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.
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.
