All heads turn in my direction
It is often very early on in any post that I undertake that my
passion for mental health reveals itself.
As many of my colleagues do not share this passion, when the
task of dealing with a patient that does suffer with mental health
issues alongside their physical health issues, all heads turn in my
To be fair, I’m happy to ‘take one for the team’. We all have
likes and dislikes, strengths and weaknesses, and I am happy to
shoulder the burden when it comes to the complex mental health
needs that can arise in the acute medical setting. Who am I
kidding? I love it!
One such situation arose recently following the admission of a
17 year old boy to the medical admissions unit. ‘John’* was not
very happy about being discharged from the inpatient mental health
unit that he had been at for a number of weeks. The situation
escalated and the police were called.
Upon their arrival, ‘John’ was witnessed to have a tonic-clonic
seizure. With no previous diagnosis of Epilepsy, he was brought to
A&E, where he was witnessed to have a second seizure and thus
admitted for further investigation.
I came to know of ‘John’ at handover on Friday morning.
Upon clerking, ‘John’ had revealed to the night SHO that he was
hearing voices instructing him to harm himself. As he was still
awaiting medical investigations, ‘John’ would not be seen by the
mental health team. I was asked therefore to review him later in
the day and refer him as appropriate.
...never leave your pen unattended, always accept the offer of a
hot drink and nurses get very twitchy at 5 o’clock on a Friday if
planned discharges fall through
‘John’ had no information about his own mental health. He denied
any formal diagnosis or medication, and was unsure of his follow-up
arrangements. We contacted his previous mental health team, in an
attempt to obtain a collateral history, but were unable to get
through to a member of staff familiar with his care. Messages were
left, and we awaited further correspondence.
Things weren’t adding up. On the one hand, I had a young man who
must have been reviewed by a senior psychiatrist very recently, if
the decision had been made to discharge him from inpatient
services. On the other however, this was my first encounter with
him, and I had very little information with which to make a
decision. I discussed the situation with a senior colleague, and
decided that we had no choice but to involve the crisis team, even
if it was simply to collate more information.
In the meantime, I was faced with facilitating the safe
discharge of a young man with no fixed abode or registered GP,
awaiting social placement who reported experiencing complex
auditory hallucinations; second person voices that were instructing
him to take his own life. As if the case wasn’t convoluted enough,
this was complicated further by the fact that ‘John’ was miles away
from his previous residence and thus care worker who was trying to
place him into a new address.
Oh and, 5 o’clock was approaching. On a Friday.
There are many interesting curiosities that I have learnt during
my time in medicine: never leave your pen unattended, always accept
the offer of a hot drink and nurses get very twitchy at 5 o’clock
on a Friday if planned discharges fall through.
I was soon approached by the nurse co-ordinator requesting an
update about ‘John’. I explained the situation and that we may have
to delay his discharge as we waited for the crisis team. Not quite
the answer she was expecting. The focus of nursing handover
surrounding ‘John’s’ care were his physical needs; working
diagnosis and pending investigations. They were blissfully unaware
of any of his previous or potential mental health needs.
I proceeded to explain the passage of events, correspondence I
had made, and information I was awaiting, only to be met with a
look of utter disappointment. “You’ve got the wrong hat on”,
followed by a somewhat despondent explanation of the aims of the
medical admissions unit, an overconfident statement of ‘John’s’
mental wellbeing topped with a condescending “when you’ve been in
the job as long as I have, you get to know these things.”
In my idealist mind I had hoped that I was entering a health
service that valued holistic patient care, working towards
upholding health as a complete state of physical, mental and social
wellbeing. It seems however that this is not the case.
The feelings of disappointment were soon reciprocated.
I left the conversation feeling bruised, not by her discourtesy,
but by her obstructive approach. We may well have excluded any
urgent medical cause for ‘John’s’ seizures, but it was my
responsibility as the discharging doctor to be sure that ‘John’ was
not a risk to himself or others.
Fortunately, there was a happy ending for ‘John’. The mental
health unit returned my call and reassured me that these
hallucinations were known to them, and that ‘John’ had community
follow-up arranged for the following week. His care worker, also
came through at the last minute, with a temporary placement into
which we could discharge him and so the nurse co-ordinator got her
way after all and my conscience could rest knowing that I was
discharging my patient with a number of safety nets in place.
The feelings of success were short-lived however, overpowered
instead by feelings of disenchantment. In my idealist mind I had
hoped that I was entering a health service that valued holistic
patient care, working towards upholding health as a complete state
of physical, mental and social wellbeing. It seems however that
this is not the case. Rather, I find myself surrounded by
super-specialists and managers preoccupied with turfing patients
We are more concerned with who is responsible for a patient
rather than who is looking after the patient, and I find this more
often than not, when dealing with patients with simultaneous
physical and mental health needs.
There are clearly financial and political reasons involved in
this divide, but there are also personal factors much closer to the
front-line.For example, nurses no longer receive general training.
Newly qualified general nurses often only have 4-6 weeks of mental
health exposure, as do medical students- the majority of whom will
not undertake a foundation post in psychiatry.
This plants a seed of fear in the workforce when dealing with
mental health. We all fear the unknown as it is, let alone when the
unknown can potentially pose a risk to one’s safety.
Furthermore, as juniors, we look to our seniors for support and
expertise – themselves even more distant from their psychiatric
training. How therefore can we expect to provide holistic
healthcare to patients if there is such limited shared expertise?
Or do I actually have the wrong hat on after all?
*Patient and clinical details have been altered in the
interests of patient confidentiality.