NHS

Day 339

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In a special little box highlighted in a greyish shade of blue the BNF (British National Formulary) says:

“The balance of risks and benefits for the treatment of depressive illness in individuals under 18 years is considered unfavourable for the SSRIs citalopram. escitalopram, paroxetine, sertraline, mirtazapine and venlafaxine. Clinical trials have failed to show efficacy and have shown an increase in harmful outcomes. However, it is recognized that specialists may sometimes decide to use these drugs in response to individual clinical needs; children and adolescents should be monitored carefully for suicidal behavior, self-harm and hostility, particularly at the beginning of treatment.”

This has been known for 10 years.

GlaxoSmithKlien came under heavy criticism when they were accused of ‘concealing’ important information from the public at the risk of harm to patients in the US.

In the UK, criminal action was taken against GSK and these medications were labeled as ‘suicide pills’.

Adolescent brain development studies have shown that the structure of the brain continues to change from the teens till early twenties before it assumes adult form.

In different countries, the definition of ‘adolescence’ differs. In America, consumption of alcohol is illegal below 21 whereas in the UK it is illegal under 18. In a medical setting, does ‘under 18’ mean that if the patient is a few days or months over, the rule does not apply to them?

My son was ‘around 18’, at the beginning of treatment, not monitored carefully and not under specialist care. This side effect of the medication that he was taking was not mentioned, leave alone ‘emphasised’ to me. No safety plan was put in place.

Could the choice of medication be responsible for what happened?

Or was it the way it was used that contributed to it?

Questions, questions and more questions.

The report of the joint investigation between the Mental Health services and NHS England is delayed again. They are also probably grappling with many questions. The Coroner’s Inquest is in less than 2 weeks.

Let’s see if we can find any answers.

Day 333

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A young nurse approached me and said “I just wanted to thank you for writing that article. I was not sure but now I know exactly what I need to do.” We stood hugging each other for a while in the hospital corridor this morning. I felt grateful for that moment. Her heartfelt gratitude brought tears to my eyes.

The response to the article makes me feel as though people have been waiting to hear more about mental illness and suicide. They have been like unacknowledged entities that exist amongst us silently. Or maybe we have been deaf-mute so far and now are ready to speak and listen. It is about time; already too late for some of us.

Last week I met a young doctor whose wife is near the end of her GP training. He told me that she has not spent any dedicated time in psychiatry during the 3 years of her training. Nothing at all. This is still happening. 1 in 4 patients attending a GP surgery present with a problem which has a direct or indirect bearing on their state of mind.

CPR (Cardio Pulmonary Resuscitation) is part of mandatory training for all doctors because it saves lives. But Suicide Prevention is not. Does that not save lives?

Those that speak out tend to be those who have been most affected by mental illness and suicide. That something good comes of their/our suffering and loss is but a small consolation but perhaps it was always this way:

Like to a ship that storms urge on its course,
By its own trials our soul is surer made.
The very things that make the voyage worse
Do make it better; its peril is its aid.
And, as the storm drives from the storm, our heart
Within the peril disimperilled grows;
A port is near the more from port we part –
The port whereto our driven direction goes.
If we reap knowledge to cross-profit, this
From storms we learn, when the storm’s height doth drive –
That the black presence of its violence is
The pushing promise of near far blue skies.
Learn we but how to have the pilot-skill,
And the storm’s very might shall mate our will.

– Fernando Pessoa

Day 312

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Today I met this lovely little 70 years old lady at work. She had come in as a patient for a minor procedure under anaesthesia. She was well dressed and I couldn’t help but notice her hair. It was as though she had just walked out of a hair salon. It was beautifully styled. I could imagine her sitting with her rollers on under the hair dryer reading a magazine. I was impressed by the effort she had put into looking so good to come into a hospital for cancer surgery.

Instantly my mind flashed back to 2 days before Day 0. That day we had an appointment to see the GP. I had requested my son to shave as I gently woke him up reminding him of our planned visit. 10 minutes before we were to leave the house he came down the stairs. He had not shaved. I sent him right back and insisted he shave even if it meant we were a few minutes late. He really didn’t want to but he did. (Now I know how terribly difficult it must have been for him.) I was pleased to see him looking so neat and tidy.

The doctor’s report to the Coroner says – “He was well dressed, shaven and fresh. He made good eye contact. His speech was coherent and we had good rapport throughout. He said he had had a recent ‘set-back’. On being asked if he had suicidal thoughts he said yes but he had no plans. He said that he felt he would never recover from this illness. I reassured him that he would. He asked me how long it would take……. If other patients had returned to work….. There was nothing to indicate a relapse of psychotic features. The Citalopram was increased from 10mg to 20 mg daily.”

Despite the fact that during the previous visit 2 weeks prior, his PHQ9 (Patient Health Questionnaire 9, a monitoring tool for depression) score was 27/27, indicating the worst possible level of depression, the GP did not repeat the test on this visit. Was it because he looked ‘well dressed, shaven and fresh’? Would it have made any difference?

We will never know.

What we do know is that there is a huge need for education. Pills alone do not save lives.

Day 268

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Successfully completing medical school was an exhilarating experience but confusing at the same time. I figured that becoming a doctor was just the beginning. I had no idea where I wanted to go from there. What did I want to specialize in?

After a year and a half of trying this and that I found my vocation. It sounds cheesy to say that I did not choose Anaesthesia, it chose me. But that is true. It was just right for me. I learnt to comfort and reassure patients and their families just before their operations when they were vulnerable and worried. I developed delicate practical skills in the form of medical procedures and sensitive difficult conversations. I learnt a lot about patient safety as, when under anaesthesia, it is completely up to us to ensure that every patient is safe in every way possible. Maintaining good blood circulation and keeping the blood well oxygenated, hence keeping the patient alive is the very basic requirement.

In addition, we worry about the smallest things – a slight drop in temperature, a little scratch on the cornea of the eye or a tiny chip on a tooth, causing pressure sores or nerve injuries as a result of lying in one position for a long time or a bit of nausea or sore-throat after the operation. Many other seemingly tiny considerations are borne in mind to avoid the smallest possible complication.

Death directly related to anaesthesia is a highly unlikely event. A cause for much concern if it happens! Especially to a fit and healthy 20 year old lad.

Clearly, not all specialties think like we do. Every disease process is different and what is applicable in one field is not in another.

When it comes to safety there are many parallels drawn between medicine and the aviation industry. Martin Bromley is a pilot  who lost his young wife Elaine, when under anaesthesia. He has used that experience to educate a lot of people about the importance of Human Factors in medicine.

This video tells us his story and the lessons learnt. It is humbling to hear him speak. I have watched it many times and also used it for teaching junior medics. It is called “Just a Routine Operation”. A lot of learning in 14 minutes.

Day 253

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“I hope you are not thinking of doing something stupid?”
“I hope you are not getting strange ideas in your head?”
“I hope everything in life doesn’t seem too pointless?”
“I hope you are not getting desperately dark thoughts?”

Yes. These are real quotes from real people who are concerned about their patients or friends but are unable to directly ask the question and utter the word – SUICIDE.

Taboo is defined as ‘a social or religious custom prohibiting or restricting a particular practice or forbidding association with a particular person, place, or thing.’

Stigma is defined as ‘a mark of disgrace associated with a particular circumstance, quality, or person.’

Simple non-acceptance.

The reply to my request for permission for a vigil from the park authorities on Day 249 was my most recent exposure to the stigma associated with suicide. It is not a unique occurrence. I should prepare myself for more.

Today I met a bunch of committed and passionate people who dedicate a lot of their time and efforts towards prevention of suicide in the young. I attended a Papyrus Conference.  It was an inspiring event and I learnt a lot.  ‘Removing Stigma’ is one of their prime objectives.

Apparently there are numerous schools that refuse suicide prevention training for their pupils. While sex education and road safety get so much attention from the schools and governments, somehow mental wellbeing doesn’t.

The academic study of suicide has been dropped from the Sociology syllabus at A-levels.  This is the situation when more young people die from suicide than from having sex or being in a road accident.

One chief coroner went as far as making this suggestion, “May be we should call it something else.”

We have a long way to go!!!