Covid-19: Reflections from the hidden frontline - psychiatric care
By Ciara O’Donnell and Carlos Escudero King, medical students at King’s College, London, and Dr Koravangattu Valsraj, Consultant Psychiatrist at South London and Maudsley NHS Foundation Trust
At the height of the global pandemic, medical students remained in lockdown and we watched our colleagues, professors, consultants, trainees, doctors, nurses, other health professionals and mentors battling this unprecedented crisis on the frontlines.
We heard constantly of the tremendous burden Covid-19 had placed on emergency departments, intensive care units and care homes across the UK and worldwide, but we were unaware of what was happening in mental health units. Eventually, as lockdown restrictions eased in the UK, medical schools grappled with trusts to get students back onto academic placements. Our first stop was a psychiatric intensive care unit at the renowned Bethlem Royal Hospital in South East London, but nothing had prepared us for what we were about to experience on the hidden frontline.
Psychiatric hospitals have been plagued by the coronavirus across the UK, yet garnered little media attention. A psychiatric intensive care unit (PICU) can be complex and challenging at the best of times, but particularly with regard to observing social distancing and other Covid guidelines, due to the nature and level of acuity of illness, structure and environment, among other associated factors. A PICU must meet patients’ medical, psychological and sociocultural needs. Covid-19 swabs have become mandatory upon admission and this is a challenge in itself. At the height of the pandemic, Croydon PICU cared for seven Covid-positive patients and the staff felt proud of the care they provided and have shared this learning widely.
We witnessed first-hand patients’ propensity for violence and aggression towards staff, including physical and verbal abuse, as well as spitting behaviour, which pose exceptional risk scenarios for staff as well as other patients during this pandemic. Staff in mental health units are highly skilled to de-escalate situations using appropriate techniques, but psychiatry was not an area equipped with the hazmat suit-style PPE, as seen on BBC news every evening. Inevitably, staff members were exposed to the virus. When the public thinks of essential workers they most likely think of A+E doctors, nurses, carers, supermarket workers and delivery drivers; mental health professionals are less likely to feature. However, many risked being exposed to Covid to provide 24-hour care for extremely unwell and vulnerable patients, so we salute our dedicated mental health colleagues.
Despite encouragement from staff and our engagement with the placement opportunities, our time as medical students at PICU has been over-shadowed by the omnipotent threat of Covid-19. We were often ‘surplus’ to the new Covid room capacities, which meant at least one of us was required to sit out of meetings and ward rounds. This led to missed teaching opportunities and often meant being sat in rooms separate to other staff members. Understandably, all patient and colleague interactions took place using face masks, but psychiatry is a specialty built on trust, and the clinician’s demeanour is paramount in establishing a successful patient-professional relationship. The mask is seen as a hindrance by patients as they prefer to remove them when they speak and some prefer not to wear then at all, even on repeated persuasion and encouragement from staff. Something as simple as covering one’s face could have all sorts of hidden obstacles to recovery and the therapeutic relationship.
Life did not cease during lockdown. In hospitals, not only did strokes, fractures and births continue, but also mental health crises, new psychiatric diagnoses due the pressures and stresses from COVID and acute deterioration in mental states.
Psychiatry may not have directly received the public recognition given to those deemed to be responsible for the fight against coronavirus, however we have been witness to the acute strain of a front-line approach to the pandemic. We ask that the mental health frontline should not be forgotten.