Inpatient Psychiatric Consultation at QECH

18 August 2016

We are becoming accustomed to the rolling blackouts. The drought has so lowered the water level in reservoirs that conservation is necessary. Today we had no electricity from 6AM to 4PM—-I made tea just before 6, happily. Yesterday there was no power from 4-9PM. We skipped supper. It isn’t so difficult to skip a meal, actually. A bit of hunger for awhile and then it vanishes. Good for the pocketbook and the waistline. Sometimes we have a Green or a Malawi G&T with lime, if we can get tonic. Tonic water is often unobtainable in the entire country. Makes you want to stock up.

After morning clinic today I tailed Stefan and Alex to do three consultations (of 5 requested) on the wards.  Alex is a young doctor who wants to do a Psychiatry Residency. He is well-suited for it, having a quick, psychologically-adept mind and a lovely way with patients. He currently works in the Pediatric Emergency Department. Stefan is trying to persuade the Ministry of Health to fund Alex for the residency training, along with three other residents, starting in March. Given the mountain of trauma, depression and major mental illness here, it seems like a no-brainer to train some psychiatrists to lead the country.

I was concerned that the smells in this hospital would be overpowering, given the lack of staff and the crush of patients and the families attending them.  While the hospital provides food for the patients, the “guardians” attending them (Noting the conditions at some times, I see the need for guardians!), who lounge in the sun on the many, many lawns and dirt courtyards enclosed by and surrounding the hospital, often cook for and feed them. But miracle of miracles, the floors are scrubbed by uniformed teams at least twice per day and the hospital wards smell very neutral. I suspect they cannot afford much disinfectant, which fact improves the air quality.

Our first consultation was a 37yo woman who had a C-section and subsequent hysterectomy (multiple fibroids) the previous day. She awoke from the anesthesia combative and psychotic, terrified people were trying to kill her. She’d been restrained and sedated over 24 hours with chlorpromazine (Thorazine) and diazepam (Valium). She was sedated at first when we met her and her husband. He was able to tell us that she’d never been crazy or violent in the past. As we talked she gradually awoke and became more alert—-and calm. We removed her restraints and considered that she had a brief psychotic episode secondary to the anesthesia. Simple, our work was done for us. It may turn out that seeing a consultation 24hours after the request is submitted is not a terrible way to practice, given the resources.

Consultation #2 was on one of the male wards, an open affair with wings and probably 75 beds, all told. He was an unresponsive 23yo man lying on his side with a naso-gastric tube taped to his nose. He’d been violent at home and then swallowed keys and other metallic objects, which we could see on an x-ray film, traversing his g-i tract. His eyes were open and he followed movement but was otherwise catatonic. After futile attempts to talk with him, we took his mother to an exam room where she provided the following history. He was HIV negative in March, always a first step here. He had a history of cerebral malaria at 2yo and was unconscious and in hospital for a month, with consequent delays in locomotion and speech. He seemed to do alright with primary school but struggled in 4th Form (high school) and dropped out. Described as friendly and liking to make music, last December his behavior changed abruptly, he became violent and after a week had a single grand mal seizure. He was put on phenobarbital (even the supply of Dilantin/phenytoin is insecure) and hasn’t had a repeat seizure. He was also on an unknown psychotropic for a few months but hadn’t taken them for the past 2 ½ months. On the day of his admission he had trashed their hut and broken all his electronics. It is unclear why he had a dramatic behavioral change and a seizure in December and it requires investigation with an EEG and a CT scan or MRI—the latter may not be possible until he passes all the metallic objects he swallowed. Stefan prescribed a small amount of iv diazepam and im risperidone, hoping to lyse the catatonia. We’ll follow up with him in a couple of days.

The last man, a 57yo farmer with a long history of well-treated Bipolar Disorder, was referred from a district hospital where he’d been discovered to have a tumor in his mouth. At QE he had the resection of a large squamous cell carcinoma from under his tongue and a skin flap rotated to cover the deficit. After surgery he became agitated and psychotic. Rather quickly, we realized that he hadn’t been given his antipsychotic, which he had taken religiously after spending a year in the Zomba Mental Hospital in 1996-7. His guardian, a maternal uncle, was very helpful with the history. Again, the Clinical Officer on the ward had given him some chlorpromazine and he was lucid and calm with us. He couldn’t speak much because of the surgery and, we sensed, because of privacy issues. The valproic acid supply is not reliable; lithium isn’t used because of the difficulty with monitoring levels. I haven’t seen tardive dyskinesia but I anticipate there must be a lot, given the broad use of (especially) first generation antipsychotics (Thorazine, Prolixin depot, Haldol).

It is an experience to walk onto a large ward where every bed is surrounded by between 1 and 4 relatives attending to each patient. Colorful chitenje’s cover the blanket on the bed, there is chatter and nsima with relish being devoured, and it feels a bit like a party, despite the fact that some of the patients are desperately ill and will die soon.

The consequences of severe head injuries from motor vehicle-pedestrian or motor vehicle-bicyclist interactions are commonly seen on the medical wards. For many people, I suspect, “Progress” has meant a degradation of their lives. Certainly degradation of the environment.  Lots of plastic bags by the roads, all small and a nice azure blue, looking like flowers. There is a BMW dealer in town.

I was thinking, since this major hospital in Malawi is named Queen Elizabeth, perhaps I should write a note to Her Royal Highness (though some of her kids seem determined to make it Lowness) requesting a modest sum to improve things. If any of you readers have her ear, please let me know.

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