Forensic psychiatry

Psychiatry is defined as the study and treatment of mental illness, emotional disturbance, and abnormal behaviour. Psychiatry is a medical specialty, and so psychiatrists need to be medically trained to perform this type of medicine. This is the main difference between psychiatry and psychology; which can be defined as the study of behaviour and the mind, and can be thought of more as a social science. Forensic psychiatry is a specialised branch of psychiatry which deals with the assessment and treatment of mentally ill offenders in prisons, secure hospitals and the community. It is a particular aspect of psychiatry which I find interesting as it has extreme consequences in terms of the threat posed to society.

Forensic psychiatrists provide psychiatric treatment in a secure environment or where patients are subject to legal restrictions- meaning that the doctor needs an in-depth understanding of criminal, civil and case law as it relates to patient care in these settings. Treatment areas can vary from high security rural prisons to community centres. Referrals can range from those who have committed minor offences to serious and violent offenders, and for this reason the day of a forensic psychiatrist is never the monotonous. Forensic psychiatrists may also assess non-offenders displaying high-risk behaviour. Forensic psychiatrists also provide specialist advice to courts, probation services, and the prison service. They also prepare reports for mental health review tribunals, hospital managers’ hearings, other practitioners and criminal justice agencies.

Expert opinions given to court:

• ·         defendant’s fitness to plead and fitness to stand trial
• ·         capacity to form an intent
• ·         advice to the courts on the available psychiatric defences
• ·         appropriateness of a mental health disposal at the time of sentencing
• ·         nature of a particular mental disorder and link to future risks
• ·         prognosis and availability of “appropriate treatment”
• ·         level of security required to treat a patient and manage risk

The wonders of ECMO

The extra-corporal membrane oxygenation machine is one of the wonders of 20th and 21st century medicine, as it acts as an artificial lung outside of the body, oxygenating the blood and pumping it round.

ECMO was first used successfully in the USA in 1976 and was introduced in the UK in 1989. It was first set up in a paediatric setting at Great Ormond Street Hospital in 1992 and to date they have supported over 850 babies and children. This is of vital significance as ECMO machines are mostly used on children and babies, but are sometimes used in adults with cardiac and respiratory failure.

There are two main types of ECMO: veno-arterial and veno-venous. In both types, blood drained from the venous system is oxygenated outside of the body. In VA ECMO, this blood is returned to the arterial system and in VV ECMO the blood is returned to the venous system- in this typr of ECMO there is no cardiac support.

In veno-arterial ECMO, a venous cannula is placed in the right common femoral vein for extraction and an arterial cannula is placed into the right femoral artery for infusion. The tip of the femoral venous cannula should be kept near the junction of the inferior vena cava and right atrium, while the tip of the femoral arterial cannula should be kept in the iliac artery. Central VA ECMO may be used if cardiopulmonary bypass has already been established (with cannulae in the right atrium and ascending aorta).

In veno-venous ECMO cannulae are usually placed in the right common femoral vein for drainage and right internal jugular vein for infusion. Alternatively, a dual-lumen catheter is inserted into the right internal jugular vein, draining blood from the superior and inferior vena cava and returning it to the right atrium

ECMO can be used in the operating theatre straight after surgery or on one of the intensive care units. If a patient is going through ECMO after cardiac surgery, the surgeon will usually insert the cannulae (tubes) during the operation, directly into the heart through the chest. Whereas, if ECMO is started in the intensive care unit, the cannulae connecting the patient to the ECMO circuit are placed directly into the blood vessels on the side of the neck.

Once in place, the cannulae are then connected to the ECMO circuit. Dark deoxygenated blood drains from the patient through the tube in the vein and is pumped through the membrane oxygenator where carbon dioxide is removed and oxygen added. The blood is then re-warmed and returned to the body. This process goes on continuously while the patient is on ECMO. Additionally, they will also stay on a ventilator but on very gentle settings which allow the lungs to rest.