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Meeting the needs of the most complex patients

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As a specialist provider of mental health support, caring for some of the most clinically complex patients in the UK’s mental health system, St Andrew’s has a team of experts to provide the bespoke support to enable vulnerable patients to recover. Here, NR Times meets consultant neuropsychiatrist, Dr Vishelle Kamath

 

Can you summarise your role and career to date?

I work as a consultant neuropsychiatrist on the brain injury admissions ward. I have worked both in the NHS and at St Andrew’s within the independent sector. I have been fortunate to have the opportunity to have worked both as a clinician and as a manager of clinical services in a clinical director role. 

Aside from my day-to-day job at St Andrew’s, I am an honorary neuropsychiatrist at UCL Queen Square, the National Hospital for Neurology and Neurosurgery. It helps me to keep my skills updated and understand services across the country, which then allows me to use that knowledge to support the team at St Andrew’s and the patients I care for.

Tell us more about the Neuropsychiatry brain injury service at St Andrew’s? 

We support people who have had a recent or long-standing brain injury. These can be acquired either by trauma, like a road traffic accident (RTA) where there is structural damaged to the brain, or through different illnesses, such as encephalitis or meningitis, where the illness itself causes a change in the way the brain functions and leaves people with both physical sequelae as well as psychological and behavioural elements. 

Physical symptoms from brain injury are something you can see – such as difficulties with speech, swallowing, walking, and mobility – but there can be significant psychological and behavioural sequelae of brain injury, not necessarily visible to the eye, which may include the way someone thinks, how they process information, use judgement, plan, and make choices for themselves. 

The impact of trauma can be far-reaching, for example, a brain injury may affect parts of the brain that control appetite – a person can eat excessively as they do not know when they are full – or alternatively, they don’t have any feelings of hunger or thirst so do not eat or drink. 

A brain injury may also affect the way a person perceives other individuals. They may not see them as helpful, and instead see people as persecuting them or harming them, which results in agitation, aggression and resistance or non-compliance with care. 

People admitted into our service may have experienced significant brain trauma and the loss associated with the attendant physical, cognitive and psychological deficits are life changing.  This is aside from the impact that this has on loved ones and families. 

How do you support patients living with these types of brain injury and symptoms? 

Much of the work we do relates to understanding an individual’s specific needs and what has happened to them. Many people come from acute trauma centre or step down neurology wards and have been sedated for long periods or intubated. 

Patients usually come to us at the point when they are beginning to realise what has happened to them and are coming to terms with not being able to care for themselves in the way they had been able to, prior to their brain injury. 

Some individuals come to us with significant memory loss and their ability to learn new things is impaired. Some people have evident mental disorder as a sequelae of their brain damage. They may have developed psychosis, anxiety or depression as a sequelae of their brain injury. We help them to process the environment, situation and the trauma they may have had so they can develop coping strategies. 

During the assessment process we employ many tools and clinical observation assessments to understand what difficulties a person may be experiencing; their ability to function, what they can do for themselves, including simple things such as daily living activities, feeding, changing, recognising the need to go to the bathroom, which can all be affected by a brain injury.

Once we understand this, we can think about interventions that may support a patient to achieve a level of functioning similar to that which they had prior to their injury, and we subsequently develop holistic neurobehavioral and neurocognitive programmes tailored to the individual needs of each person.

A huge part of the service is also about supporting loved ones of the patient, who themselves are often struggling to understand what has happened, and helping them to understand the process. Establishing the pace of recovery, and setting realistic expectations as to what an individual’s journey may be, is part of what we do.

What is the difference between the St Andrew’s brain injury services and those elsewhere?

At St Andrew’s we are able to meet the needs of patients who present with significant behaviours that challenge. With our experience and expertise, we’re able to support people when they have layered complexities; complex physical health needs that are overlaid with significant and complex mental disorders and mental health needs. 

We have the procedural capability and wide breath of knowledge to support patients whose risk profiles cannot be met in other brain injury environments. 

On our assessment ward, we are able to get patients to a point where they are able to access neurorehabilitation at the earliest opportunity. Until a patient’s behaviour is managed in a way that allows them to engage with and access rehab services, it is unlikely they will achieve the outcomes they want for themselves and return to their premorbid functioning. 

How has your work been affected by COVID-19? 

The pandemic has been a huge learning curve for us. We have continually needed to ensure that patients are risk accessed appropriately in terms of their potential of contracting COVID and the likelihood of them developing a more serious illness. 

Early on in the pandemic, I devised a COVID risk assessment tool and care plan which helped clinicians to systematically think about and understand the risks to other patients with strategies to support all patients and staff safely. This risk assessment is co-produced with the patients and their families, understanding what their views are around escalation of care and any elements of advanced care planning, to reach a shared decision. 

One of the key things in our brain injury service is that we are true advocates of the value of the patient voice and within the context of COVID understanding what the patient wants for themselves, whether we agree or disagree, is a key to the development of these care plans. 

In line with PPE requirements, we all wear masks, we are bare below the elbow, and we maintain a two-metre distance where possible. Staff use appropriate techniques when delivering care during the pandemic. We have hand hygiene audits and are regularly reminding staff of good Infection Protection Control (IPC) measures. We implement periods of isolation and wear scrubs that are discarded/washed appropriately centrally. 

All of our patients are high risk and we undertake four hourly physical health assessments, using a NEWS2 tool to detect any change in physical health, this is especially important for patients who are unable to articulate in the way they feel or report physical health symptoms. We have had to think more creatively, but allow our patients safe ways to access the community, leave and contact with families. Importantly, we have been helping patients and families to understand why restrictions have been put in place.

What are the challenges you face in your role?

I love working in brain injury. As a neuropsychiatrist, I love the interface between organic illness, mental disorder, the layered complexity it has with physical health and various individual elements based on how that person acquired their brain injury and the subsequent physical and psychological sequelae of their condition. 

There is a tendency for brain injury to be seen as a physical disorder and many healthcare settings place all the emphasis on physical rehabilitation, there is limited understanding of neurocognitive and neurobehavioral rehabilitation and this is a challenge across the wider sector. 

Everybody has a different story and some of the obstacles we need to overcome are around how we support patients with high needs, including how we help them to step down into community settings because provision across the country is very limited. 

What do you most enjoy about your role? 

The complexities of individuals and the interface between physical and mental health. Understanding patients in the context of who they are (mother, father, their education and interests, and so on) is integral to any neurobehavioral programme and these are the elements I really love.

Working in a diverse, multi-disciplinary team is also extremely rewarding. I’m very fortunate to work as part of a very skilled team using a comprehensive multi-disciplinary approach and the different perspectives it brings is something I love. 

What do you enjoy doing away from work? 

I love the time I spend with my family and love to cook. 

I also love to travel, exploring different places, enjoying the food and culture. There are so many stories of travel that have enriched my life. I was brought up in South Africa, but explored lots in South East Asia, India, Thailand, America, Europe, Australia and New Zealand. My parents used to love travelling, so I was very fortunate to have travelled when young and when at University. I lived in India for a while, which again was a very enriching experience.

Exploring, cooking and sitting down to a board game or movie with my children and husband are things I really enjoy. The banter I share with them on a day to day basis is the best part of my day.

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