Bedlam

Here is one for my psych colleagues. As some of you may know, my last job in the UK was spent working for an incredible psychiatric liaison team at King’s College Hospital, London. I have always had a slight slant for the ones that are slightly loopy in the head – psychiatrists and mental health nurses; I enjoy the interaction with the patients too. As a student I spent many a Tuesday evening with a troupe of terribly enthusiastic psychiatrists, terrifyingly good actors and sheepish pupils like myself – but we soon learned the joys of working in mental health and many of our initial fears in dealing with “difficult to handle” patients soon dissipated. Now, you may ask, how can someone who loves dealing with the blood and gore of casualty also enjoy the long in depth assessments involved in psychiatry? True, they may be on different ends of the spectrum, but both are equally exciting and drab at the same time – in the emergency department you get the stab wounds, but also the sore throats; in psychiatry (often in the emergency department too) you see the floridly manic, but also the young teenagers who come in every week having just taken enough paracetamol to get them some attention, but never enough to die (I must say I do prefer it when they take the non lethal dose; also the conversation that is had is much more interesting than that of someone with a sore throat). As a result of all this I thought I was pretty prepared for dealing with mental health out here. How wrong could I have been?

Psychiatry – the talking medicine. Trying to get a medical history is hard enough here, let alone ask about mental health complaints. The culture and language is so different. Did I mention Xhosa is full of clicks and clocks of the tongue? Now, I am slowly learning this tongue, but at the moment my vocabulary consists of about 40 words and only around 4 of which are actually understood by my patients. According to them I still can’t pronounce the word for “cough” properly. They just give me a vacant stare and turn their head to look at the nurse who repeats exactly what I just said, but with a little extra fairy dust. This magic twist of the tongue turns my patient’s confused frown into a nice verbal response. Unfortunately, I often can’t understand what their reply is. And so, the process reverses as I turn to my nurse with a look of “what did they just say?”

I have quickly learnt that we don’t do too much talking to our patients here that are referred to as: “Doc, we have a mental case – can you prescribe some intravenous sedation?” The first time I was asked this, my initial reaction was – no way, let’s try and de-escalate this situation in a nice step wise manner – I have done a job in psychiatry don’t you know. So, let’s talk first. Plan “A” failed at the starting block when I found 3 security guards sitting on my “mental case”. One guard was gently pushing his foot on the patient’s neck (they had just zapped him with a taser). I didn’t like this one bit and kindly asked the guards not to antagonise our patient any further. Talking didn’t work when I remembered: “Oh yes, I can’t speak Xhosa. I can’t even pronounce Xhosa properly. Silly me.” My nurses weren’t very keen on opening any kind of dialogue so I offered him some oral medication to calm him down. Eureka – he happily swallowed down the cocktail of benzodiazepines and antipsychotics. Half an hour later, he was still causing havoc. At which point my boss showed up and said: “don’t bother with that, just give him the stuff intravenously.” Despite initially objecting, I caved in – the patient got his shot and quickly dozed off into la la land. This had taken about one hour of my time. I have fast realised that we don’t have the luxury to properly give our full attention to these patients, or any patient for that matter. When there is only one of you in casualty and several other people also needing your urgent undivided time, all one can do is temper the situation (and try to stop the security guys from using their taser). This often means heavily sedating our psychotic clients as first line treatment, making sure they are calm enough to put the rest of the department at ease but not so chilled that they stop breathing. The talking happens later, at some point.

We see a lot of psychotic patients. I expect most of the cases are drug induced as there is a serious amount of marijuana smoked here. The stuff grows like a weed. Every disturbed patient I have seen so far inhales chimneys of the stuff. Along with these lively characters, there are a lot of overdoses. Many involve similar circumstances to what is seen daily in a UK emergency department – young boys and girls that take a few tablets because they were having relationship issues, exam stress or just a bit frustrated with the normal ups and downs of life. Unfortunately the drug of choice here is a nasty organophosphate pesticide that is freely available. People use it to preserve millet, one of the staple foods eaten by the local population. Just one tablet needs to be taken and it can be game over. In fact, since I have been here I don’t know of anyone that has survived, but we do try as it is potentially reversible if you have the right drugs and equipment. We occasionally have the former, but rarely the latter. The saddest thing is that when you talk to these patients, the awake ones, they often regret what they have done and want to live. There is often little we can do apart from cross our fingers (not quite true, but it does feel like that is all we are doing).

So, that is a brief summary of the wayward state of psychiatry here – the pathology is present, but the effective management is not. The patients that remain on treatment are often on very old drugs that have many, often irreversible, side effects. They are quickly labelled as a “mental case”, which tends to stick for the rest of their life. However, on the up side, many of these psych patients often have a family member or friend that supports and stays with them – I just hope it is because of the love and affection and not the government grant that people with mental illness receive every month. Food for thought, though.