As I mentioned in my previous posts, I was able to join this great team without much trouble. My worries about endurance, adjusting with colleagues etc turned out to be...just worries.
I observed that the key issue with all patients was autonomic instability and maintaining vital parameters was the main task being done. Second was to prevent further infections. I attempted very earnestly to learn all that- and came to the conclusion that it was not worthy pursuit considering that my posting was only a fortnight. I decided to concentrate more on the things that I could already do so that I could make a true contribution to the team efforts. Organising the day's work, taking down notes, finding out details of clinical history or talking to resident doctors and talking to patient's relatives were the things I started with. In a couple of days, I progressed to diagnosing small clinical issues and addressing them- like whether a patient is getting dehydrated, having acidity feeling and the like. As the different wards are segregated according to the treatment facilities available, we have to match the patients case with the wards and then admit them. Soon I was able to take these decisions.
Simultaneously I was continuously observing the course of illness in patients. The unit was completely supportive of mental health interventions. So I checked the pharmacy and luckily all basic medications were already present there. In this hospital, we have a 'cubicle' system. It consists of a transparent cabin, in which the health professional is seated. Patients are outside the cabin and communication is through intercom. This was a very good facility for primary assessment. I decided that every patient should be screened by brief mental status examination at the cubicle. Then I went inside wards in the PPE to screen patients who were on oxygen therapy and could not come to cubicles. Now the hospital has hired full time counselors, who will do the screening and supportive counseling.
I found that none of the COVID 19 patients were on antidepressants. The other surprise was that none of the patients had reported or found to be having signs of alcohol or tobacco withdrawal. A small minority were on anti epileptics and anti psychotics. Psychological distress was more common in women than in men. Majority of the patients reported feeling frightened and sleepless and apparently breathless on the first night of their hospitalisation. They reported feeling much better physically as well as emotionally on the second day itself. Sleeplessness, palpitations, restlessness and worrying continued in a small minority of patients. These were also patients whose vitals were taking longer to stabilise. All these symptoms were of recent onset and not fulfilling criteria for diagnosis. Few patients had symptoms amounting to depression, generalised anxiety or dysthymia. In another hospital, I had found that a number of patients became anxious at the time of their discharge- this was accompanied by destablisation of their vital parameters. Most patients in this hospital were however eager to go home and lengthening of hospital stay due to anxiety was a rare scenario. One patient suffered lasting cognitive deficits.
The task force had recommended using Melatonin for sleep. But I found that insomnia was always accompanied by anxiety and restlessness. So I preferred to use low doses of clonazepam, amitryptiline and relaxation training. Patients were thinking a lot about the disease and most of them needed proper information about the virus, disease, vaccine and so many other things that keep appearing in the media- and reached patients through their phones. Almost all patients were baffled by their infection and preoccupied with determining exactly when and how they got the infection. Facilitating acceptance and moving towards recovery was required. We also reached out to family members in some cases- addressing their mental health needs as well as advising them actions to facilitate patients recovery. One patient with special needs required behavioral intervention- he was being non cooperative with treatment because of unfamiliarity and cognitive limitations.
So here we are- at the very beginning of doing mental health interventions in this COVID unit. Patients appreciate that we enquire about how they are feeling and give them some solutions to their immediate problems. I have decided on a policy of short term interventions to facilitate recovery from COVID19. It is difficult to tell whether the emotional issues will persist.The patients with clinically diagnosable conditions will be referred for further evaluation and treatment in the community.
Any Psychiatrist who wants to be a part of the COVID intervention will have to work closely with the team to understand COVID19 as well as the treatment approach. The protocols are different at different places. For example, this COVID unit treated only mild and moderately ill patients. In units treating more severe cases one can expect more mood instability, delirium, cognitive problems, grief reactions- due to greater use of steroids, toxic antivirals and higher mortality. Ideally, one will need to spend a few weeks working full time and getting familiar with the team members and the disease. The Psychiatrist will need to brush up basic knowledge about respiratory, cardio vascular and Gastro intestinal physiology- including Circadian rhythms, correlation with menstruation. We need to refresh our knowledge about history taking of symptoms of these systems. Also we need to read up about the common drugs used and the thinking behind how short term interventions are done and when long term interventions are required. Along with the full pathophysiology of COVID19 (as it is being discovered and understood).
If given a few months more here, I could understand the full picture of the physiological issues and how they correlate with mental health. I could look at how patients do after recovery. My present level of knowledge is nowhere near what is required to realise the ambitions I came here with. I will continue to supervise the mental health interventions. I will also visit part time and try to solve clinical problems. Still I know its not like working full time and being there when the learning opportunity presents. I guess, I have to accept this to be the best deal under the circumstances.
I observed that the key issue with all patients was autonomic instability and maintaining vital parameters was the main task being done. Second was to prevent further infections. I attempted very earnestly to learn all that- and came to the conclusion that it was not worthy pursuit considering that my posting was only a fortnight. I decided to concentrate more on the things that I could already do so that I could make a true contribution to the team efforts. Organising the day's work, taking down notes, finding out details of clinical history or talking to resident doctors and talking to patient's relatives were the things I started with. In a couple of days, I progressed to diagnosing small clinical issues and addressing them- like whether a patient is getting dehydrated, having acidity feeling and the like. As the different wards are segregated according to the treatment facilities available, we have to match the patients case with the wards and then admit them. Soon I was able to take these decisions.
Simultaneously I was continuously observing the course of illness in patients. The unit was completely supportive of mental health interventions. So I checked the pharmacy and luckily all basic medications were already present there. In this hospital, we have a 'cubicle' system. It consists of a transparent cabin, in which the health professional is seated. Patients are outside the cabin and communication is through intercom. This was a very good facility for primary assessment. I decided that every patient should be screened by brief mental status examination at the cubicle. Then I went inside wards in the PPE to screen patients who were on oxygen therapy and could not come to cubicles. Now the hospital has hired full time counselors, who will do the screening and supportive counseling.
I found that none of the COVID 19 patients were on antidepressants. The other surprise was that none of the patients had reported or found to be having signs of alcohol or tobacco withdrawal. A small minority were on anti epileptics and anti psychotics. Psychological distress was more common in women than in men. Majority of the patients reported feeling frightened and sleepless and apparently breathless on the first night of their hospitalisation. They reported feeling much better physically as well as emotionally on the second day itself. Sleeplessness, palpitations, restlessness and worrying continued in a small minority of patients. These were also patients whose vitals were taking longer to stabilise. All these symptoms were of recent onset and not fulfilling criteria for diagnosis. Few patients had symptoms amounting to depression, generalised anxiety or dysthymia. In another hospital, I had found that a number of patients became anxious at the time of their discharge- this was accompanied by destablisation of their vital parameters. Most patients in this hospital were however eager to go home and lengthening of hospital stay due to anxiety was a rare scenario. One patient suffered lasting cognitive deficits.
The task force had recommended using Melatonin for sleep. But I found that insomnia was always accompanied by anxiety and restlessness. So I preferred to use low doses of clonazepam, amitryptiline and relaxation training. Patients were thinking a lot about the disease and most of them needed proper information about the virus, disease, vaccine and so many other things that keep appearing in the media- and reached patients through their phones. Almost all patients were baffled by their infection and preoccupied with determining exactly when and how they got the infection. Facilitating acceptance and moving towards recovery was required. We also reached out to family members in some cases- addressing their mental health needs as well as advising them actions to facilitate patients recovery. One patient with special needs required behavioral intervention- he was being non cooperative with treatment because of unfamiliarity and cognitive limitations.
So here we are- at the very beginning of doing mental health interventions in this COVID unit. Patients appreciate that we enquire about how they are feeling and give them some solutions to their immediate problems. I have decided on a policy of short term interventions to facilitate recovery from COVID19. It is difficult to tell whether the emotional issues will persist.The patients with clinically diagnosable conditions will be referred for further evaluation and treatment in the community.
Any Psychiatrist who wants to be a part of the COVID intervention will have to work closely with the team to understand COVID19 as well as the treatment approach. The protocols are different at different places. For example, this COVID unit treated only mild and moderately ill patients. In units treating more severe cases one can expect more mood instability, delirium, cognitive problems, grief reactions- due to greater use of steroids, toxic antivirals and higher mortality. Ideally, one will need to spend a few weeks working full time and getting familiar with the team members and the disease. The Psychiatrist will need to brush up basic knowledge about respiratory, cardio vascular and Gastro intestinal physiology- including Circadian rhythms, correlation with menstruation. We need to refresh our knowledge about history taking of symptoms of these systems. Also we need to read up about the common drugs used and the thinking behind how short term interventions are done and when long term interventions are required. Along with the full pathophysiology of COVID19 (as it is being discovered and understood).
If given a few months more here, I could understand the full picture of the physiological issues and how they correlate with mental health. I could look at how patients do after recovery. My present level of knowledge is nowhere near what is required to realise the ambitions I came here with. I will continue to supervise the mental health interventions. I will also visit part time and try to solve clinical problems. Still I know its not like working full time and being there when the learning opportunity presents. I guess, I have to accept this to be the best deal under the circumstances.
Great work Vani
ReplyDeleteThank you