Psychological Distress Among South African Healthcare Assignment

Assignment Task

Introduction

The burden of mental health illness weighs heavy on South African health services. Any clinician who has worked in an emergency department has had to deal with an aggressive or combative patient. It is very important to know how to manage these patients safely.

What would be your immediate actions?

• Stay calm and be ready for more disruptive behaviour. Make sure the police or security are present throughout the interview.
• Try to calm the patient down and offer an oral sedative. If patient accepts, give Diazepam 5mg STAT per os and wait until patient is calmer.
• Try to get some information if patient is able to communicate, also try to get an address and information of next of kin. Do clinical examination to rule out organic causes, (DIMTOPS). (DeVos 2019)
• If patient does not agree to oral sedative, sedation will need to be given against the patient’s will with security back-up at hand. Sedate with short-acting benzodiazepine e.g. Midazolam 10mg IMI (anti-psychotic can also be used). MHCA form 1 needs to be filled before starting emergency treatment against patient’s will. Thereafter do examination as discussed above.
• Monitor vital signs throughout sedation to prevent cardio-respiratory collapse from oversedation.
• Restrain the patient only if absolutely necessary.
• Arrange transfer to appropriate facility.

What are the implications of the Mental Healthcare Act?

Due to the mental state of the patient, treatment will most likely be given against the patient’s will. This is because they have been assessed as incapable of making an informed decision regarding their treatment. Usually this means that without treatment, the patient is a harm to him- or herself or to others, or treatment is needed to protect their finances or reputation. To protect the patient against unfair intervention or abuse, as well as protect the healthcare practitioner, a written application should be made to the head of the health establishment to treat the patient.

How will you proceed with the further management of this patient (assuming you will remain responsible for his further care)?

Legal

• Apply for admission with MHCA Form 04.
• Fill out MHCA Form 05 with another healthcare worker after examination.
• Admit for 72 hours for observation and fill MHCA Form 06 after this period.
• This will be followed by admission to psychiatric hospital (MHCA Form 08) or discharge (MHCA Form 3).

Medical

• Ensure the safety of the patient by nursing in a locked, isolated room with all items removed that could harm the patient.
• Try to conduct a psychiatric interview as soon as patient is awake and able and establish a provisional diagnosis. In this case I would exclude substance induced psychotic disorder, bipolar disorder with manic episode, delirium, schizophreniform disorders and depressive disorders with psychotic features (Sadock and Sadock 2010).
• Special investigations include a urine drug test, U&E, thyroid functions, RPR/ TPHA, HIV test (if consent can be obtained), fasting glucose test and CRP.
• Keep patient calm and sedated but awake with Haloperidol 5mg daily per os. Prescribe emergency sedation in case of emergency like Midazolam 10mg STAT IM.
• In this case I would start specific treatment for bipolar disorder with manic episode by adding a mood stabilizer like Carbamazepine 400mg bd per os. Psychotherapy and education.

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