Psychiatry Rundown
Teams and wards
The inpatient Psychiatry unit is called Te Whetu Tawera (TWT). There are four teams (colours), two “open”/”general” wards s (Ward A (Te Kakenga) and Ward B (Te Whitinga) and one ICU (Te Tumanako). The open wards are literally open. The patients are allowed to come and go as they please essentially because it is now illegal to lock them in. They are expected to comply with leave protocols and the majority do but there are still a lot of AWOLs.
Daily duties
You start around 0830 and the handover place depends on the team. Contact Joyce Fonseca to get access to the L: (location of patient lists, etc) and HCC access as all notes are electronic. You will meet her on your first day at orientation. There are 2 full days of orientation! There is a great booklet that Dr Kenedi set up given to you at orientation for medical presentations in psychiatric patients. This will be your bible.
During patient reviews with the SMO, MDT meetings once a week (QUITE LONG), and daily morning handover you are expected to type minutes.
When a new patient comes in from the community, do a medical history and exam, review ECG, complete a form for urine toxicity screen and take bloods as able. The registrar does the psych part of the admission. Usually your admission needs to be done within six hours of them arriving. You are expected to complete the medical part of the discharge summary but not the psych part. This will be done by either the registrar (if you have one) or the consultant. If you are unable to complete a physical exam for any reason, sight the patient to ensure they don’t have any acute issues requiring immediate action and document this on HCC.
Teaching
Prioritise attending PGY1 HO teaching Tuesdays 12.30PM – this should be prioritised over any psych meeting unless patient is needing urgent medical review
Dr Read‐Smith (Gen Med SMO) provides teaching every Wednesday at 1300
Clinical tips
You are essentially the GP to the patients and the secretary to the consultant. Keep in mind service users (patients) may have minimal access to health services when in the community so be opportunistic about managing health issues (outstanding scans arranged in the community, etc).
When reviewing a patient, do keep in mind organic causes for presentations – don’t just assume it is related to mental state.
You will get REALLY good at checking the QT and QTc interval as this needs to be done for ALL patients on admission, and regularly in some cases.
Every patient on Clozapine needs bloods every Tuesday (put form up on Monday).
Limitations in TWT
There is no Lamson. Drop bloods at reception and tell them if it’s urgent. The phlebotomists do not come to TWT anymore. A few nurses have been trained to take bloods, with the intention of training more. However in the interim, as the HO you may have to do some bloods yourself.
Nurses are very good at psychiatric management of patients, but effectively they do not have much on-going training of medical management. As a result, you will likely need to be more involved in ensuring investigations/obs get done and medications administered, and ECGs have correct lead placement.
Beth Jackson is the Medical Nurse Specialist who will introduce herself during orientation. She is the go-to person for medical management of patients and can help if you are having difficulty getting bloods, ECG etc done for your patients.
There is no capacity for regular IV therapy in TWT – fluids or medications. They sometimes do iron infusions. There is also no oxygen therapy other than nasal O2 and basic resuscitation equipment. If they need this, they need to be transferred to the main hospital.
Patients won’t always let you do what you need to. This is okay, and their right (unless it’s life or limb threatening, in which case you can utilise the MHA to ensure investigations/management occurs.
Make sure you are safe, never do anything you are uncomfortable with. The patient population can be challenging. Don’t ever interview, examine or interact with a patient alone. Even if the nurses say they have no time to chaperone, just do not do it. Never do bloods on someone you are concerned may become aggressive (to avoid needle stick injuries).
Often if a person is being sent “up the hill” for scans/a review, they need an escort nurse/security so keep this in mind. The x-ray department are very accommodating and will let TWT patients come up at any time and they will fit them in. There is also a portable x-ray service available if the patient is too unwell/risky to be sent up to the hospital (phone number: 6230274)
There is only one automatic defibrillator in the building, no manual.
On call
You get a phone to use during the run. Nurses will call you on this.
Bonus: you don’t need to be on site, but within 10 minutes of the hospital when on call (truly on call).
On long days, you cover TWT, FMU (Fraser McDonald Unit) and CFU (Child and Family Unit). Learn the shortcuts to get there – it will save you time. Unless the jobs are urgent, it is sometimes more efficient to let a few jobs build up and get them done at once instead of going back and forth several times an hour!
It can be a bit daunting to be on-call especially to start with, because the psych buildings are separate to the main hospital and the psychiatry registrars and consultants only deal with the psychiatric side of things and not the medical side. Remember, if you need help or want to just run a plan by a registrar – call the medical registrar.
On the weekend, you don’t really need to rush to get in. The nursing staff will call you if things need to be done. Emergencies should always have a code called. Call the duty manager to find out about new admissions coming in.
Overnight you also cover OPH and Gen Med. New psych admissions are sometimes too unwell to be properly clerked (or you may be too busy on the wards in the main hospital) so ensure to at least sight them, ensure no acute medical concern is present and if you have time/the patient is willing then do a systems review, exam, ECG, urine toxicity and blood test.