympathy for poor Militant Medical Nurse who seems to work with medical colleagues who instead of adding helpfully to their process are seen to be unhelpful. I appreciate that in psychiatry Consultants can have much more latitude to shift clinical activity around and generate flexibility, whilst a surgeon has to operate when they've theatre time and that's that, so it's not possible to be as flexible in other disciplines. Yet somehow Militant Medical Nurse's account leaves me frowning and feeling a little ashamed at how my medical colleagues are felt to be adding to, rather than helping with, the stresses that nursing colleagues are grappling with.
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