It is eleven o’clock and I am listening to Radio 4 and sipping a nice cup of Earl Grey. I could be a middle-aged lady. Perhaps I am. In fact, I have just been visited by a middle-aged lady – one year off retirement, so maybe more than middle-aged. She is one of the other med secs and she’s nice enough but really rather bitter about her work and life. Her conversation is littered with expletives, which are spat out with such force that I like her less.
I have completed my work for the day (so far anyway). I have done well to stretch out that work for these two hours as really I could have done it in about 20 minutes. In any case, I feel I am now suitably free enough to document the events of yesterday afternoon, namely the ward round and SHO supervision.
The ward round is when the consultant goes and meets the patients and chats with them about their progress and treatment plan. We met a young lady, who looked so sad and pitiful and a product of her history that I crumpled a bit inside. She was admitted after setting fire to her apartment as she thought there were spy cameras in there, through which people could watch her, and ultimately clone her. She was on crack cocaine at the time and in the past has been a heroine and cocaine addict. She left school at fourteen and her baby has been taken into care. She lives in council housing and was given the crack by a man who comes to take photos of her to put on a website (you know the kind I mean). The doctor thought that maybe she had a psychotic episode through the crack. She said she had to drink and take crack to help her stop thinking about her problems. During the ward round she seemed reasonably upbeat and wanted to sort things out for herself. All they could really do for it seemed was to give her advice and contacts to help her e.g. adult literacy classes, drug rehab, council housing phone numbers etc. She won’t be discharged until the end of the week.
The consultant told me that a lot of the time the inpatients get better by themselves, or with a bit of medication, once their episodes are finished. The hospital gives them some time out from society and reality, with people who are focused on their care and wellbeing, so that they can feel strong enough to get better. For the manic patients it is a calm place where they can just be more controlled.
I was looking at the ward list and listening to the briefing meeting and so much of it just made me sad about how these people have come to where they are and what was wrong with them. Granted we are in a deprived area but really for people to go through some of the things that seem to happen here is just inexcusable.
On a more positive note, the new SHOs have started in the department and so yesterday I got to sit on a supervision. We learnt about mental state examinations and the five indicators people check for. These are: mood, energy levels, suicide risk, hallucinations, and delusions (thought disorders). Delusions were postponed until next week because apparently they are the most complicated. For the other four there were loads of definitions and case studies to talk about. Really it seems you can only properly link all the different aspects together after you’ve seen lots and lots of patients and so you know what symptoms constitute what illness. Most interesting to me was the discussion of suicide risk. Apparently a lot of patients say they are a suicide risk but you don’t really need to take them seriously unless they have a plan i.e. have thought through the logistics of their intentions. Otherwise they have only vague ideas, which aren’t so much to worry about. The exception to this, obviously, is the impulsive suicide candidate. In both cases there is usually a precipitating, or trigger, factor, which will set off the suicide, or in some cases, save the patient. The doctor gave the example of a woman who was going to jump in front of train, but decided to have just one last cigarette before plunging, and then by the time she had finished her fag, she had changed her mind. Who would’ve thought cigarettes saved lives?! Another interesting thing we learnt was how the expression “one for the road” came about. It seems that there used to be a prison on Tottenham Court Road, and prisoners that were sentenced to death were hanged down at Marble Arch, so when they had their last drink it was to pluck up the courage to make the long walk down Oxford Street. Again, interestingly, there is a lower risk of homicide amongst mentally ill patients compared with the general population – so low in fact that the risk of homicide is hardly ever formally assessed unless the patient has a forensic history.
The stuff on hallucinations was also really interesting. Hallucinations are perceptual abnormalities i.e. people actually sense these things through touch, sight, hearing etc. Sufferers don’t normally have gustatory, kinaesthetic or olfactory hallucinations – auditory and visual hallucinations are far more common. Hallucinations are a major symptom of paranoid schizophrenia. It was interesting to hear that normally when sufferers hear voices they are simply commenting on what is going on e.g. the voice might say “you’re typing, good, you’re typing” or something like that. The voices are supposedly without emotion or inflection and speak very simply i.e. no clauses or conditions or complicated syntax structures. Sometimes they can even be positive – when people hear “nice” voices it can be difficult to treat them (the doctor said he only treated people who were actually in distress, and not if they didn’t want him to). Normally the voices are not positive though – they are either neutral or derogatory. Often they encourage the sufferer to harm him/herself which is why there is a big risk of self-harm amongst schizophrenic patients. The doctor gave many examples of patients he had had who experienced hallucinations, especially those with alcohol withdrawal symptoms (the ones who see snakes and spiders and all of that).
The final thing I looked at yesterday was a twenty-four page document by a manic patient about how he was going to save all the world’s problems through crying and having a nervous breakdown. It really was a rant of the most fabulous proportions, ridiculously grandiose (he mentions marrying Barbara Bush, and also being given $15 million from the US Government) and repetitive. Mostly I found it sad, that this man was so convinced he could fix the world. Imagine being in such a frenzy and imagine the pressure you could put on yourself at that point. No wonder manic episodes are often followed by major depressions.
Right Radio 4 are doing a programme on controversial books, maybe I’ll have a listen.
