Case study: our 1st ECT

Mr MN

Baling, Kedah
1^st admission:

Was shouting non-stop and talking irrelevantly on admission

Reason for admission: tried to harm family members, decreased appetite and sleep

Noted changes of behaviour 2005; social isolation – acquired traditional Rx

Condition deteriorated 2006; Talking To Self and Laughing To Self, wandering around, claimed being bullied by seniors at school, wanted to see ‘Tuanku Sultan Abdul Halim’, claimed people going after him, bringing ‘parang’ to go to war

seek Rx at psych department for 3 f/u, then refused to come back again

In ward:

+ Paranoid delusions with religious preoccupation:

Saying that Muslims are being victimized in Penang and Singapore

Wanted to chase ‘ghosts’

+ family history of mental illness: uncle-maternal side

Stopped schooling at 15 y/o

Used to take ganja

Started on haloperidol and changed to sulpiride

2^nd admission:

Readmitted around 1 month after discharged

Reason for admission: irrelevant speech, poor sleep, disturbing public

In ward:

Need to be restrained nearly 2 days, preoccupied, hostile

Was put on 2 days of IM Acuphase

Still not yet settled considerably after 3 days of admission; praying in a disordered manner around the ward, still need to be restrained on 4^th day of admission

+ Nihillistic delusison:

Claimed he was deaf and dumb during his childhood years because insects which were actually ‘syaitan’ flew into his ears, and currently being eaten up by dwarfs – ‘orang-orang kerdil’ which will be dancing on his pillow at the beginning before feasting on him

Crawling in the ward – claimed now being an ‘animal’

Still need to be restrained occasionally after more than 1 week of admission

Prominent psychotic symptoms still took place with gross thought disorder, hallucinatory behaviours and also some features of flight of ideas. Tangentiality developed after a initial short time of relevant answers during each interview

Slow response to haloperidol and developed EPS (Parkinsonism features and drooling of saliva)

ECT was started:

Better presentation after 6 course – came forward, calm but anxious to go home

ECT was continued until the 7^th course, then allowed home leave

Came back from home leave:

Manageable at home for first 2 days after came back home, then started talking irrelevantly again about silat etc

Wanted to be a silat master to teach others how to fight the ‘dajal’ in the big war

IM depot 200 mg

T.Risperidone 2 mg BD

T.Artane 2 mg BD

Came back from 2nd home leave:

Still wanted to be involved in silat to defend the village and country

Mother agreed there were improvements, but not yet fully stable – able to care himself, able to take Rx accordingly , still had bizarre/irrelevant answers and ideas

T. Risperidone 2 mg OM 3 mg ON

T. artane 2 mg BD

Clinic f/u:

Improves a lot, no TTS, no paranoid ideation

Clinic f/u:

Improving

Clinic f/u:

Continuous improvement; mother more cheerfull

Start to socialize back again, riding motorcycle to g/mother’s house, helping the house chores

Planned to cont schooling next year

Reactive affect, euthymic mood, orientated, no flavid psychosis

eHIS: 3rd phase postmortem

The hospital decided to held a postmortem today regarding the implementation of all the three phases of the system. I represented my department because my boss was away in Penang attending the psychiatrists’s meeting. And I also had the opportunity to take some time off from the busy clinic. Hehehe!

 

The meeting was also attended by the MOH’s big shots that are involved with eHIS implementation. Some of them were Dr Akmal (Hospital Selayang) and Dr Fazilah (MOH). It started on a low note with a dull presentation about the changes and problems encountered since the beginning of the Go-Live phase, that was given by the SPK project manager. However, the tone picked-up when problems regarding specialist clinics were brought up.

The ‘uproar’ was headed by the O&G and paediatric specialist, mostly about the inadequacy of computers and their IT terminals in the clinic area.

Solution: see patient where ever there is a computer and IT terminal and convert other available rooms into Clinical Examination (CE) rooms. I would like to stress that psychiatry clinic already took that step forward by allocating a MO to see patients in the administration room. Kudos to me!!!

 

I managed to ask about when SPK gonna provide me with a computer, and the project manager has given his assurance that it will be settled by this evening. Unfortunately, nothing had been done till 5 pm when I left. Perhaps they’ll do it tonight? I doubt it. Sorry…..

 

Most of the questions later on were on the usage of the CE rooms by 2 MOs, and it was shot down as MOH is pushing towards the privacy of the patients. Then, the older/veteran specialists and consultants were arguing whether this system should go on, as it slows down the workflows. That also was shot down because by hook or by crook, everybody who works in IT-based hospital will need to run it based on the HIS. I think that is correct because why must the helthcare system still living in a manual and darkaged working system when the police force, for example has already been using and recording their works in the IT system. I can’t really understand why health providers are so slow and stubborn in receiving changes in the was they work. They still want to use and implement the workflows that are already ancient. Some might argue that it is because it is already tried-and-tested. But, my argument is; why don’t we try and test another system, that might produce better results? The new system might be slower with multiple teething problems. We must remember also that some of the initial problems are related to us, eg; not attending the introductory courses thus failing to know how to work with the system, and also due to our illiteteracy of computers. The patient care is still being given the utmost attention even at the beginning of the implementation. It is still up to the heath providers, especially the doctors to notify urgents cases for immediate assessments, and to notify pertinent life threatening signs and symptoms of the patients. Don’t just start blaming the system when you can’t get your desired results/orders. Think back again; did I actually follow the correct procedures? If all fail, kindly call the IT helpdesk at 3131/3132/3133