First ward round: Counting chickens

First attempt at a ward round today. I arrived on the ward, M1, and was once again immediately approached by throngs of patients proffering their hands for shaking or greeting me with manic shouts. By now I am getting used to it and feel more comfortable wandering out into the courtyard and along the concrete floors, stepping over patients, greeting informally but without committing to a full conversation. The courtyard and corridors are filled with many white-uniformed bodies, milling around in groups talking uneasily to each other, and sometimes engaging with a patient. My initial reassurance at this apparent surplus of staff turned to mild frustration when I saw that they were all nursing students, very few of whom were interacting with patients, some listening to iPods. In the smallish office there is apparent chaos, two patients sitting with torn clothes on the floor, shouting at a fellow patient outside, various white-clad nursing students flipping idly through patient notes, and the nurse Monday writing furiously while telling a patient to get out and a student to come in. He flashes a brief smile when he sees me and I ask him if he’d like to do a ward round. There is a brief ripple of his temple muscles as he contemplates the further chaos this will cause now. “Of course, you know, we can do a round.” I check again, “What would be good for you Monday? I can see things are busy here.” I feel helpless, not speaking the language, not yet knowing how patients are admitted, or even how many there are on the ward today. I don’t want to cause more work for anyone. Monday is sure though, “No, we can do a round. Let me call the patient.”

I think Monday is torn between needing to do some work on the ward, and wanting patients seen by a clinician. For the past five years, nurses have been doing the majority of the clinical work, including basic diagnosis and prescribing, leaving no time for nursing or patient care. Mr. Phiri, the only psychiatric Clinical Officer during this time, could understandably only see a few of the 250 hospital patients whom the nurses had particular difficulty with. Still there are only one or at most two nurses for each ward of between 30 and 60 patients, and I am not surprised that in between clerking patients in, dealing with emergencies, speaking to relatives and dishing out medication there is no time left for patient care. As Rob says ruefully, “The nurses just want to get back to nursing.” So I keenly feel the need to be useful and efficient, not to waste the single nurse’s precious time. For each minute the ward round continues, there is no nurse on the ward.

With this brief introduction, I take a seat at the broken swivel chair with the torn padding in front of the desk, waiting for the appearance of the patient. Monday has left the office to call him, and some students gather round in an expectant tight semi-circle. Some of them, I find, are not nursing students, but third year Clinical Officer students. As mentioned before, the Clinical Officers in Malawi do a three year medical course with a practical emphasis. They have a six week psychiatry block during which they must clerk in patients and present them to a doctor (me). One of the students has a patient to present, and I suggest we do that after we see Monday’s patient who has just arrived.

The patient saunters in somewhat stiffly and sits at the chair next to the desk. He is a young well-built man in his mid-twenties, slightly slowed up as a side-effect of his medication. Monday sits on the desk and tells me about the patient. “Of course, this patient was admitted two weeks ago…” He carries on, but I find it difficult to hear him as patients are jabbering outside, the door guard is roughly pushing one of them away from the door and shouting at him, and more nursing students are drifting in and standing around the walls of the small office. Some of them leave with no obvious reason or purpose. Monday carries on valiantly, telling me about this man who was wandering and beating people. It is not immediately clear that there are any psychiatric symptoms, and I start to ask some questions which Monday translates. The patient looks quite calm and answers readily, using hand gestures and occasionally raising his voice a bit. I watch him but can’t gather anything particularly helpful from his manner and speech. Monday translates his answers, though I struggle to hear over the background din. I wonder if ward rounds such as this are usually done in the ward office, with the patient present throughout the presentation and discussion, then I remember that a ward round is not part of the usual routine here, and that’s why it feels so impromptu. I make a mental note that we will need a quieter, more private room in future. But the translations keep coming. The patient’s “presenting complaint”, of wandering aimlessly and beating people, I have subsequently learnt is fairly typical, and psychiatrically not very helpful. Monday did not clerk this patient in himself though, and the only collateral history is from a three-line referral letter, which means we have little good quality information to work with. We have little idea why the patient was behaving like this, and have to almost disregard the history and work with how the patient presents himself now – two weeks later! I ask a few questions, and Monday translates again. The patient launches into a complicated answer, far more than I would have thought my question deserved, and Monday and one of the students enter into a brief dialogue with him. I’m not sure if the patient is talking sense or not, or is deluded as the history tried to suggest. The surrounding students listen intently, sometimes giggling unashamedly as a group at something which is said. I have no idea what is being spoken about. Monday translates a summary as best he can, though clearly much more was said, and many nuances have been lost. Another question from me is translated, and as the patient responds I look to the students’ reactions for a clue to the quality of the answer. I hope that their faces will show me the sense or non-sense of what they are hearing, a type of “extended counter-transference”. I feel like Derren Brown, focussing on minute details of their facial expressions, looking for amazement, astonishment, surprise, amusement, bafflement, concern or disbelief. It’s partly helpful, and we do end up agreeing that the patient was unwell and probably psychotic, justifying the use of chlorpromazine he is receiving.

The next patient is presented by one of the 3rd year Clinical Officers. He was brought to hospital apparently because he was killing chickens. Again the history is perfunctory, and there is little exploration of the possible reasons for the aforementioned slaughter. I think to myself that it might be appropriate to kill chickens at times, and encourage the student to ask the patient for more details, specifically looking for any indication of abnormal or unusual experiences. There is some dialogue, and the student says that there were two chickens, and they had been given to the patient. Killing one’s own chickens hardly seems worthy of detention in hospital, I think, so we continue to look for signs of mental illness. More students enter the exploratory fray, one correcting the other. No, they weren’t his chickens after all, but his family’s. But he may have been told to kill them. Possibly for dinner. Wait, no, he was actually given five chickens. He killed two of them, or maybe all five, which everyone agrees is clearly too many to kill at one time. I listen with fascination and some frustration, not immediately knowing how to direct things. Hold on, his brother killed the chickens and the patient tried to stop him. Or not. Somebody thinks he ate one. The students say the man is contradicting himself. We are all desperately trying to work out who owned the chickens, whether the patient was acting on instructions, how many of them were killed, and why. After about twenty minutes of this confusion, I suggest that the actual details are interesting but not crucial to the case, and we agree that the man is probably thought disordered and that is why we cannot work out what he means. This satisfies everyone, including me, though it’s really just a guess.

This is hard work, and I end up exhausted after two more patients. It’s confusing and chaotic, and the diagnoses which seemed to fit in Scotland don’t match up here at all. I’ll write more about this when I’ve had some more experience with it and tried to make some sense of it.

Don’t take your chickens for granted.

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