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‘Please, I would like to go home now.’

It was 2am, and I was stuck. I was the sole on-call foundation doctor 2 at the local psychiatric unit where Ms P had been admitted earlier that evening.

She was demanding to leave, and it was my responsibility to discharge her home, persuade her to stay, or detain her under the Mental Health Act — something I had never done before.

Ms P was a slim brunette in her 40s, previously unknown to psychiatric services.  She had been found by the police earlier that day, wandering along a motorway.

She was fully conscious, did not appear intoxicated, and had no obvious injuries.

Ms P was not forthcoming with her history, meeting all my questions with an insistent ‘please, I would like to go home now’.

I tried to engage her with a friendly ‘why would you like to home?’  She just looked at me.  Or should I say, looked through me.  Silence. Ms P appeared attentive, she inhaled, she opened her mouth — all signs she was about to speak. Silence.  Then, ‘Please, I would like to go home now’.

Inside, I sighed.  ‘As I have explained, Ms P, to discharge you safely I need more information.  Please answer some of my questions.’

Ms P deflected and ignored her way through the entire psychiatric history, and every question was met with the same unwavering request to go home.

Could I discharge her or detain her? Without further information, I was stuck.  Then, it dawned on me. Her non-verbal cues, the attentive staring through me.

Ms P was listening, but to words I could not hear.

Time for a new approach. I asked another question, then swiftly interrupted the ensuing silence with a further question: ‘Who are you listening to, right now?’

I was ignored.  I tried again, more emphatically, ‘Right now.  Who are you listening to, Ms P, right now?’  Slowly, as if it required a great effort, Ms P dragged her eyes to focus on mine.

Calmly, she stated: ‘The people talking, they put thoughts in my head.  I’m telepathic, you know.’

A few more well-timed questions and I was satisfied that Ms P was acutely psychotic.  She was unwilling to stay as an informal patient, and sending her home at 2am was unsafe.  I explained the Mental Health Act to Ms P, the on-call mental health officer attended, and she was detained.  Ms P wasn’t pleased about her enforced stay on the ward, but she remained perfectly settled.

Ms P and that lonely night on-call taught me that when you feel utterly stuck, sometimes it is what a patient doesn’t say that gives you the vital clue.

Abbey Gray, foundation doctor 2 in psychiatry in Scotland

Posted in:  Communication skills

Tags:  Mental health communication skills juniors diagnosis

Comments

  • dxejswer

    3 February 2014

    1

  • dxejswer

    3 February 2014

    1

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