Seeing the world through the Nurse's Eye

Year: 2022

How I meet my father…

Be warned: This is a tale that I have stitched together from random facts shared to me by relatives and strangers alike, and sprinkled with my own faded memories. In those memories and random facts, the dates of my conception do not line up to the timeline of my birth. I have, therefore created my own timeline. I must admit I like this fact: That I own the story of how I came to be.

A fact: I was born in Los Angeles and raised by a single, immigrant, Mexican mother in East Los Angeles. Due to lack of childcare, I was passed between Los Angeles and Mexico for most of my youth. I was an inquisitive child, eager to know a mystical person that my mother’s friends would sometimes mention, a man named Manny that my mother had been married to, my papa.

At the age five, on hot sticky Los Angeles night, he called for the first time. My mother asked if I wanted to speak to “tu papa.” I said yes with yearning of a fatherless child. I can still feel the heaviness of the faded telephone receiver as my tiny hands wrapped around it. I heard his deep voice on the other end asking if I wanted to go to Disneyland with him and his family the following day. Of course I agreed to Disneyland especially with my new papa his “new” family. 

His new family at that time was a daughter and an all-American wife, complete with blonde hair and blue eyes who loved NASCAR and Coors Light. His new family welcomed me, taking me shopping for much needed clothing and hosting belated birthdays when I visited them. With time, Manny and his wife would have four children. Then, they too would divorce. The day at Disneyland is the day I gained a papa: Manny Alvarez, the man who gave me my surname, and my father symbol until I reached the age of 14. 

A memory: age 14, sitting in a car, my mother driving up the mountain. She hugged each curve, turn by turn, rising up from the San Bernardino valley to Lake Arrowhead where we lived. We had moved us from the inner city to the segregated mountain community four years earlier. I was complaining to her, using my moody teenage tones. “I have nothing in common with that man, or that family. They are like strangers.” I was talking about my papa, Manny.

He did not feel like family. I did not feel the connection I imagined a family should give me. During the years of visits, I would be grasping at straws trying to find commonalities between us, looking for similar tastes, similar facial features, for anything. I’m not sure what triggered my mother’s confession. But that evening, her hands gripping the steering wheel on each turn up the mountain, she said the words that forever changed my life.

“No es tu papa, es otro hombre” – “He is not your father. It is another man.”

She did not allow any pause for me to absorb the news. The gates were opened, she told me everything. My father was a man whom she had work with many years ago at a hotel. They were in a short relationship, and then she broke it off, proceeding rapidly to marry Manny, not knowing she was already pregnant. (This is my version of the story). He was of Irish decent, she said, a well-off American, and he owned a restaurant in Santa Barbara that we had visited when I was three years old. I sobbed with the knowledge that my papa was a stranger, and that my feelings of uneasiness were not me, I was right, I could Trust my gut.

The Search

My mother gave me my only link to him she had, an old business card from his restaurant. She asked me not to search for him until I was eighteen. I was a rebellious teenager, I did not listen. For the next few months, I searched for my father helped by the local librarians.

Of course, I had immediately called the number printed on the card. A soft voice had answered. She sounded hurried, I could hear kids in the background. A mother and she was partly confused with an uneasy laugh. She did not understand why she was still getting calls about this restaurant, but was kind enough to give me the number of the new restaurant in the same location. The next call was to the current restaurant owner, which led me to another business nearby in which the owner knew my father. She told me about his restaurant and that he had moved with his new wife to Japan about ten years ago.

I felt defeated and lost. I needed to find this man, this possible link to the person I was or was becoming.  As I started to thank her for sharing a glimpse of my father, she cautiously stated “have you thought of looking for your grandparents?  They still live in Santa Barbara. Your grandfather’s name is Roger Smith.”

Ah ha, a new link!

Then call after call, standing in a local phone booth, using saved quarters and dimes to extend the time on the phone when needed. I started a new search. I requested the white pages from Santa Barbara County and saved up for new roll of quarters. Thankfully, there were only four Roger Smiths in Santa Barbara in 1995. Calling the first one, I left a message; I would try calling back tomorrow. With the innocence of a child, my message went somewhat like, “Hi. My name is Tamara. I am looking for a Roger Smith who has a son named Bruce.  I think I am Bruce’s daughter and would like to talk to him.”

The second person, I started leaving the same message but she picked up before I finished. With the grace of age, she told me it might not be a good idea to share that type information over an answering machine. With those words, in that moment, I gained some wisdom and understood the gravity of my search.  So, as I dialed the next number, after contemplating the previous caller’s advice, I decided to start the conversation by asking if they knew anyone by the name of Bruce Smith. To my surprise the phone was quickly answered and a stern male voice came through the receiver

“Hello. My name is Tamara and I am searching for a man name Bruce Smith. Do you know anyone by that name?”

“Yes. That’s my son. Why do you ask?”

There was a pause in time as I gathered my courage and explained the situation, that he had dated my mother many years ago, and that I was the result of that courtship. My grandfather updated me on my father’s whereabouts. He had moved back from Japan, and was living in Berkeley with his wife. He gave me his telephone number. I scribbled it down on the corner of the phone book, and thanked him.

The Call

Once again, with the yearning of a fatherless child, I quickly dialed the number with the remainder of coins I had for the day. He picked up. “Hello?” his voice had a slight accent and the formality of a proper education. The slight accent, I would come to find out, was the result of speech therapy due to being born partially deaf.  “Hi. My name is Tamara and I believe I am your daughter.” Not giving him a moment to doubt the situation I explained “You and my mother had dated 14 years ago, and I am a result of that relationship.”

He was calm and pensive, “Oh, I see,” he said “I remember your mother, but I am not sure if I am your father. She was married at the time.” We proceed to speak for what in my mind was hours, but the reality was that I was at a phone booth, and it could not have been more than 15 minutes. In that short conversation I shared why I thought he was my father, the lack of emotional connection or physical resemblance to my papa. We also learned a little about each other. I told him I was learning to play the violin, was good at school, and enjoyed reading. He had tried to play the violin as well in college and loved books. Already, there was more in common than with my papa. He said he would call me another time, and I gave him my number.

As a responsible adult, my father proceeded to contact my mother the following day. I was in trouble. She had already asked him for help when I was younger, and did not want to be refused again; she did not want anything to do with that man.  I continued to speak with him on occasion, learning more about his life, and sharing my life with him.

That summer, I left for Mexico, as I always did, to spend the summer studying Spanish. But this year, my mother called me back early before the sweltering heat of southern California had calmed down. My father was coming from Berkeley to Southern California to meet me.

The Meeting

We arranged to meet in the lobby of the local mountain lodge, one of the few places with overnight accommodations on the mountainside where we lived.  Here I was, a 14 year old girl, straggly hair, trying to define myself, hoping this person would provide answer to who I was.

That day, 2 pm could not come quickly enough. I paced in my bedroom, waiting until it was time. I arrived alone at the lodge, my mother already there working. The lodge was saturated with “flat towners,” the folks who lived at the bottom of the mountain and did not know how to drive on the mountain roads. I looked through the crowd of people, and I can only describe it as a cheesy, Hallmark movie scene, where the crowds parted and there he was, a tall, skinny man, wearing a straw hat, the same thin lips and smile I had, the same malformed nose. We saw each other, we embraced, and I was home.

That afternoon, with my mother at work, I spent the day getting to know my father, my stepmother, and my half-brother. We walked to the town center, browsed the small shops filled with things you do not need, but desperately want. We walked and talked and my nervousness started to ease. I asked plain questions, and looked for answers to confirm our similarity: favorite foods, favorite color, and favorite candy? The answer to the last question caught me off guard, a vignette of my life story. I asked, and simultaneously, we both said “Good & Plenty.” That was the moment I was reassured that this stranger was my father. The assurance is so strong, for both of us, we have never done a blood test to confirm paternity. We didn’t need to.

The thing is, there is a parallel story that never leaves my mind: What if I had not met him?

The summer I met my father, I lived at the edge of an elite, white, upper-class community. At the periphery were the undocumented workers that built their homes and cleaned their floors. I was part of this community. My mother was a housekeeper at the hotel where my father and I met. On her days off, we would clean houses. By the age of 10, I knew how to dust and put things back as I found them, so as not to disturb the home owner’s way of life. My mother taught me the art of cleaning, of maintaining the home owner’s perceived privacy, as we cleaned up their secrets, their hidden bottle of alcohol, the overpriced makeup that no longer matched their tans.

Saturday evenings were the highlight of my week. My community would gather at Lady of our Lake Catholic Church for the Spanish service, the only one offered within a twenty-mile radius.  After the service, we would flock to someone’s home, whether a small house or an apartment shared by multiple families, and celebrate a birthday, a baptism, a marriage, any excuse for a celebration. And on those Saturday evenings, we would dance.

I had my first of many innocent crushes at these dances. I would blush when I would be asked to dance, wearing an appropriate below the knees length dress. My only world was that of an immigrant, fighting for their rights, making a voice for ourselves our responsibility as the first generation, struggling, going to church, and looking forward to the Saturday evening dances.

 I can still smell my musty bedroom and see myself laying solitary on the skinny bed writing after the dances. I recently found an old journal from that era, the time before my father. I had gone searching in these journals to find a more factual reaction to the time I meet my father instead of leaning on memories ages by time.  As I read the words of my fourteen year old self, I realized, I had a palpable urgency to meet a boy, get married and have a baby. At that point in my life, it was a plan that I could accomplish and was accepted. I could meet a boy, and have baby, all before I would turn 17. And then, finally, I would really be free to live my own life; independent, in that world a child equals freedom from the constraints of your parents. And I wanted that freedom. It was as clear as daylight in my writing. Even now, this very day, I can feel the truth behind this sentiment.

In the immigrant community, you do what you know: You get married. You have a baby. It is shown all around to you. It is your normal. You are a young, innocent voice, and you do not know how to make yourself heard, so you keep yourself busy doing what is expected, helping clean houses, cooking, school work as needed, and then marry. It makes me think of those times you are bored at home, and you are looking for something to entertain you: you cook, sleep, and have a drink, all these things to fill up your time till the real thing happens.

It was like that, my illusory childhood, waiting to be old enough to marry, to have a child; that is, until I met my father.

That summer, I learned my father’s morning ritual of eggs cooked in his oatmeal, and I met his three sisters. We drove to Santa Barbara to meet my three new-found aunts and my cousins. For the first time in my life, I was going to be part of the upper-crust, white community, and not on the edge. The worries of the privileged were more casual in my eyes, versus my worries more based on Maslow’s Hierarchy. But that weekend in Santa Barbara, I did not think about how much something cost, or if should clean the house, or if dinner needed to be cooked. I was able to be a child, to laugh and play with my cousins and half-brother.

my aunts in my home years later

That fall, I moved to Northern California to get to know my father better. My first evening in Berkeley, my father and stepmother needed to pop in to a music performance of a fellow classmate of my stepmother. My stepmother was studying music UC Berkeley. As we walked into the small, wooden performance hall, the sunset light glowing, there were only four of five rows of chairs and we took seats in back. I said hello to the many strangers that my parents introduced me to. I was still an awkward, 14-year-old, knowing I did not fit in this crowd. The performance started, and I do not recall if it was cello, or violin, but I do recall thinking it was one of the most beautiful sounds I had ever heard. The size of the room made sense. It allowed for the music to come alive, to fill every corner. I did not belong there, but I was there, and that was now my life. The following years were a steep learning curve for my father and me, but as we both evolved, I am happy to call him one of my closest allies.

It is remarkable to think that one simple moment can alter the path of your life. I keep thinking about how much I was complaining to my mother, and if I had not been so adamant about not visiting my papa, where would my life have taken me. Maybe my father’s voice resonated through. Or if I would have been more obedient, would I have been exposed to another world that influenced my future decision? Meeting my father was not just about discovering myself, or why my forehead wrinkles in that pattern, but also about pulling myself away from a subculture I lived in, and to some extent, still defines who I became. The truth in this story is that I would not have been able to be pulled away had I not been introduced to the man I now call my father.

My father, stepmother, and siblings at my wedding

Mental Health Care in an English A&E

Part two of two: Closing the loop, the continuation piece of a patient’s journey with a mental health crisis in an English Emergency Department. Part one provides additional background and the start of patient’s journey.

After a decade of emergency room nursing in the USA, the compare-and-contrast of working as a nurse in England this past year is constantly eye-opening.  I’m thankful to those I work with for the learning experience. For example, there is Amy, a RMN (Registered Mental Health Nurse) who has helped me understand the mental health system in England. Something very different from what I was used to in the States.

Amy

Amy

One summer afternoon, Amy shared with me some of her adventures as we walked along the Itchen River. Amy took off traveling soon after finishing her dual degree in mental health and adult nursing. She headed to a remote area of Mozambique to volunteer in a clinic. A place so impoverished that each patient kept a pin cushion with a single needle to use for their injections. Still to this day the thought of it startles her. After Mozambique, she headed to New Zealand. With a soft giggle, she told me how she got lost in the wilderness while hiking. And how her Trust in the universe led her back to safety. 

She had taken off a solo, climbing into the New Zealand backwoods, not seeing a soul for days. At one point, she told me, “I was in the middle of the bush and didn’t know which way to go. I was utterly completely lost.” So she just stopped.  She stood there. “I asked the universe for help and a bird appeared. I decided it was a sign, I followed it, and it led me out, back to safety.”

Amy is the kind of person who allows the universe to guide her; she is a strong woman with a gentle soul and great source of mental health knowledge. She is one of the people you may see if you come with a mental health crisis to the Emergency Department. Or as it is called in England, the A&E, for Accident & Emergency.

Before seeing the patient

Prior to evaluating the patient in the A&E, Amy logs into a larger data base using the patient’s National Health Service (NHS) number. There she can see their social, medical, and mental health history. She is also able to see which resources have already been established in the community for the patient. And whether the patient has used them. Every person that lives in England should have an NHS number. On a side note, we were able to spot a person being sex trafficked due to their lack of an NHS number when I first arrived.

A Suicidal Patient

Every day we have at least one patient that has intentionally overdosed on their medication or over-the-counter paracetamol (acetaminophen/Tylenol), possibly mixed with alcohol. Normally the patient will arrive via ambulance after they realize the error in their actions. Or sometimes, it’s after a friend or family member reads between the lines of their text messages and calls an ambulance. The patient normally arrives numb and is compliant with our interventions.

Once the patient is deemed medically fit, a mental health evaluation is requested. Within an hour of the referral, a registered mental health nurse (RMN) such as Amy, also known as a mental health liaison, will come and assess the patient. For myself, as a staff nurse, seeing it from the outside, it looks like a mini-therapy session. The RME assesses the triggers that brought the patient into the A&E. Most importantly, the RMN assesses their mental capacity and whether the patient is at risk to themselves.

Mental Capacity

The patient that comes to mind is a person with multiple recent stressors. A recent breakup, layered with a loss of job, previous childhood trauma, and no social safety net. And at that moment found their life to have no purpose. In an impulsive action, they swallowed the contents of the medicine cupboard and washed it down with alcohol. Either through their own regret, or by reaching out to someone, help was called and they arrived at the A&E.

At the moment of their actions, their emotional distress caused them a lack of mental capacity. After getting treatment in the A&E, and at the point the RMN is evaluating the patient, they may have gained mental capacity. And most times will be discharged with a referral to community resources. But how can someone who earlier wanted to end their life be safe to go home?

In England the answer lies in the mental capacity act (MCA).

“People can lack capacity to make some decisions, but have capacity to make others. Mental capacity can also fluctuate with time. Someone may lack capacity at one point in time to make a competent decision, but may be able to make the same decision at a later time.”

The National Health Service

Amy in her gentle manner assesses the triggers that lead to their actions. She takes into consideration the emotional distress or ambivalence towards their actions, which can be deemed to lack mental capacity, prior to making a final recommendation. But if the patient can restate their actions, understand them and the consequences, and realizes the triggers that lead to the events and the fault in their action, the patient has mental capacity. As Amy recalls “a mother furiously called me after I had discharged her daughter. It’s always hard to explain to the family that the patient had mental capacity. That they understood the consequences of their actions.” She continues in a solemn tone, “I cannot hold someone against their will just because they wanted to harm themselves. They must be willing to accept the help.”

The Ethics of Mental Capacity & Mental Health

In my conversations with Amy, she confirms the importance of the mental capacity assessment. “It has to be rock solid, it is the corner stone of our treatment. If something happens to the patient, you must be able to stand your ground in court. You cannot hold a patient against their will if they have mental capacity.”

I have seen patients with suicidal thoughts, no plan of action, discharged with referral to outside resources, and I wondered if they will stay safe. After working over a decade in the USA it is hard for me to see these patients go home in a similar state as when they arrived.

But back home (USA) I also recall the ED over half full of mental health patients on “hold” for days waiting for the appropriate resource to become available. Holding patients against their will, days after the crisis had resolved. In a windowless room no less, with minimal consideration to potential emotional triggers that might be brought on by the isolation. It is a different method of treatment here in England, not better or worse, just different.

England does realize however the gap in treatment. A gap which is currently being filled by charities, such as Maytree Suicide Respite Centre. Maytree offers free respite stays for people in suicidal crisis. These organizations provide support for patients who are at risk of suicide, but have mental capacity.

A patient who is discharged, is not set loose in the community. An important part of the assessment is figuring out their level of risk. And the resources they will need and be provided once they are discharged.

The Assessment

Amy completes the mental assessment within the hour and determines whether the person is a low, medium or high risk to themselves. In addition, she also determines the cause of their distress, which will guide the treatment plan. A raped victim will have a different treatment plan as compared to someone going through grief, even though both patients may have attempted suicide. Part of the assessment is getting to the root cause.  Specialized resources are available for rape victims, post-traumatic stress disorder, eating disorders, grief groups, and anxiety, just to name a few.

A low risk patient

A patient at low risk will be provided with a self-referral to group therapy, cognitive behavioral therapy, in person, or online (iTalk,). A full initial assessment will be completed ideally within one week by the community mental health team.

An important resource is group therapy that focuses on teaching patients appropriate coping skills or strategies. An important tool to have prior to starting one-to-one therapy and having work through deep emotional wounds.

Medium Risk Patient

A medium risk patient will be contact by the community health team. Depending on acuity, as soon 24 hours or up to a week after being discharged from the A&E. The team is composed of a RNM, social work, and psychiatrist. The patient then gets reassesses and provided the resources necessary based on their needs.  The social worker may also assist the patient with accessing services they may be entitled to such as housing or assist with their employment. While the psychiatrist will provide any acute medication needs.

High Risk Patient

A high risk patient will get assigned an acute mental health team. Which is a 24 hour service and works alongside the community health team mentioned above. The team is known as ‘hospital at home.’ Services includes medication at home and creating a safe home environment to treat the patient. The idea is, there is greater chance of recovery, even in a state of crisis, when the patient is at home. The safety of their home environment can facilitate recovery, or the opposite. It can also alert the medical team of triggers that need to be addressed.

The recurrent patient

In any A&E, you have the regulars, aka frequent flyers, or more politically correct, a high frequency user. This is the patient who comes in with a mental health crisis but knows you just got your hair cut. Normally they are lonely and have come to see the A&E as a safe place. In the USA, this patient finds a community in the emergency room and, at times, it is their only community.

But in England it is a bit different since these patients have community resources in place which are less available in the USA.  The care-seeking behavior the patient often at times presents as parasuicidal. This behavior in England is not encouraged by the RMN. Amy lets me into the mini-therapy session she has with the patient in which she inquiries about their behavior. She asks what happened that day and what barrier they had preventing them from using coping skills they have been taught in therapy. High frequency users are promptly assessed and discharged. The goal and encouragement for them is to use the community resources already in place for them.

Lack of Mental Capacity

The patient that arrives in acute psychosis, lacking mental capacity, can be detained under the Mental Health Act. The term used here is holding a patient “under a section 2.” People detained under the Mental Health Act need urgent treatment for a mental health disorder. These patients are at risk of harm to themselves or others. A section 2 detains the patient for up 28 days, allowing for in hospital assessment and treatment in acute phase.

Under a section 2 the patient will receive medical treatment whether or not they consent to it. But if the health team determines the patient has gained mental capacity, the patient can be discharged prior to the 28 days. If treatment is required past 28 day, the patient is placed under a section 3; which can be up to 6 months detainment in hospital for treatment.

Mental Illness versus Addiction

My observations in the treatment of mental health in England has expanded my perspective. But one disappointing difference is the distinction made between mental illness and addiction, treating them as two separate entities. Amy has had to advocate more than once for appropriate treatment for patients with addiction. The battle lays in two of the division of resources for patient. A patient with history of intravenous drug usage will fall into addiction sector. Mental health services will not see the patient until they are drug free, “clean.” But, the reality is that they require mental health treatment to get clean.  This type of separation causes poor patient treatment. Addiction and mental illness overlap and in my humble opinion cannot be separated.

photo credit https://www.mentalhelp.net/aware/mental-illness-and-substance-abuse/

After the crisis

After the assessment, the crisis normally passes and the patient is discharged home. And provided with community resources. A patient in a mental health crisis is at a turning point and with the help provided by the RMN is usually guided in a better direction. Amy works hard to help each patients find their own answers, guiding them to appropriate care. Maybe, like Amy, we have to Trust the universe a little bit more and let the people in crisis guide us to the care they need.

Mental health is a vast concept with many branching off points. It is impossible to sum it up in two posts. But I do hope my observations have allowed you to see how things can be done differently. We can learn from one another to provide better treatment to those in need.

The Lake District, Cumbria
Photo Credit Andy Blakemore

A Glimpse of Mental Health Treatment in the A&E

Part one of two: I have decided to divide the post into two parts due to the amount of information and complexity of the subject. Thank you for taking the time to read.

Mental Health Part One

Mental health, no matter where in the world, is a difficult topic to address. We all battle with mental health issues at some point in our lives. Even so, society shuns the topic and resources are minimal. In England it is not necessarily better but just different, like many things here. This piece is a broad overview of England’s mental health system primarily from the eye of a mental health nurse and an Emergency Room/Accident & Emergency (ED/A&E) nurse. I hope to guide you through our process when I patient presents with a mental health concern. I will also highlighted some of the difference between the USA and England.

In my world, when I see a patient in a mental health crisis, I see a person at their most vulnerable. Majority of time it is out of their control. Whether it be a chemical imbalance, the lack of knowledge or resources available to them. Mental health presentation in the A&E accounts for 5% in England and 10% in the United States .

The initial treatment of a mental health patient in England is definitely different, we do not strip patients of their clothing or belongings (their dignity), or make them change into spice colored scrubs/a hospital gown. We also do not make them pee in a cup for a drug test. Or check an alcohol level if they are intoxicated. The A&E does not even have a breathalyzer kit. We do assess the patient’s mental capacity, including assessing whether they are clinically sober. And, we do place them in a safe environment free from ligature risks or sharps hazards.

So, without knowing which illicit drugs are in their system, how do you treat the patient? Do you need to know what drugs are on-board to treat them? And do you actually need to know their alcohol level? Questions I find myself asking.

Registered Mental Health Nurses

A key difference in the United Kingdom are the nurses. A nurse chooses their field of study with in nursing prior to entering university. The types of nursing are adult, children’s, disability, and mental health. Midwifery is another subdivision. An adult trained nurse does not have any formal education in mental health nursing and vice versa. Rachel Cutshall, a fellow American nurse working in England summarize the four fields of nursing in her blog if you would like to learn more.

A registered mental health nurse (RMN) assesses and plans the treatment of a mental health patient in the A&E. If a patient requires a safety observer an RMN will be one to stay with the patient. Therefore you have one qualified profession that handles the majority ,if not all, the mental health issues that arise in the NHS, not a social worker like in the USA.

Amy

Amy was one of the first nurses that I met and my initial introduction to the mental health system in England.  Her first exposure to mental illness was from a young age since her mother suffered from a complex mental health history. Her mother was unable to care for her and she was placed in the hands of her grandmother until the age of five. The years she spent with her grandmother were filled with routine and love, a thriving ground for a child. With her knowledge in adverse childhood exposure (ACE), she attributes this time of stability the building blocks for her resilience.

https://www.wavetrust.org/adverse-childhood-experiences

Amy’s grandmother left a strong imprint on her life, her words and actions echoed in her own life, “she always found a way to be kind and helpful,” and Amy wanted to follow in those footsteps. At five years old she was reunited with her mother, but it was short lived and was soon placed in the foster care system. As she aged out Amy found refuge in homeless hostels where she also volunteered. This is where she saw that mental health overlaps our physical health. She did not just want to volunteer, she really wanted to help the people. She knew to gain the skills she would have to become a nurse.

During our initial meeting Amy and I talked about the complexities of mental health management and treatment in England, including addiction treatment. She is well versed and has read books by one of my favorite authors Gabor Mate. Amy primarily wanted to be a mental health nurse but she realized she needed the knowledge of both an adult and mental health nurse. And so she became a dual qualified nurse.

A mental health patient in the A&E

My interactions with a mental health patient presenting to the A&E is minimal. Common presentations include depression, anxiety including panic attacks, suicide attempt, self-harm behavior, or acute psychosis. A new acronym I use is DSH, deliberate self-harm. Other than providing reassuring words, we triage, obtain a set of vital signs/observations and then complete a mental health liaison form. The from includes environment safety check and a mental capacity assessment. The form also provides the mental health team a quick overview of the presentation of the patient to the A&E. The only treatment we may provide is the ever elusive healing cup of tea. Within an hour of arrival to the A&E the mental health liaison (nurse), Amy, will evaluate them.

Overdoses

Most overdoses are an effort to numb the intense feelings of our lives. We even try to numb the good ones. I always think about level of pain or grief the person has gone through which requires them to numb it out with drugs or alcohol.

The patient with an overdose the process is a bit different. First we provide medical treatment, we establish vascular access, get blood work and an ECG/EKG. We administer appropriate antidotes and monitor airway.

A common drug overdose is Paracetamol (acetaminophen/Tylenol), especially in the youth. And we routinely administered the antidote Acetylcysteine, also known as N-acetylcysteine. So common that there are prefilled forms with the protocol and dosages based on weight.

In England controlled substances are less prescribed and are more difficult to obtain but still account for half of all drug overdoses in England and Wales. Multi-drug overdose is more common than back home which includes a cocktail of their normal medications including antidepressants.

The local street drugs are Spice K2 and marijuana. Methamphetamine is more rare, but I have heard it does exist here, even though I have yet to see it. We still have the intravenous drug user with heroin overdoses who will walk out after Naloxone administration.  Marijuana is an illegal substance here therefore we do see patients who arrive high. We monitor them and send them home before they purge the sandwich supply.

Alcohol Intoxication

Patients who arrive intoxicate and depressed or suicidal, time is the main treatment whilst the airway is patent. We administer Pabrinex, an intravenous concoction of vitamins, the equivalent to a banana bag. We sober them up with sleep, tea and toast. After they are clinically sober and have mental capacity, the mental health teams evaluates them.

Intoxicated teenagers on the other hand have the additional requirement of getting a safeguarding referral to alert social services. If there is a greater concern other than intoxication, a safety concern for the child, they will get admitted to the pediatric ward. After admission the Child and Adolescent Mental Health Service (CAMHS), another division of the National Health Service (NHS), will evaluate them. In the future I hope to go into detail regarding the mental health services and treatment for children.

After the patient is medically fit (cleared) and drank their cup of tea we wait. The mental health nurse soon arrives to assess the patient and guide treatment or plan of care.

The cup of tea

What is this magical cup of tea? The process of asking a patient not only if they would like a cup of tea but how they take it gives them gives them a chance to voice their needs. They have to stop and think about what they want, one or two sugars, sometimes that simple thing makes us think about bigger wants and needs. I have found having a warm cup of tea during a stressful moment does slow you down just enough to catch your breath. I believe it does the same for some of our patients. Therefore I mention many times the healing cup of tea, but I do not mean in jest, it does have great value.

Part two

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