I find myself increasingly reliant on good nursing colleagues, with investment in our service over the last 5 years involving reducing medical staff numbers whilst increasing nursing staff, OT and social work staff numbers substantially. Still fretting that I don't have enough pharmacy time, but that's a battle for another day.
My junior doctor does very little work. It's not a criticism. He's there in a training post, to learn. Gone are the days when junior doctors worked every hour and were the cheapest resource; I was paid less than porters, student nurses and domestics for my work out of hours and on bank holidays. Come to think of it, I still am. But my junior doctor's hours are scrutinised and all have to be purposeful in progressing his training needs.
Also, all junior doctors in psychiatry now have to do Old Age Psychiatry in their first year. This mean my junior doctor has done his medical training at university, then his Foundation training as a doctor, then started in psychiatry with me last month. He had an induction so he's being doing psychiatry for all of, oooh, about 4 weeks. Clearly he's not in a position to give meaningful input, on his own, in out-patient clinics or the like.
The Royal College of Psychiatrists recognise this and define what it's reasonable/desirable for junior doctors to do at different stages of their training. In their first year, as mine is, they're to learn core skills. It's even called Core Training, so if after a year he thinks psychiatry's a terrible mistake and he want instead to be, say, a gynaecologist, off he can go and his year in psychiatry is useful and translates into a year of gynae training through teaching him consultation skills, approach to examinations, documentation, governance frameworks, evidencing rational prescribing practice, undertaking clinical audit and other such skills a medic is expected to develop.
As such, he can't do clinics on his own. Or skip off and see new referrals in the community. Or do liaison psychiatry, seeing folk on medical/surgical wards.
It's genuinely a training role which has the advantage that the service ticks along quite nicely whether he's here or not, it gives him time to read and study and shadow loads of folk to get a good understanding of practice, and it's hardly a stressful post. It also means patients get medical psychiatric input from a Consultant Psychiatrist, not a junior doctor.
As well as junior medical staff having a training (rather than a service commitment) role, as a Consultant Psychiatrist I input into other peoples' work. Mornings and afternoons our teams meet up and discuss the work to do/work done and consider what needs to be changed. As such, every patient has both this informal discussion when a Consultant can think if specific investigations need to be done, or psychiatric/other medication reviewed, or physical health symptoms unpicked or whatever. Every patient has formulation and care planning discussed with a Consultant Psychiatrist. Equally, all mine are discussed with nurses, OT, support work, pharmacy and social workers so they can chirp up with their thoughts on input into care.
The consequence of this is that all medical decisions within our service are through a Consultant Psychiatrist, and through both formal and informal forums there're mechanisms for medical input into every patient's care, every day.
At least when someone's stuck and refers in to our service, the diagnosis is made by a Consultant Psychiatrist (for good or bad, in my corner, nobody else does diagnosis) and medical dimensions are considered by the Consultant. I think this is of value, enabling non-medics to work at the top of their game doing what they do best, with medics contributing their bit, and the whole working synergistically.
I have seen a gentleman with mild cognitive deficits. He's in his 40s. He's unfortunately got dementia. He had a jerky tremor and poor balance/coordination. He said his mouth wouldn't work; he often chomped down and chewed his cheek, sometimes he couldn't swallow solid things easily. I thought he had something other than Alzheimer's disease or another neurodegenerative dementia unfolding, it looked like he'd neurological deficits. Huntington's disease sprang to mind, or p'raps normal pressure hydrocephalus. More sleuthing by clever physicians was in order.
I wrote back to his GP giving the results of his assessment, mental state examination, cognitive testing and brain imaging, suggesting that an assessment and neurology opinion would be helpful.
A few weeks later, I got a copy of my own letter back, as part of a referral to me, with a covering letter asking if I could give an opinion on this gentleman who had been invited into the GP's surgery and seen and discussed referral, so could I please see and advise. A mistake had been made. It should have gone to a neurologist, not back to me. It happens. The mistake had been made by a First Contact Practitioner. It rang bells because this is not the first time she's made a mistake.
I shouldn't, but I do feel somewhat piqued if I spend 2 hours assessing and investigating a patient, identify organic disease that merits more sophisticated assessment than I can do (it's many years since I worked in GP land, now), but the history and examination and formulation and care planning is undertaken by someone who consistently doesn't seem to be doing a brilliant job. Maybe it's bias and prejudice, maybe it is factual, maybe it's idealistic but unfounded, but I do reckon it all worked better (for our patients) when GPs did this work.
I'm all for clinical teams doing work that they do best, but inadequate assessment/management of neurological deficit, trying to gain tighter glycaemic control of a diabetic patient and making things worse, review of a patient's use of triptans with a poor outcome, and stopping someone's lithium (that had kept them stable for decades) are all recent undertakings of a First Contact Practitioner that perturbed me.
Most GPs in my area are really, really good. I'm fearful that in the future most Primary Care won't be. Much badness.
Thursday, 24 September 2009
Monday, 14 September 2009
Benzodiazepines
I've differing views on the use of lorazepam and other benzodiazepines (here and here).
The Jobbing Doctor has quite rightly highlighted how mental health can be overly zealous in dishing out lorazepam. Got me thinking.
Bit of a delay in getting an answer to this one since it got me hassling a pharmacist to suss things out for me.
The outcomes were rather heartening.
Most patients prescribed lorazepam within my corner receive it as part of an adjunct to their dementia care. By "most patients" I in fact mean all of them. I have two patients who are prescribed a benzodiazepine for anxiety states. Every other patient on a benzodiazepine is taking it as a part of their package of dementia care.
One lady has anxiety which necessitated hospital in-patient care over many months, she relocated to my corner a few years ago to be near to family and now is on oxazepam 5mg as required. The tablets are 10mg, so it's half a tablet a time. The dose range in older adults is 10mg to 20mg, 3 or 4 times a day. 30mg to 80mg a day, then (which is what she was taking when we first met). She now takes 5mg a couple times a week. At such a tiny dose there's no risk of pharmacological dependence, no problems of side effects. Okay okay, it's homeopathy in all but name, yet for her it's invaluable. She finds that when she's anxious she can take half a tablet, she's in control, it's a key tool for her in her toolbox as part of her anxiety management. Developing an internal locus of control, patient choice, an empowered patient, person centred care, frame it how you will. For her, being able to have a bottle of tablets with just one tablet used up each week is incredibly effective in enabling her to manage her mood state and functional level.
Another lady's had a major adjustment disorder and is currently taking diazepam 2mg half to one tablet once a day. Again, a dose that doesn't cause pharmacological dependence (or side effects for her) but a dose which gives her feelings of relief that she finds necessary to help her cope. And cope she does, now managing activities of daily living that six months ago eluded her. Sure, her CBT and SNRI and twice weekly CPN input are far more meaningful than a sniff of diazepam, but for her the choice of taking a dose (or not) when she wishes is a choice that she feels she needs, a choice that puts her back in control, a choice that enables her to feel she's better equipped to cope.
Other than these two patients, every other prescription for a benzodiazepine since April has been purely as an aid in the management of dementia care. It's not used a lot, at all. We've specialist teams to support care in my corner so if there're problems then the team looks at causes and understanding and interventions, I look at physical comorbidity and concurrent medication, our commonest intervention is stopping drugs not starting them.
I still find it amazing how much medication is used for the right reasons at the right time, but then when dementia progresses the medication's side effect profile and tolerability generate treatment emergent adverse events (e.g. wailing, sobbing, battering carers) which a GP and I can improve upon through review and rationalising a drug regimen.
But if you've dementia, and this advances to cause the inevitable cognitive decline but also non-cognitive changes (i.e. behavioural and psychological symptoms of dementia, BPSD), and these are intense (e.g. battering your wife), and these are pervasive (happening in most situations or most of the time or in a repeatable fashion such as each time personal care's delivered), and there's distress to the patient and carer through this, and practical changes haven't improved things, and behavioural changes haven't helped, then I'll consider medication too. I'm not keen on antipsychotics in the first instance since they ramp up risk of serious things (like strokes and death) significantly and invariably the patient's not psychotic (so an antipsychotic's use is contentious). The evidence base increasingly shows that an acetylcholinesterase inhibitor is more effective with less side effects in the management of BPSD than an antipsychotic. If you've Alzheimer's disease. What if you've vascular dementia, or you've Alzheimer's and the drug doesn't work?
Increasingly the evidence suggests that in this patient population (of dementia and BPSD) that a benzodiazepine is a safer and more effective agent than an antipsychotic. Makes sense, too. It's an anxiolytic, it reduces anxiety, it's a "minor tranquilliser" and if someone's distraught through poor memory, or frustration, or through misperception of situations, or misinterpretation of activities/events, or losses, or fears, it helps reduce the anxiety and distress.
On using a benzodiazepine, it's then reviewed by a nurse or myself to see if it works. If it does, huzzah! If not, can it be increased to have a therapeutic trial at a decent dose for a decent duration? Still no benefit? Then it's stopped. We have to do this otherwise I end up writing FP10s forever (which I've not the inclination to do) and my nursing colleagues are locked in to reviewing outcomes forever, which they've neither the capacity nor the need to do. Hence a desire to robustly evaluate effectiveness then determine whether to continue or stop the drug.
A less distraught patient's a good thing, since they feel better and have a lower symptom burden. Too, they're then more likely to accept the reassaurance, reality orientation, personal care or other interventions from carers more successfully, more of the time.
Overall, I'm with the Jobbing Doctor that the NHS can be keen to dish out benzodiazepines too readily, some of the time. But, babies an' bath water, I'd not want to unhelpfully simplify the discussion into use of benzodiazepines is bad, since that's not true. Inappropriate use of benzodiazepines is bad. Rational prescribing practice is not bad. On that basis, within such a framework, I'm far more enthusiastic about a bit of lorazepam than haloperidol/more noxious agents.
The Jobbing Doctor has quite rightly highlighted how mental health can be overly zealous in dishing out lorazepam. Got me thinking.
Bit of a delay in getting an answer to this one since it got me hassling a pharmacist to suss things out for me.
The outcomes were rather heartening.
Most patients prescribed lorazepam within my corner receive it as part of an adjunct to their dementia care. By "most patients" I in fact mean all of them. I have two patients who are prescribed a benzodiazepine for anxiety states. Every other patient on a benzodiazepine is taking it as a part of their package of dementia care.
One lady has anxiety which necessitated hospital in-patient care over many months, she relocated to my corner a few years ago to be near to family and now is on oxazepam 5mg as required. The tablets are 10mg, so it's half a tablet a time. The dose range in older adults is 10mg to 20mg, 3 or 4 times a day. 30mg to 80mg a day, then (which is what she was taking when we first met). She now takes 5mg a couple times a week. At such a tiny dose there's no risk of pharmacological dependence, no problems of side effects. Okay okay, it's homeopathy in all but name, yet for her it's invaluable. She finds that when she's anxious she can take half a tablet, she's in control, it's a key tool for her in her toolbox as part of her anxiety management. Developing an internal locus of control, patient choice, an empowered patient, person centred care, frame it how you will. For her, being able to have a bottle of tablets with just one tablet used up each week is incredibly effective in enabling her to manage her mood state and functional level.
Another lady's had a major adjustment disorder and is currently taking diazepam 2mg half to one tablet once a day. Again, a dose that doesn't cause pharmacological dependence (or side effects for her) but a dose which gives her feelings of relief that she finds necessary to help her cope. And cope she does, now managing activities of daily living that six months ago eluded her. Sure, her CBT and SNRI and twice weekly CPN input are far more meaningful than a sniff of diazepam, but for her the choice of taking a dose (or not) when she wishes is a choice that she feels she needs, a choice that puts her back in control, a choice that enables her to feel she's better equipped to cope.
Other than these two patients, every other prescription for a benzodiazepine since April has been purely as an aid in the management of dementia care. It's not used a lot, at all. We've specialist teams to support care in my corner so if there're problems then the team looks at causes and understanding and interventions, I look at physical comorbidity and concurrent medication, our commonest intervention is stopping drugs not starting them.
I still find it amazing how much medication is used for the right reasons at the right time, but then when dementia progresses the medication's side effect profile and tolerability generate treatment emergent adverse events (e.g. wailing, sobbing, battering carers) which a GP and I can improve upon through review and rationalising a drug regimen.
But if you've dementia, and this advances to cause the inevitable cognitive decline but also non-cognitive changes (i.e. behavioural and psychological symptoms of dementia, BPSD), and these are intense (e.g. battering your wife), and these are pervasive (happening in most situations or most of the time or in a repeatable fashion such as each time personal care's delivered), and there's distress to the patient and carer through this, and practical changes haven't improved things, and behavioural changes haven't helped, then I'll consider medication too. I'm not keen on antipsychotics in the first instance since they ramp up risk of serious things (like strokes and death) significantly and invariably the patient's not psychotic (so an antipsychotic's use is contentious). The evidence base increasingly shows that an acetylcholinesterase inhibitor is more effective with less side effects in the management of BPSD than an antipsychotic. If you've Alzheimer's disease. What if you've vascular dementia, or you've Alzheimer's and the drug doesn't work?
Increasingly the evidence suggests that in this patient population (of dementia and BPSD) that a benzodiazepine is a safer and more effective agent than an antipsychotic. Makes sense, too. It's an anxiolytic, it reduces anxiety, it's a "minor tranquilliser" and if someone's distraught through poor memory, or frustration, or through misperception of situations, or misinterpretation of activities/events, or losses, or fears, it helps reduce the anxiety and distress.
On using a benzodiazepine, it's then reviewed by a nurse or myself to see if it works. If it does, huzzah! If not, can it be increased to have a therapeutic trial at a decent dose for a decent duration? Still no benefit? Then it's stopped. We have to do this otherwise I end up writing FP10s forever (which I've not the inclination to do) and my nursing colleagues are locked in to reviewing outcomes forever, which they've neither the capacity nor the need to do. Hence a desire to robustly evaluate effectiveness then determine whether to continue or stop the drug.
A less distraught patient's a good thing, since they feel better and have a lower symptom burden. Too, they're then more likely to accept the reassaurance, reality orientation, personal care or other interventions from carers more successfully, more of the time.
Overall, I'm with the Jobbing Doctor that the NHS can be keen to dish out benzodiazepines too readily, some of the time. But, babies an' bath water, I'd not want to unhelpfully simplify the discussion into use of benzodiazepines is bad, since that's not true. Inappropriate use of benzodiazepines is bad. Rational prescribing practice is not bad. On that basis, within such a framework, I'm far more enthusiastic about a bit of lorazepam than haloperidol/more noxious agents.
Sunday, 6 September 2009
Medication
I work full time. If patients problems through the working week, I am keen to sort them out with them. Sometimes, problems can be around the use of medication. Maybe it isn't working. Last week I had a patient 'phone because they'd been prescribed something else and wanted to know if she could take both tablets together. Maybe it's side effects (a patient last week had his rivastigmine patches stopped and a yellow card filled out after they caused ghastly rashes beneath each patch). Often it's because something destabilised the otherwise manageable situation (such as a patient last week with a chest infection who's otherwise manageable confusion/dementia became unmanageable and another lady who's daughter was going on holiday so couldn't give mum her tablets for that week).
My secretary receives messages from patients and carers that need attending to. Partly because it's important to them, partly because I don't like delays, partly because I've to do the work anyway so may as well do it straight away and largely because I get stressed if there's work to do that I leave for another time, I sort out such queries straight away. Well, my secretary gets their file out and attaches the message to the front, but such queries are invariably dealt the same morning or afternoon.
Some GPs write to me for advice about medication, which I very much welcome. Whether it's about a specific patient or whether it's about a concern they have/have read I usually get a touch too enthusiastic in replying. Because I know GPs need the information to be clinically relevant and because in Primary Care those who work with the GPs and need to understand and give the same message/work in the same sort of way, my letters back to Primary Care are not too abstract/theoretical and instead focus on the broad clinical headlines. Sure, I'll mention authors' names if relevant, so the GP can look it up if they have an interest, and so it's clear what the sources of my opinions are (and it's not just me making stuff up!) but by and large shared information is me waffling a bit about a topic. This is in my thoughts because the last letter was on why I wanted an ECG done before I planned to see a patient with dementia (who'd been seen by my nursing colleagues) in her care home. The typed letter was a touch over 2 A4 pages long. This is typical. What can I say, as is evident here, and as nurses chide me, I all too readily can waffle.
Getting medication right and sharing information about it matters. Patients, rightly, are keen to remind us of this.
Clinicians changing medication that another clinician initiated can cause difficulties. A GP changed a gentleman's lorazepam to haloperidol last week. The gentleman was under my care and had been for a couple months, with progression of his severe dementia, with nursing colleages and me seeing him at least once every week.
The gentleman was in respite care, where I'd seen him and nurses spoke with staff about his management.
He was wandersome, the home called his GP saying he was restless and distressed and hard to manage, the GP stopped lorazepam and started haloperidol.
The gentleman's Lewy Body dementia did not respond well to haloperidol, oh no. Poor bloke was rigid the next day. And drooling, come to that. By rigid, I mean he was so rigid he couldn't stand up, couldn't walk and couldn't eat. He was on 5mg of haloperidol twice a day which in older adults is a very significant/high dose, typically x10 what could be started.
The marketing authorisation for haloperidol says, "Baseline ECG is recommended prior to treatment in all patients, especially in the elderly . . ." and when the dose goes up an ECG is desirable, "During therapy, the need for ECG monitoring (e.g. at dose escalation) should be assessed . . ."
No ECG was done for this gentleman before starting haloperidol or during it's use.
Drugs in dementia cause risk as well as benefit. My GP colleagues can't be reasonably expected to keep up to date with this since it's a specialist area of prescribing and consideration to risk/benefits, often with incapacitated adults. Can a GP reasonably be expected to have read about the DART trial published this year and the effects of an antipsychotic doubling your risk of death in dementia (with 3 year survival of 30% on placebo vs 59% on an antipsychotic)? The trial was published in the Lancet Neurology. If a GP reads that, they can't read about, say, dermatology. GPs have so much to keep up to date with I can't expect GPs to know that this Summer a trial showed that dementia drugs increase your risk of syncope (collapse from an abnormal heart rhythm) by 12.9 per 1000 patient years) because reading such trials within the Archives of Internal Medicine and digesting and considering clinical implications. These are meaningful to Consultants who prescribe a lot (e.g. 1 in 77 patients every year will have a syncopal event, which is serious, since I've far more than 77 patients on these drugs) but less meaningful to individual patients (e.g. a patient would need to be on the drug for 77 years to be likely to have one episode of syncope).
Because of this, I have offered to take all decisions on prescribing of all antipsyhotics off my GPs. I offer to visit all GP surgeries a couple times a year for an hour on a lunchtime to talk through what heads up they may need about new stuff, what they want our service to do well/differently. Most GPs bit my hand off in their enthusiasm to do pass it over prescribing decisions to me. I visit every single care home in my patch, they all know to call our service if they've problems (since we've a specialist team to support them who're in the care homes every week).
The GP who stopped the lorazepam and started haloperidol was a locum GP covering for a GP who was on holiday. There were reams of letters from me/my team about the gentleman but still the systems didn't work optimally.
Grrr.
Time for more thought on how to solve that one.
My secretary receives messages from patients and carers that need attending to. Partly because it's important to them, partly because I don't like delays, partly because I've to do the work anyway so may as well do it straight away and largely because I get stressed if there's work to do that I leave for another time, I sort out such queries straight away. Well, my secretary gets their file out and attaches the message to the front, but such queries are invariably dealt the same morning or afternoon.
Some GPs write to me for advice about medication, which I very much welcome. Whether it's about a specific patient or whether it's about a concern they have/have read I usually get a touch too enthusiastic in replying. Because I know GPs need the information to be clinically relevant and because in Primary Care those who work with the GPs and need to understand and give the same message/work in the same sort of way, my letters back to Primary Care are not too abstract/theoretical and instead focus on the broad clinical headlines. Sure, I'll mention authors' names if relevant, so the GP can look it up if they have an interest, and so it's clear what the sources of my opinions are (and it's not just me making stuff up!) but by and large shared information is me waffling a bit about a topic. This is in my thoughts because the last letter was on why I wanted an ECG done before I planned to see a patient with dementia (who'd been seen by my nursing colleagues) in her care home. The typed letter was a touch over 2 A4 pages long. This is typical. What can I say, as is evident here, and as nurses chide me, I all too readily can waffle.
Getting medication right and sharing information about it matters. Patients, rightly, are keen to remind us of this.
Clinicians changing medication that another clinician initiated can cause difficulties. A GP changed a gentleman's lorazepam to haloperidol last week. The gentleman was under my care and had been for a couple months, with progression of his severe dementia, with nursing colleages and me seeing him at least once every week.
The gentleman was in respite care, where I'd seen him and nurses spoke with staff about his management.
He was wandersome, the home called his GP saying he was restless and distressed and hard to manage, the GP stopped lorazepam and started haloperidol.
The gentleman's Lewy Body dementia did not respond well to haloperidol, oh no. Poor bloke was rigid the next day. And drooling, come to that. By rigid, I mean he was so rigid he couldn't stand up, couldn't walk and couldn't eat. He was on 5mg of haloperidol twice a day which in older adults is a very significant/high dose, typically x10 what could be started.
The marketing authorisation for haloperidol says, "Baseline ECG is recommended prior to treatment in all patients, especially in the elderly . . ." and when the dose goes up an ECG is desirable, "During therapy, the need for ECG monitoring (e.g. at dose escalation) should be assessed . . ."
No ECG was done for this gentleman before starting haloperidol or during it's use.
Drugs in dementia cause risk as well as benefit. My GP colleagues can't be reasonably expected to keep up to date with this since it's a specialist area of prescribing and consideration to risk/benefits, often with incapacitated adults. Can a GP reasonably be expected to have read about the DART trial published this year and the effects of an antipsychotic doubling your risk of death in dementia (with 3 year survival of 30% on placebo vs 59% on an antipsychotic)? The trial was published in the Lancet Neurology. If a GP reads that, they can't read about, say, dermatology. GPs have so much to keep up to date with I can't expect GPs to know that this Summer a trial showed that dementia drugs increase your risk of syncope (collapse from an abnormal heart rhythm) by 12.9 per 1000 patient years) because reading such trials within the Archives of Internal Medicine and digesting and considering clinical implications. These are meaningful to Consultants who prescribe a lot (e.g. 1 in 77 patients every year will have a syncopal event, which is serious, since I've far more than 77 patients on these drugs) but less meaningful to individual patients (e.g. a patient would need to be on the drug for 77 years to be likely to have one episode of syncope).
Because of this, I have offered to take all decisions on prescribing of all antipsyhotics off my GPs. I offer to visit all GP surgeries a couple times a year for an hour on a lunchtime to talk through what heads up they may need about new stuff, what they want our service to do well/differently. Most GPs bit my hand off in their enthusiasm to do pass it over prescribing decisions to me. I visit every single care home in my patch, they all know to call our service if they've problems (since we've a specialist team to support them who're in the care homes every week).
The GP who stopped the lorazepam and started haloperidol was a locum GP covering for a GP who was on holiday. There were reams of letters from me/my team about the gentleman but still the systems didn't work optimally.
Grrr.
Time for more thought on how to solve that one.
Saturday, 29 August 2009
Absence
We're not absent, a lot.
I've not had a day off sick, this year. Or last year, come to that. On working through an annual appraisal with one of my Consultant colleagues, we pulled his sickness record for the last 16 years. He'd had just one day off sick.
I know some colleagues who don't use all their annual leave entitlement. Instead of going on holiday or having time off at home or whatever, they stay at work instead.
Gets you thinking.
No, it's not that all my Consultant colleagues are workaholics and passionately addicted to saving lives and making the world a better place. No, it's not that there's any financial advantage to working more (indeed, none of the extra hours or overtime or worked leave is paid). No, it's not that they've dysfunctional lives or grim home settings so would rather be at work.
The issue that one of my Consultants shared at appraisal was this. A holiday was less relaxing and more stressful than being at work. When we're away from work, nobody does our job. Our teams have discussed this. CPNs cover for each other. Ward staff cover shifts. Our OTs and social workers cross cover. Even our secretaries cover each other. This cover is substantial, involving sorting out work, doing depots, reviewing patients, typing letters, getting the work done.
With Consultant Psychiatrist cover, it's just cover for emergencies and specific problems. Nobody does my clinics whilst I'm away. Nobody does my home visits. Nobody does my reports. Nobody does my CPA reviews. Nobody sorts all the GP and solicitors' queries.
We've less Consultant Psychiatrist time than the Royal College say we should have, for our population. We've markedly less Staff Grade and junior doctor time than any other mental health unit I know. We've no Associate Specialist of Hospital Practitioner sessions. We don't have capacity to do the work of anyone else whilst they're on leave.
Through this, when we come back after leave, we've that week's work to do, plus the work of the last week when we were away. All the letters, emails, 'phone call messages, supervision, care home reviews, meetings, teaching, out-patient clinics, home visits you didn't do last week you somehow have to fit in to the week or two when you return, on top of everything else.
The stress some colleagues feel from this is such that they simply feel they can't be off for more than a week, or would give up their holiday entitlement and not go on leave at all.
Can't be healthy.
Must think on how to manage this differently . . .
I've not had a day off sick, this year. Or last year, come to that. On working through an annual appraisal with one of my Consultant colleagues, we pulled his sickness record for the last 16 years. He'd had just one day off sick.
I know some colleagues who don't use all their annual leave entitlement. Instead of going on holiday or having time off at home or whatever, they stay at work instead.
Gets you thinking.
No, it's not that all my Consultant colleagues are workaholics and passionately addicted to saving lives and making the world a better place. No, it's not that there's any financial advantage to working more (indeed, none of the extra hours or overtime or worked leave is paid). No, it's not that they've dysfunctional lives or grim home settings so would rather be at work.
The issue that one of my Consultants shared at appraisal was this. A holiday was less relaxing and more stressful than being at work. When we're away from work, nobody does our job. Our teams have discussed this. CPNs cover for each other. Ward staff cover shifts. Our OTs and social workers cross cover. Even our secretaries cover each other. This cover is substantial, involving sorting out work, doing depots, reviewing patients, typing letters, getting the work done.
With Consultant Psychiatrist cover, it's just cover for emergencies and specific problems. Nobody does my clinics whilst I'm away. Nobody does my home visits. Nobody does my reports. Nobody does my CPA reviews. Nobody sorts all the GP and solicitors' queries.
We've less Consultant Psychiatrist time than the Royal College say we should have, for our population. We've markedly less Staff Grade and junior doctor time than any other mental health unit I know. We've no Associate Specialist of Hospital Practitioner sessions. We don't have capacity to do the work of anyone else whilst they're on leave.
Through this, when we come back after leave, we've that week's work to do, plus the work of the last week when we were away. All the letters, emails, 'phone call messages, supervision, care home reviews, meetings, teaching, out-patient clinics, home visits you didn't do last week you somehow have to fit in to the week or two when you return, on top of everything else.
The stress some colleagues feel from this is such that they simply feel they can't be off for more than a week, or would give up their holiday entitlement and not go on leave at all.
Can't be healthy.
Must think on how to manage this differently . . .
Sunday, 23 August 2009
Private Psychiatry
People dabble in private practice, within the mental health arena. Patients seek solutions outside of NHS care, especially if care's shabby in their corner. Practitioners ply their trades, cross their palm with silver to receive whatever benedicition you desire.
Mostly it's innocuous stuff. A nurse charmingly nailed it when she said it's all a bit like internet porn, everyone knows it's going on and is somewhat unwholesome, it's pervasive and there in the background, but it doesn't change day to day life that much.
I don't do any private work. Partly it's because I simply don't have the time to do so. Mostly it's because the NHS can do it better.
A lady with a bereavement had input from us a few weeks ago. I saw her 3 times in one week, my nursing colleague saw her every day, for an hour, doing CBT. A support worker's since got her out, shopping and swimming and baking and doing again. She had a few days as an in-patient, under my care, when things were bleak. For 5 years she's been housebound. She's had a fair investment of care, over a couple of months.
- I got the referral from a GP on a Friday afternoon, rightly worried she was suicidal. She was seen by me, a Consultant Psychiatrist, at home, that afternoon.
- I saw her twice the next week, visiting to talk with her and her husband, whilst fiddling with tablets, formulating with them and looking at what she wanted to do to cope better
- She's been seen by an OT, looking at getting out to do more, in a purposeful and meaningful and pleasureable way, rather than just doing more
- She's been seen by our support worker who takes her out and goes with her to tea rooms, filled out forms with her, got her back to feeling okay in practical day to day tasks
- She's had input from a Consultant Psychologist who's not seen her but has given advice on her care and CBT that's undertaken
- She's had indirect input from our pharmacist too, discussing her medication with me
- She's seen by a CPN a lot, from subsequent joint visits with me to daily input for CBT to weekly input
Two months on she's strikingly better, will it last? Time will tell.
Could she have received better care, privately? No. Could she have received comparable care within the private sector? Not within my patch, or within the adjacent cities or counties. Episodic input titrated to need, indirect care contributing to the team working, flexible care across in-patients/community, care in clinics/at home (depending on what she wanted her family to hear), joint working, daily input from different qualified/unqualified professionals, rich and meaningfuly input from numerous individuals all effecting change in her care, collaborative working without a medical or nursing or psychological model dominating.
Community Mental Health Teams get a lot of stick. Sometimes rightly so, I'd not want to be a working age adult in receipt of our Trust's services. But when they get it right, it's in incomparable.
The NHS then far outstrips other provision of care.
It's good.
Mostly it's innocuous stuff. A nurse charmingly nailed it when she said it's all a bit like internet porn, everyone knows it's going on and is somewhat unwholesome, it's pervasive and there in the background, but it doesn't change day to day life that much.
I don't do any private work. Partly it's because I simply don't have the time to do so. Mostly it's because the NHS can do it better.
A lady with a bereavement had input from us a few weeks ago. I saw her 3 times in one week, my nursing colleague saw her every day, for an hour, doing CBT. A support worker's since got her out, shopping and swimming and baking and doing again. She had a few days as an in-patient, under my care, when things were bleak. For 5 years she's been housebound. She's had a fair investment of care, over a couple of months.
- I got the referral from a GP on a Friday afternoon, rightly worried she was suicidal. She was seen by me, a Consultant Psychiatrist, at home, that afternoon.
- I saw her twice the next week, visiting to talk with her and her husband, whilst fiddling with tablets, formulating with them and looking at what she wanted to do to cope better
- She's been seen by an OT, looking at getting out to do more, in a purposeful and meaningful and pleasureable way, rather than just doing more
- She's been seen by our support worker who takes her out and goes with her to tea rooms, filled out forms with her, got her back to feeling okay in practical day to day tasks
- She's had input from a Consultant Psychologist who's not seen her but has given advice on her care and CBT that's undertaken
- She's had indirect input from our pharmacist too, discussing her medication with me
- She's seen by a CPN a lot, from subsequent joint visits with me to daily input for CBT to weekly input
Two months on she's strikingly better, will it last? Time will tell.
Could she have received better care, privately? No. Could she have received comparable care within the private sector? Not within my patch, or within the adjacent cities or counties. Episodic input titrated to need, indirect care contributing to the team working, flexible care across in-patients/community, care in clinics/at home (depending on what she wanted her family to hear), joint working, daily input from different qualified/unqualified professionals, rich and meaningfuly input from numerous individuals all effecting change in her care, collaborative working without a medical or nursing or psychological model dominating.
Community Mental Health Teams get a lot of stick. Sometimes rightly so, I'd not want to be a working age adult in receipt of our Trust's services. But when they get it right, it's in incomparable.
The NHS then far outstrips other provision of care.
It's good.
Friday, 31 July 2009
Work
The Girl asked about managing someone with suicidal risk.
It's a contentious area because how ever you deliver care for these patients, you get it wrong.
If you want no risk, you're overly draconian and coercive and admit everyone. To assess if there's mental disorder and risk to self, you recommend they're admitted under a section of the Mental Health Act 1983 for assessment, if they decline. Why not? A few days assessment to save lives, a fair price to pay, no?
If you want to preserve patient liberty, autonomy and their ownership/control of their problems, choice, collaborative therapeuric working then you'd not detain or admit many at all. So some folk would be suicidal out in the community, with some going on to completed suicide. Whether in-patient care would prevent all that is another issue.
So you admit everyone, thus notionally reducing suicidal risk. Or you don't admit everyone, thus accepting patients (and not Secondary Care) are managing a lot of the risk themselves.
Clearly, not everyone's going to be happy all the time.
It's telling that the first theme that came to me on this issue is risk managament. That's how management of suicidality is taught, reported, framed, documented, written about. The Department of Health and Royal College aren't in the habit of sending me helpful letters about clinical elements and therapeutic elements of care, it's invariably about risk. The Trust doesn't look at quality of care or constituents of care of patient pathways, it looks principally at governance and risk.
I can see that risk management is part of the equation because if the decision's wrong then someone could die. Unlike other areas of medicine, in psychiatry this patient death often could be seen as preventable. Getting the risk management right is therefore vital (in the true sense of the word) since it's about a life.
My first evening on call as an SHO involved section 136 assessments (it was in an age when the SHO did them . . . now I'm a Consultant it's Consultants who do them) and liaison assessments in A&E (again, SHO's did those, now it's not something junior doctors are allowed to do, so it's Consultant work) and GP referrals for assessment (again, this now falls to Consultants). I'd trained as a GP before going in to psychiatry, so prior work in A&E then in GP gave me some confidence in triage, risk management and safety netting, but not the clinical competence to manage acute mental health presentations.
My first night on call involved assessing a lady in her 20's who cut herself. I took took a psychiatric history, went through mental state examination, checked we had a bed for her, 'phoned the on-call Consultant to be told to send her home. I couldn't quite get it. Her self injurious behaviour was seen by the Consultant as a sign of distress, of not being well, of poorly coping, but guessed it was part of her way of coping. I was told to send her home and arrange for her team to see her in the morning.
As time moved on this started to make more sense because what the Consultant had been sifting through was information to suggest whether there was evidence of acute psychiatric illness (necessitating acute care) or whether it was more of a psychological problem (which psychiatry couldn't fix by acute admission).
That really is what an assessment of someone feeling suicidal should be about. It should be about a clinical assessment (rather than an assessment skewed by political drivers) to look at patient need, then consequent care necessary to address that need.
Taken back to basics, this makes assessment of a suicidal patient no more fraught than assessments of someone with a chest infection.
Free will. People have free will. If someone's wishing to hurt or kill themselves and have capacity to make that decision, support can be offered but ultimately it's their choice. We can't use the Mental Health Act 1983 or Mental Capacity Act 2005 if someone's capacitated, with no mental disorder. The harsh reality is therefore that it's likely that someone could elect to kill themselves after being assessed. But if they weren't mentally ill and were offered appropriate support, surely mental health services have done their job.
Believing this has resulted in significant positive risk taking, including sending a gentleman on his way with police who was covered in petrol and threatening to immolate himself. But he wasn't mentally ill.
That's how I personally manage the assessment of suicidality without finding it too scary and being risk averse, I pull back to look at the clinical presentation and consequent need, then simply go from there . . .
It's a contentious area because how ever you deliver care for these patients, you get it wrong.
If you want no risk, you're overly draconian and coercive and admit everyone. To assess if there's mental disorder and risk to self, you recommend they're admitted under a section of the Mental Health Act 1983 for assessment, if they decline. Why not? A few days assessment to save lives, a fair price to pay, no?
If you want to preserve patient liberty, autonomy and their ownership/control of their problems, choice, collaborative therapeuric working then you'd not detain or admit many at all. So some folk would be suicidal out in the community, with some going on to completed suicide. Whether in-patient care would prevent all that is another issue.
So you admit everyone, thus notionally reducing suicidal risk. Or you don't admit everyone, thus accepting patients (and not Secondary Care) are managing a lot of the risk themselves.
Clearly, not everyone's going to be happy all the time.
It's telling that the first theme that came to me on this issue is risk managament. That's how management of suicidality is taught, reported, framed, documented, written about. The Department of Health and Royal College aren't in the habit of sending me helpful letters about clinical elements and therapeutic elements of care, it's invariably about risk. The Trust doesn't look at quality of care or constituents of care of patient pathways, it looks principally at governance and risk.
I can see that risk management is part of the equation because if the decision's wrong then someone could die. Unlike other areas of medicine, in psychiatry this patient death often could be seen as preventable. Getting the risk management right is therefore vital (in the true sense of the word) since it's about a life.
My first evening on call as an SHO involved section 136 assessments (it was in an age when the SHO did them . . . now I'm a Consultant it's Consultants who do them) and liaison assessments in A&E (again, SHO's did those, now it's not something junior doctors are allowed to do, so it's Consultant work) and GP referrals for assessment (again, this now falls to Consultants). I'd trained as a GP before going in to psychiatry, so prior work in A&E then in GP gave me some confidence in triage, risk management and safety netting, but not the clinical competence to manage acute mental health presentations.
My first night on call involved assessing a lady in her 20's who cut herself. I took took a psychiatric history, went through mental state examination, checked we had a bed for her, 'phoned the on-call Consultant to be told to send her home. I couldn't quite get it. Her self injurious behaviour was seen by the Consultant as a sign of distress, of not being well, of poorly coping, but guessed it was part of her way of coping. I was told to send her home and arrange for her team to see her in the morning.
As time moved on this started to make more sense because what the Consultant had been sifting through was information to suggest whether there was evidence of acute psychiatric illness (necessitating acute care) or whether it was more of a psychological problem (which psychiatry couldn't fix by acute admission).
That really is what an assessment of someone feeling suicidal should be about. It should be about a clinical assessment (rather than an assessment skewed by political drivers) to look at patient need, then consequent care necessary to address that need.
Taken back to basics, this makes assessment of a suicidal patient no more fraught than assessments of someone with a chest infection.
Free will. People have free will. If someone's wishing to hurt or kill themselves and have capacity to make that decision, support can be offered but ultimately it's their choice. We can't use the Mental Health Act 1983 or Mental Capacity Act 2005 if someone's capacitated, with no mental disorder. The harsh reality is therefore that it's likely that someone could elect to kill themselves after being assessed. But if they weren't mentally ill and were offered appropriate support, surely mental health services have done their job.
Believing this has resulted in significant positive risk taking, including sending a gentleman on his way with police who was covered in petrol and threatening to immolate himself. But he wasn't mentally ill.
That's how I personally manage the assessment of suicidality without finding it too scary and being risk averse, I pull back to look at the clinical presentation and consequent need, then simply go from there . . .
Thursday, 30 July 2009
Shotguns
To get a shotgun in my corner (I don't know if it's a national requirement), a doctor's statement is needed.
This asserts that the person's sane and isn't going to go around killing lots of people.
Tricky one, that.
How can such an assessment of future risks be undertaken robustly? Locally, one GP practice solves this with a simple question to anyone asking for a shotgun. "Do you want a gun?" Anyone saying, "Yes!" doesn't get one. Most people don't want more guns in our society and think they're scary, so they'll assume that anyone who asks for one shouldn't have one. Their take is that they never offer a statement of support.
It's not NHS work, so my Trust obviously won't suffer me seeing folks in clinics or using patients' NHS time for private fee paying work, so it ain't something I do.
But as someone aligned to more libertarian views, it doesn't sit wholly comfortably with me. Shouldn't folk be able to have latitude to do what they want to do, but with that freedom accept the responsibility of consequences? Yet, with guns and the heightened risks to others this generates, it somehow has a different complexion to debates on drugs or other issues.
This asserts that the person's sane and isn't going to go around killing lots of people.
Tricky one, that.
How can such an assessment of future risks be undertaken robustly? Locally, one GP practice solves this with a simple question to anyone asking for a shotgun. "Do you want a gun?" Anyone saying, "Yes!" doesn't get one. Most people don't want more guns in our society and think they're scary, so they'll assume that anyone who asks for one shouldn't have one. Their take is that they never offer a statement of support.
It's not NHS work, so my Trust obviously won't suffer me seeing folks in clinics or using patients' NHS time for private fee paying work, so it ain't something I do.
But as someone aligned to more libertarian views, it doesn't sit wholly comfortably with me. Shouldn't folk be able to have latitude to do what they want to do, but with that freedom accept the responsibility of consequences? Yet, with guns and the heightened risks to others this generates, it somehow has a different complexion to debates on drugs or other issues.
Wednesday, 29 July 2009
Police
Jess raised the point of police accessing private places, to bring people to a place of safety for assessment.
In theory, this is covered under section 135 of the Mental Health Act 1983.
Someone's in a private place, refuses help, seems to need care, generates significant and risky problems (for themselves or others), what's to be done? An Approved Mental Health Professional presents their concerns to a magistrate who can then issue a warrant for police to access the person, eg forcing their way into their home, to then take them to a place of safety.
Unusually, they're then locked up in a place of safety for 72 hours, but I can't discharge them from the section 135. The police or the Approved Mental Health Professional does that.
In practice, it's hardly ever used. I've seen it used once.
If someone's in their own home or garden or other not-public area, invariably a section 2 is considered instead.
Jess is quite correct that this means someone who's presenting with a health problem, and consequent behavioural changes and evidence of ill health being manifest to one and all, then has an ambulance crew arrive who do . . . what? If detained under the MHA 1983 then they can be conveyed to hospital. If they're evidenced to be incapacitated adults (with respect to this decision) then they can be conveyed to hospital (if it's in their best interests) under the MCA 2005. Our ambulance crews need to be given completed locally agreed forms documenting this lack of capacity before they'll convey.
So locally, the use of the MHA 1983 (with sections 2 and 136) and MCA 2005 (sections 4 and 5) sort most out of hours problems where statutory powers need to be used to orchestrate care. Rarely, very rarely, section 135 is considered.
In theory, this is covered under section 135 of the Mental Health Act 1983.
Someone's in a private place, refuses help, seems to need care, generates significant and risky problems (for themselves or others), what's to be done? An Approved Mental Health Professional presents their concerns to a magistrate who can then issue a warrant for police to access the person, eg forcing their way into their home, to then take them to a place of safety.
Unusually, they're then locked up in a place of safety for 72 hours, but I can't discharge them from the section 135. The police or the Approved Mental Health Professional does that.
In practice, it's hardly ever used. I've seen it used once.
If someone's in their own home or garden or other not-public area, invariably a section 2 is considered instead.
Jess is quite correct that this means someone who's presenting with a health problem, and consequent behavioural changes and evidence of ill health being manifest to one and all, then has an ambulance crew arrive who do . . . what? If detained under the MHA 1983 then they can be conveyed to hospital. If they're evidenced to be incapacitated adults (with respect to this decision) then they can be conveyed to hospital (if it's in their best interests) under the MCA 2005. Our ambulance crews need to be given completed locally agreed forms documenting this lack of capacity before they'll convey.
So locally, the use of the MHA 1983 (with sections 2 and 136) and MCA 2005 (sections 4 and 5) sort most out of hours problems where statutory powers need to be used to orchestrate care. Rarely, very rarely, section 135 is considered.
Tuesday, 28 July 2009
Section 136
I get called to a lot of section 136 assessments, out of hours. In fact, it's pretty much all that out of hours work typically involves. Section 136 of the Mental Health Act 1983 allows a police constable to stop and manage, ". . . a person who appears to him to be suffering from mental disorder and to be in immediate need of care or control . . ." to, ". . . remove that person to a place of safety . . ."
Locally, that's a 136 suite in our hospital.
Police find someone acting "a bit odd" and have a choice. They can arrest them, with all the attendant paper work, take them to the cells, wrangle with the custody sergeant why the person needs locking up, do that paperwork . . . or they can fill out a paragraph on one of our forms and drop them at our doors.
No surprise, use of section 136 is increasing massively in my corner.
In fairness, much of the time the police get it right. It's just that sometimes it's clear that the alcohol and social situtation has generated the volatile presentation, so taking them to my door for a psychiatric assessment isn't going to generate hospital in-patient or acute psychiatric care since we've simply not been asked to (and therefore aren't resourced to) deal with this. If you're drunk and feisty, it's not a psychiatric problem.
I concede that having mental illness at the same time can ramp up risks of problems, but if the presentation at that point in time, in that place, in that situation, is because of getting roaringly drunk, I don't have an instant cure for that.
Section 136 is an interesting section of the MHA 1983. You can be picked up anywhere the public have access to. You are thought to need care. You're picked up by police. You have no choice. You're taken to a place of safety. You have no choice. You're held in this locked environment. You have no choice. You're detained there for assessment for as long as it takes, up to 72 hours (that's right, 3 whole days). You have no choice.
What rights do you have, how do you appeal, who do you appeal to? Can you get a First Tier Tribunal to discharge your section 136? No. You can't appeal. You're there for the duration. You have no choice.
Quite scary, really. Anyone acting "a bit odd" can be locked up for 3 days with no rights of appeal or redress.
In fairness, section 136 assessments usually are undertaken pretty sharpish. I always do them straight away, attending immediately. It only seems fair. I need to do the assessment anyway, so why wait? Also it's just a stress to me, knowing I've work to do but not doing it. So when a section 136 is 'phoned through, I'm skipping off to see the patient as soon as an Approved Mental Health Professional (AMHP) can get there (which in my corner still means a band 7 social worker).
The last assessment was relatively brief. A gentleman was brought, by police, after saying over many hours in a pub that he was feeling suicidal. He wasn't. It took just an hour to go through history, mental state and formulation. Discharge options were then discussed and off he was, on his merry way. He's been seen subsequently when both he and staff felt he was in fine form, consistently cheerful, with no mental illness evident.
Another gentleman. Another assertion of suicidality. Another assessment over the course of an hour, with no evidence of mental health problems (meaning neither psychological problems nor psychiatric illness) but social upsets (rows with two girlfriends, thrown out by one of them, feeling skint yet owed friends cash, hated his poorly paid sporadic monotonous work). He was told the good news by the AMHP that he wasn't that ill, he didn't need hospital in-patient care and was no longer detained. A free man. He became angry, smashing his fists on walls and kicking doors and screaming like a banshee. He wanted to be in hospital, but wanted to be detained, to show his girlfriend what she had done, what she caused. Police don't like patients being angry and violent aronud NHS staff. Thankfully they take it seriously, here. They arrested him and he had a night in the cells.
A recent section 136 assessment was different.
The gentleman was brought in mid week. He had a curious account of overdose and suicidal thoughts and actions which was inconsistent. Police didn't find his presentation was in keeping with having taken the materials he said he'd taken. When he presented it was clear he was pretty well, physically, when if he'd taken all he said he had, he'd be flat. Odd. Assessing lethality of overdose and ongoing suicidality perplexed the AMHP who sought more information. The section 136 continued after we saw him, so more information could be gleaned, to inform the assessment (and need for discharge or detention). Blood tests were undertaken and showed he'd not taken what he'd asserted. The next day the AMHP tracked down the clinical team in another county that had been looking after him, prior to his drive to my corner and subsequent overdose here. They gave details of two other counties he'd had contact in. More information was gleaned from them. It was on day 3 that he was discharged from his section 136. Only then did the AMHP feel she had sufficient information of psychosocial history, support available, past behaviour, risk, how he'd managed problems historically (with what escalated risks and what reduced risks) and what sensible discharge planning could helpfully and realistically effect support and change. Months on, he's back in his own locality but I heard that he's coping well and is much, much improved. The assessment and care planning and initial local support was of merit, did effect change and this has been sustained back in his own corner.
Maybe then sometimes, just sometimes, detaining someone for 3 days is in their best interests after all.
I still favour getting it all done and dusted in an hour, though . . .
Locally, that's a 136 suite in our hospital.
Police find someone acting "a bit odd" and have a choice. They can arrest them, with all the attendant paper work, take them to the cells, wrangle with the custody sergeant why the person needs locking up, do that paperwork . . . or they can fill out a paragraph on one of our forms and drop them at our doors.
No surprise, use of section 136 is increasing massively in my corner.
In fairness, much of the time the police get it right. It's just that sometimes it's clear that the alcohol and social situtation has generated the volatile presentation, so taking them to my door for a psychiatric assessment isn't going to generate hospital in-patient or acute psychiatric care since we've simply not been asked to (and therefore aren't resourced to) deal with this. If you're drunk and feisty, it's not a psychiatric problem.
I concede that having mental illness at the same time can ramp up risks of problems, but if the presentation at that point in time, in that place, in that situation, is because of getting roaringly drunk, I don't have an instant cure for that.
Section 136 is an interesting section of the MHA 1983. You can be picked up anywhere the public have access to. You are thought to need care. You're picked up by police. You have no choice. You're taken to a place of safety. You have no choice. You're held in this locked environment. You have no choice. You're detained there for assessment for as long as it takes, up to 72 hours (that's right, 3 whole days). You have no choice.
What rights do you have, how do you appeal, who do you appeal to? Can you get a First Tier Tribunal to discharge your section 136? No. You can't appeal. You're there for the duration. You have no choice.
Quite scary, really. Anyone acting "a bit odd" can be locked up for 3 days with no rights of appeal or redress.
In fairness, section 136 assessments usually are undertaken pretty sharpish. I always do them straight away, attending immediately. It only seems fair. I need to do the assessment anyway, so why wait? Also it's just a stress to me, knowing I've work to do but not doing it. So when a section 136 is 'phoned through, I'm skipping off to see the patient as soon as an Approved Mental Health Professional (AMHP) can get there (which in my corner still means a band 7 social worker).
The last assessment was relatively brief. A gentleman was brought, by police, after saying over many hours in a pub that he was feeling suicidal. He wasn't. It took just an hour to go through history, mental state and formulation. Discharge options were then discussed and off he was, on his merry way. He's been seen subsequently when both he and staff felt he was in fine form, consistently cheerful, with no mental illness evident.
Another gentleman. Another assertion of suicidality. Another assessment over the course of an hour, with no evidence of mental health problems (meaning neither psychological problems nor psychiatric illness) but social upsets (rows with two girlfriends, thrown out by one of them, feeling skint yet owed friends cash, hated his poorly paid sporadic monotonous work). He was told the good news by the AMHP that he wasn't that ill, he didn't need hospital in-patient care and was no longer detained. A free man. He became angry, smashing his fists on walls and kicking doors and screaming like a banshee. He wanted to be in hospital, but wanted to be detained, to show his girlfriend what she had done, what she caused. Police don't like patients being angry and violent aronud NHS staff. Thankfully they take it seriously, here. They arrested him and he had a night in the cells.
A recent section 136 assessment was different.
The gentleman was brought in mid week. He had a curious account of overdose and suicidal thoughts and actions which was inconsistent. Police didn't find his presentation was in keeping with having taken the materials he said he'd taken. When he presented it was clear he was pretty well, physically, when if he'd taken all he said he had, he'd be flat. Odd. Assessing lethality of overdose and ongoing suicidality perplexed the AMHP who sought more information. The section 136 continued after we saw him, so more information could be gleaned, to inform the assessment (and need for discharge or detention). Blood tests were undertaken and showed he'd not taken what he'd asserted. The next day the AMHP tracked down the clinical team in another county that had been looking after him, prior to his drive to my corner and subsequent overdose here. They gave details of two other counties he'd had contact in. More information was gleaned from them. It was on day 3 that he was discharged from his section 136. Only then did the AMHP feel she had sufficient information of psychosocial history, support available, past behaviour, risk, how he'd managed problems historically (with what escalated risks and what reduced risks) and what sensible discharge planning could helpfully and realistically effect support and change. Months on, he's back in his own locality but I heard that he's coping well and is much, much improved. The assessment and care planning and initial local support was of merit, did effect change and this has been sustained back in his own corner.
Maybe then sometimes, just sometimes, detaining someone for 3 days is in their best interests after all.
I still favour getting it all done and dusted in an hour, though . . .
Friday, 17 July 2009
Dignity
Let's try and keep it dignified.
Please, no wailing and gnashing of teeth at this news.
Bwah ha ha ha ha ha haar!
Sorry.
I'm composed again, now. A clinician stops meddling in GP processes and making ill informed decisions on health systems he isn't informed about and returns to clinical practice. Huzzah!
Please, no wailing and gnashing of teeth at this news.
Bwah ha ha ha ha ha haar!
Sorry.
I'm composed again, now. A clinician stops meddling in GP processes and making ill informed decisions on health systems he isn't informed about and returns to clinical practice. Huzzah!
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