Friday, 30 May 2008

The mental health lucky dip

Posted by Dr. Thunder:

I'm struggling a bit lately. I help run this "Child and adolescent behaviour clinic" once a week at my new hospital. As I've said before on previous posts, I've no real training in this kind of thing. Adults with mental health problems get seen by psychiatrsists (well, they're supposed to), but kids here get seen by the paediatrician for pretty much every ailment under the sun (medical, surgical, psychiatric). It's fine. I'll get used to it. But at the moment, I'm a little out of my depth.

I saw a kid today. A 7 year old girl with Attention Deficit Hyperactivity Disorder. She's got it BAD, to the point where she is pretty dysfunctional. Her brother has mild autism. Both her parents are disbled, and on disability allowances.

So, the little autistic boy goes to a special school, and is in a tiny class, with an individual carer. Quite right, too. The health authority seems to regard autism as an "important" illness. He does well at school, and functions relatively well in her day to day life,within pretty strict parameters.

His sister with ADHD obviosly hasn't got an important enough mental health problem. She has to go to the local state school, which is a very good school. But there's 26 other kids in her class. There's no individual teaching assistant. There is no one-to-one time.

To my mind, the child with ADHD has a better chance of managing to get what we in the mainstream would call "a good education" than her autistic brother. The autistic child is likely to require care for the rest of his life. That is not the case with his sister.

So, Nicola (with the ADHD) is doing badly at school. Her lovely parents are very worried. They came to me with an agenda today. They informed me that if Nicola was diagnosed as being on the autistic spectrum, she would get the financing for a classroom assistant.

Nicola's parents can't afford an form of extra tuition.

They looked at me, hopefully. They wanted me to diagnose Nicola with autism. I couldn't do it. It's not ethical. But it's tempting. I told the parents this. They're sensible people. They understood. But it didn't stop me feeling like crap for the rest of the day,a s I sent Nicola away with an increased dose of Ritalin.

I shall see her again in 2 months, when her school reports have deteriorated further. I have asked ther social worker to look into their situation, but she didn't hold out much hope.

I see Nicola becoming a pretty unproductive member of society when she leaves school, due to what is likely to a huge educational deficiency. We'll complain about how much benefits the state will have to pay her for many many years. Sadly, the savings would be enormous if we could just give her the money she needs to get some help at school.

Roll on next week's clinic!

Sunday, 11 May 2008

Psychiatry services making me crazy!!

It's been a long week. Nothing too out of the ordinary, but there's a lot of sick kids kicking about in my neck of the woods right now.

One in particular is "sick", but not in the way in which we think of sick kids. Sarah has a psychiatric illness. I think. I'm no psychiatrist, but when you're on-call for paediatrics, all kinds of things come your way.

So, earlier this week i took a call from a worried GP. He had just seen Sarah*, who's in her early teens, and had been brought to him by her mother. Mum was worried as Sarah has been becoming more withdrawn over the last few years, and is now at the stage where she hardly speaks. She also suffers from delusions and paranoia.

So, the GP sent her to me as he was having difficulty finding the psychiatrist on-call, plus he reckoned a kids ward would be a more friendly "waiting room" than either A+E or the psych department. I agreed entirely, and told him to send her straight to me.

When I met sarah, 2 things struck me.

1) She has a LOT of issues, and needs psychiatric assessment, and likely psychiatric treatment.

2) She has been neglecting her own healthcare. Sarah has other quite serious medical problems, and is required to take medication every day. Mum reckons she never takes her medicine. In fact, mum is SURE she never takes her medicine.

I had a chat to both of them. I told them that I'll phone the psychiatrist and get him to have a chat. They agreed. Mum was amazed that sarah was open to the idea of psychiatric input, as previously she wouldn't even go to her GP. We had to ride thinsd wave and take the opportunity to get her help while she was willing to be helped.

You could see they were both relieved that something was going to happen.

I phoned switchboard and asked them to put me through to the psychiatrist on-call. "No problem, doctor, one moment".
The phone rings, and a very pleasant lady answers.

I say "Hello, this is Dr. Thunder from paediatrics, are you the on-call psychiatrist?".

"Well, I'm on-call FOR psychiatry".

"Ok, well, I need a psychiatric evaluation of a patient. I'm not sure if she's psychotic. She's a teenage girl who has a 2 year history of ......."

"Can I stop you there, doctor?".


"I can't assess your patient, i'm a social worker".

"Oh, OK, not to worry, can you put me through to the psychiatrist, then , please".

"No, I'm on call for psychiatry".

"But you're a social worker".


Oh fuck.

After a few minutes of trying in vain to explain my situation, I was put through to "our clinician".

Thank christ.

"So, are you the psychiatrist on-call?"

"Well, I'm on-call FOR psychiatry"

"Are you a psychiatrist?"

"No, I'm a psychologist"

Sweet baby jesus on a motorbike.

Better than nothing, i suppose, and definitely better than me! After finding out that there are psychiatrists around, but none of them are on-call. I asked the psychologist to come and have a chat to Sarah and her mum.

"I can only get involved in conjunction with the psychiatrist".

"OK, can we get the psychiatrists involved then?".

"They're not around today"

I hung up.

So, the question is...what in the name of good is a social worker doing "on-call" for psychiatry??? Is their doctor sitting in the social work office helping people with their housing applications?? It beggars belief.

I let sarah and her mum go home. I spent half a day trying to get them psych input. They really need it. But instead they are coming back to see me at the general paediatrics outpatient clinic next week. I've slotted them in at the end of the day. So, I will try to get them a psych review at 4.40pm next thursday. I don't hold out much hope.

When you're a sick kid, and you have a "trendy" illness, the whole world wants to know. If you have no hair, and a tube in your nose, then you are worthy of sympathy at the highest levels. Actors and sports stars come and see you in hospital. there is huge govenment funding for new buildings, and no drug is too expensive. Quite rightly, too. these are some of the most vulnerable people in society, and that's who we should be doing everything in our power to help.But, if you're an adolescent with a psychiatric illness, you are also vulnerable. Probably as vulnerable as anyone else in society. But there are very few hospital visits by the rich and famous, and you might not even have access to a doctor. Imagine theheadlines if a child with cancer couldn't get access to a doctor in a developed country.

On a lighter note, I bumped into one of my cardiology colleagues yesterday. It had been a rough day for both of us, as we both chatted in ED. I'd just admitted a septic baby, and a diabetic ketoacidosis. He'd been involved with some clot-busting shenanigans that I don't really understand anymore. It was 2am. We had both been in work since 8.30 that morning.

So, exhaustedly, he says...."I really wish i'd done a specialty like paediatrics instead of cardiology. I'd love to just play with kids all day. I mean, you wouldn't believe how sick people get on my ward".

Indeed. At that point I left to go and deal with the 3 year old having uncontrolled seizures in cubicle 3..............

*As always, I have used a false name.