Warning. The following entry contains referencing. Vancouver referencing. For any academic students of the past or present, I apologise deeply for any flashbacks and panic attacks incited by those horrible little numbers at the end of references.
Well here it goes, the one I nearly didn’t write, the one nobody really wants to talk about. The elephant in the room. The boogeyman’s twisted sister.
Do I hear a groan of derision? An eye roll? Is Div going to repeat the same messages that we’ve already heard a thousand times over? Are we about to experience another rant from the liberal left, or the righteous right? Read on, read on, read on dear reader.
There are a few cursory sentences to get out of the way, a little revision from all those behavioural-sciences and psychosocial-studies lectures our eyes were wide open for:
Mental Health is big – it’s the third leading cause of health loss for NZers (1)
It affects our youth – one quarter of our young people have mental health issues, and our youth suicide rate is amongst the highest in all OECD countries (2)
It affects our mums – maternal suicide is a leading cause of maternal death in NZ, and is seven times more common here than in the UK (3)
It affects us – publications over the last 15 years have shown high physician burnout rates in various medical fields throughout Europe, Australasia, and America (4)
What’s going on? I don’t know. There are a lot of answers. Generally speaking, New Zealand actually performs better than the majority of OECD countries across most measured parameters with regards to our social wellbeing (5). So is this a problem where all the answers lie under the banner of “social reform?” Again, I don’t know. I’m not being facetious, I’m saying I genuinely don’t have any answers, and it’s probably not my place to provide any answers. There are people cleverer than me, richer than me, and definitely more qualified than me to have a go at finding the answers. They have CVs that stretch for miles, whereas mine starts and ends with, “Med school. High school. Able to iron his own shirts.”
There are so many deep seated misconceptions about mental health in society and even as children we’re taught to fear this boogeyman. The most terrible villains in the most horrific films will be labelled “schizophrenic” or “sociopathic”. Their diseases demonised, the sufferers systematically turned into monsters. Even in children’s movies and books, mental illness is vile and ugly; to quote our generation’s bastion of virtue, Hermione Granger, “even in the wizarding world, hearing voices isn’t a good sign”. Far too often we demonise what we don’t understand, creating devils where there should be none. I’m not saying we need to rewrite Hannibal Lector, where Lector is a cannibalistic endocrinologist instead of a psychiatrist – feeding on his sweet, sweet diabetic patients. I’m saying that mental health is complicated, and needs a grown-up approach without being perverse or scorching.
I digress. Anyway, for about 3 months this year I was set upon the world as a mental health house officer. Boy was that a ride and a half. The work stories are unbeatable, the work experience is unpredictable, and it’s really no wonder the mental health facilities are seen as houses of divine comedy. Oh and this is where I also need to let everyone know, once and for all, that our mental health colleagues have the best banter. I’m not just saying that to try and get some brownie points from a hottie (or am I?) but these fine folk have come up with some of the most bizarre and unexpected twists of wit, most of which are probably far too inappropriate for the public eye. Nothing phases them. Nothing. After performing a restraint a that required three personnel and resulted in two separate head injuries, a tiny wisp of a nurse walked up to me and cheerily offered me a slice of cake. Wide eyed and slightly shaken, I asked if this was something of a usual occurrence. “Oh no,” she explained “I don’t always bring cake to work, I’m on a diet.”
So what was my job? I mean, I’ve had time to reflect over my experience since I finished the run and I’m still not sure what I actually did – if anything. The doctors and nurses told me I was in a constant state of high functioning mania – probably because I was drinking 6 cups of coffee a day (don’t worry mum, I’ve cut down). I did a lot of physical examinations, coaxing the poor paranoid psychotics into begrudgingly having their hearts and lungs listened to. I ruled out organic causes for mood or perception abnormalities, always hoping I’d come across a case of acute intermittent porphyria that I could publish as a case report and have more than just “NZMSA First Year House Officer Blog” on my CV. I stabbed people with 22 gauge needles whilst they battled with their voices in their head that told them I was poisoning them, all the meanwhile smiling at me as if nothing was wrong.
I was, in essence, a half-baked general practitioner trying to find exciting new ways to do things that are usually a lot easier in other circumstances (for example, removing stitches without anything sharp on hand – I seriously considered using my teeth for a few seconds). I remember this one time a nurse helped me debride and dress a self-inflicted burn wound. They explained that a large, tense blister generally requires the overlying skin to be snipped and then it should be dressed with a non-adherent dressing. The nurse was far better at wound care than I was, despite having only one free hand and being on enough benzodiazepines to calm an enraged warthog. Why was the nurse on so many benzos you ask? Well the nurse was also the patient. Yes, you read that correctly. Remember folks, having run-ins with mental health services does not preclude one from being an exceptional member of the healthcare workforce.
An unfortunate recurring theme in the psych department I noticed is that our link with the main hospital was quite fractured. Nobody knew what we did and I’m not sure anyone in our building knew what the rest of the hospital did either. It wasn’t until a few weeks into my attachment that I was even made aware of a corridor that lead to the main building. It didn’t really matter though, my swipe card didn’t allow me access in or out of that door and if there was ever to be a code called, my resus colleagues assured me that they had no clue in hell as to how to get to the psych ward either. To get someone to the emergency department sometimes required the use of an ambulance.
Think about that, an ambulance… and we were on the bloody campus. It never really made sense. We were in a way kept out of sight and out of mind and calling another specialty and letting them know you’re from the spooky psych department often incurred a goofy yelp of surprise. This yelp is a special noise. It’s almost exactly the same as the one made when meeting your sister’s new hipster boyfriend who has no shoes, smells, and tells you he cuts his own hair with a pair of scissors he found on the floor of a Belle and Sebastian concert. “Oouuwh-hi!”
To be honest I don’t blame the medical registrars I rang. I once had a patient hypokalemic at 1.8 who was confused, constipated, homeless, and agitated; and I decided I need advice from the poor bastard holding ward referrals phone for that day. That particular conversation conversation went something like this;
Me: “Hi there. ISBAR. Hypokalaemia 1.8. ECG has small wiggles. Halp.”
Reg: “Oh… that’s quite low, this patient will require stat IV replacement and telemetry, can you please put the request through, run through a bag of saline with potassium, get the following bloods, and chart …:”
Me: “Wait.. dude whoa, wait”
Me: “We can’t do IV lines.”
Reg: “…you don’t know how to do an IV line?”
Me: “What? Of course I know how to – no I mean we physically don’t have any IV lines here, something about registration or something, or any fluids with potassium. Oh and we can’t do telemetry either because the signal gets all funky here.”
Reg: “Um… well ok I mean we need them on the ward a.s.a.p then I guess. Can you give them oral replacement while we arrange that?”
Me: “Nah she believes the food is poisoned, that’s how the potassium fell in the first place. Oh wait she’s eating a banana though, if that helps…”
This transfer actually took about an hour longer than it should have as we tried to figure out how to physically get the patient into the main building. The wards were asking for a mental health transfer nurse or assistant, but we were short staffed that day with a full ward during full moon. The next piece of advice given was to call an ambulance which was, at best, forty five minutes away based on the current acuity status. After arguing with bed managers, coordinators, and whoever the hell else, I let out an exasperated warble and had a whinge to the charge nurse.
Now, this charge nurse had the capacity to cause havoc that was inversely proportional to her stature and let me tell you – she was tiny. She was a hell raiser, and I’d be lying to you if I told you I didn’t fiercely admire that funny little lady. She spoke in a strange accent and more often than not I had no idea what she was saying. She sometimes called stairs “apples and pears,” feet “dog’s meat,” and on that particular day was talking in full sentences without a hint of cockney slang. Which was a subtle hint that she was in a terrible, terrible mood. She listened to me for a full minute, thanked me in a gentle tone, and proceeded to take the patient to E.D. by herself.
Smaug himself would’ve shivered in his scales…
I’m not sure what she did, I can only imagine what she said, but ever since then our patient transfers began running a lot more smoothly.
I miss that scouser honeybadger.
When my patients were behaving from the medical side of things, I scribed for meetings. It might sound boring but when you’re sitting in the room with clinical directors and team leaders you begin to understand how the health system works. One thing I noticed is that everyone who works in mental health was … angry. Not at me, and not in everyday life, sometimes at each other (because that bitch Becky just called in sick after having a two week holiday and now you have to pick up an extra shift); but usually because they all had a deep seated, unwavering loathing reserved for ‘the system.’
It’s quite simple, really, our health system has resources allocated on a basis of need (I think resources means money, but can sometimes mean other things like bags of saline) but because we operate on a basis of opportunity cost (where resources put in one area usually means a loss in another area) we must find a compromise.
What is compromise? – Compromise is defined by the fine nerds who write the oxford dictionary as “an agreement or settlement of a dispute that is reached by each side making concessions”. Note the term ‘making concessions’
What is concession? – A concession is something you give someone to reach an agreement.
So what concessions are granted to our lovely mental health sector? Type in “mental health budget NZ” into google for your answer. You’ll also begin to understand why everyone in the nuthouse is so nutty and why this compromise isn’t exactly a compromise. The mental health sector is starving, absolutely starving. Every morning meeting would go on for five minutes longer so that everyone could address their dissatisfaction and frustration with how little the mental health system is being given, or rather, how much is being taken away from it. From budget cuts stopping occupational therapists taking patients out for group activities, to staffing issues that have nurses working doubles upon doubles – there’s always something hellishly frustrating that has been decided from far above the average employee’s head. It’s an almost accepted fact of life – mental health is the weird little cousin that sits in the corner of the room and so he doesn’t get the same, shiny new toys as everyone else.
I must stress that it’s not all bad, most of my memories as a psych housie are fond but they don’t all translate into interesting discussion points. I will say that the consultants were amazing and approachable, always offering advice when asked and more so than any other specialty I’ve worked for. I found it incredibly easy to befriend nurses and allied health colleagues, many of which I still talk to when I get the chance. The work atmosphere although slow, is cooperative and has a fantastic multidisciplinary approach that’s communicates better than any other I’ve ever worked in.
As a final word – and I suppose with the inevitability of hundreds if not thousands (one can dream) reading this little brain fart of mine – I have a small sense of duty to try and reach out and encourage everyone to save the world or something… and be better people… or whatever.
I don’t have a heartbreaking, glamorous story about how I battled anything. I doubt my life story would be much of an inspiration for anyone, but I have had my insecurities and anxieties. At times they’ve had the better of me, and at times I’ve wandered around aimlessly trying to figure out what was broken, what needed fixing, and what anything ever meant. Eventually I found that for me, the answer was maturity.
As we mature we begin to incorporate self-maintenance into our lives – getting a WoF for the car, folding the laundry before putting it away, filling out forms for tax returns. These are boring, mundane chores that we know we must do – otherwise everything snowballs into a giant mess. Sort of like when a gall-stone finds its way into the small bowel, collects up debris and calcifies into an obstructive mass leading to a gallstone ileus. To prevent our own mental ileus I think it’s important for us to incorporate one more thing into the daily routine – the cleaning and fine-tuning of our own mental health. Be it mindfulness, meditation, exercise, painting upside-down smiley faces on eggshells, whatever. Do it. Do it, and help others do it too. Do it and help shape a world where it’s easier for everyone else to do it.
I’ve learned to take pleasure in the small things, to congratulate myself on small victories like making my bed or cooking a meal (instead of buying subway for the 938th time). Whilst looking at the big picture of our lives these small victories might seem meaningless or even cheap, but they’re not. They’re small signs of self respect and dignity. They help build the foundation of our character. They help us find peace. It’s not airy-fairy, it’s grown up. It’s not an abandonment of our childlike curiosity for the world, but the focussed channeling of it.
Make time and take care of the little things.
- Foundation MH. Mental Health Foundation. Quick Facts and Stats 2014. Mental Health Foundation; 2014.
- Keith McLeod, Robert Templeton, Christopher Ball, Sarah Tumen, Sarah Crichton, Sylvia Dixon. Using Integrated Administrative Data to Identify Youth Who Are at Risk of Poor Outcomes as Adults [Internet]. New Zealand Treasury; 2015 Dec. Report No.: 15/02. Available from: http://www.treasury.govt.nz/publications/research-policy/ap/2015/15-02/ap15-02.pdf
- Health Quality & Safety Commission New Zealand. Perinatal and Maternal Mortality Review Committee. Tenth Annual Report of the Perinatal and Maternal Mortality Review Committee. http://ndhadeliver.natlib.govt.nz/delivery/DeliveryManagerServlet?dps_pid=IE28351765: Health Quality & Safety Commission New Zealand;
- Cole TR, Carlin N. The suffering of physicians. Lancet. 2009;374(9699):1414–5.
- Comparisons with OECD countries: The Social Report 2016 – Te pūrongo oranga tangata [Internet]. [cited 2017 Aug 16]. Available from: http://socialreport.msd.govt.nz/social-wellbeing-summary/comparisons-with-oecd-countries.html