The Capacity Games

As I walked into the room he was laying face down on the bed, arm hanging over the side and bleeding heavily. A constant stream of blood was trickling out into the ever increasing pool on the floor. He was seemingly unconscious and very pale. I applied some significant pressure to the wound in the bend of his arm whilst trying to find out what had happened. It turns out that he wasn't unconscious but just playing dead. Within a minute or so he was up and talking, full of bravado and attitude. I applied a pressure dressing to the wound and bound it up relatively tightly. 

In terms of numbers he was OK. His pulse and blood pressure were stable and was showing no signs of shock despite the blood loss. That said, he needed to go to hospital. Clearly this was a cry for help and I wouldn't be happy leaving him on his own. For a suicidal self harmer however, he was surprisingly up beat. Very chatty, very well spoken and extremely knowledgeable about mental health law. He quickly made it very apparent he was not going to be going to hospital under any circumstances and was well aware that currently the ball was in his court. I had hoped some well chosen words and my power of persuasion could have made inroads with him but he was as determined as he was smug. 

Plan B then. If I couldn't force him to go to hospital, then I had to bring the most relevant bits of hospital to him. I discussed options with him and we settled on getting an out-of-hours GP to visit to ensure the wound was clean and appropriately dressed and then contact a mental health crisis team who WILL visit within two hours. Well, that's what they are supposed to do! He was happy with the plan, his dad was happy with the plan and seemed in good spirits. I wasn't happy with the plan but that was probably fed by the compulsion to do something for someone in crisis and not getting my own way. The patient had capacity so this was the best I could do! At a stretch the fact he was drunk could effect his capacity but I was able to have a more than rational conversation with about the pros and cons of staying and going and depute my disagreement with his opinion, it was after all his opinion and ultimately, his choice.

*REMEMBER THIS MOMENT* At this point, no ambulance had arrived, so I phoned control, to tell them that the patient was refusing treatment so no ambulance was required. 

"We also have the police running on this CAD, would you like them cancelled too?"

"Rog, patient is compliant and isn't being aggressive. Cancel police."

"Rog, thank you, red base out."

I explained to the patient and his dad that I needed to go and get my paperwork and phone various people to arrange the referral. I needed to speak to our Clinical Support Desk, the GP and the Mental Health crisis team and that could take a little while to get the ball rolling.  What I did assure them of, was that I wouldn't be leaving until I knew exactly when someone would be coming.

I went down to the car and started my phone calls. Midway through my first conversation there was a knock on the window. It was the dad looking rather panicked.

"He's done it again, I can't wake him, it's bleeding everywhere."

*face palm* 

I hung up the phone and rushed (Ambulance Run - above average walk) into the house and back upstairs. As I got to the landing I could hear the blood pouring onto the wooden floor. He was now lying on his back, other arm hanging over the edge of the bed and blood was literally pouring out of him. He was white as a ghost and unconscious. Again, I applied pressure and held his arm as high as I could. I was now in an extremely awkward situation. *REMEMBER THAT MOMENT* 

I was on my own with a bleed I was struggling to control. I had cancelled the ambulance and considering I had already waited 40 minutes and one never arrived, the chance of getting one instantly was minimal. I had also cancelled the police, who in this situation could be of great use!

"You see the radio on my belt, twist it off, hold down '*' to remove the key lock, then hold down '#' (priority) for me."

His dad followed my instructions and within a couple of seconds the radio started ringing. 

"Hold down the button on the side for me."

"Red base, patient has cut himself again, I need the police and an ambulance as a priority, I'm struggling to control the bleeding." 

"Rog, will do that for you now, nearest ambulance is some distance away, sorry!"

"Right, take the key off my belt loop, in the boot is a big black bag with 'Paramedic' written on it. Bring me that bag please."

Off he ran (Non-ambulance run - Actual running - Weird phenomenon). I managed to apply a pressure dressing to the arm which seemed to do the trick. This time bound even tighter than the first! On his return I got his dad to hold the arm in the air, allowing me to do other stuff. His blood pressure was in his boots so I got a cannula in him (for the medical lot, an orange in the back of the hand, sadistic git that I am) and started running some fluids through. The patient gradually became more coherent and was soon back and telling me to go away and leave him alone. Unfortunately for him and luckily for me, the leaving alone option was no longer viable.

First to my aid was the police. They helped me with everything I was doing and also attempted to convince the patient that now hospital was a must. He was having none of it. 

"You can't section me, I'm old enough to make my decisions and I'm not going to hospital. There is nothing you can do to make me go."

"I think you'll find we can."

"What powers are you going to use to take me from my own home, a place of safety, right here and now. You can't do anything legal and you know it."

The poor copper looked a little stumped and unfortunately had no answer for him which somewhat undermined his authority.

Although the patient had apparent capacity to refuse treatment, on balance I now felt I had reasonable grounds to use the Mental Capacity Act to enforce treatment. As far as I was now concerned he lacked capacity to make an informed decision and didn't appreciate the severity of his injuries. Unfortunately for the patient, he came up against someone with greater knowledge of mental health law than him. I was able to quote section 4(B) of the MCA at him and outline why the deprivation of his liberty was necessary. My rationale was because my proposed treated was wholly or partly for the purpose of giving life saving treatment to him and that, as the medical professional currently in charge of his wellbeing, I was well within my right to ensure he got treatment.

I explained all this in quite a self gratifying speech which left the patient looking rather deflated!

"Aaaaahhh, you just got schooled on the law by a paramedic, aren't the police supposed to know more?! Embarrassing!"

I felt a little awkward but luckily the copper took it on the chin and seemed happy to follow my lead and confirmed to the patient that I could do what I was saying. I also backed that up by telling him that under section 6 of the MCA he could be retrained by the police to ensure said life saving treatment happened and to prevent further harm to himself or us. Faced with three people who were much more well read on mental health law than he was, he quickly got on board with what was going to happen and became compliant. 

When the ambulance arrived he came voluntarily and was most apologetic to all of us. His initial reluctance to go to hospital was easily explained......

5 hours earlier......

A 23 year old guy who suffers from bi-polar and depression, who has a history of self harm and suicide attempts, is feeling particularly low. He is feeling suicidal and wants some help. He tries but fails to get hold of his crisis team. They simply don't answer the phone. Because of these feelings, he has been drinking heavily but being self aware enough to know that he is likely to do something stupid, he self presents and his local A & E. He tells the triage nurse he has been drinking and is feeling very low and suicidal. He said he just wants to die. 

The hospital is very busy, majors and minor are full and the waiting room is at bursting point. The triage nurse listens to a young guy tell her he has been drinking and apparently takes no notice of his medical history and wish to die, so puts him in the waiting room where he waits.....and waits. After 4 hours he got up and left. His cry for help had been ignored by mental health services and his local hospital.  He got on a bus and went home where he carried on drinking. And drinking. 

He then smashed a glass, picked up a shard and rammed it into the crook of his arm. He then called his dad who was downstairs, to tell him what he had done. His dad phoned 999.

"My son has self harmed, he is bleeding from his arm quite heavily."

"OK sir, help is on the way."

"23 year old male, self harm, serious bleeding, access OK"

Luckily I was only round the corner so was on scene within a minute or so. I grabbed all my stuff and headed up the path for my first mental health of the night......

A patients outcome, positive or negative should not be based on luck. Luck that I was close by. Luck that his dad was in the house to find him bleeding when he did. Luck that the bleeding was stopped and he was quickly treated. This should be the basic of mental health care. There are services in place to not only treat this demographic of patients but to safeguard the risks that are associated with their conditions. A patient in crisis and at significant risk of harm should have instant access to their crisis team. Time and time again mental health services are impossible to access outside of 'Mon-Fri 9am-5pm'. It just isn't good enough. With the glaring failings in an understaffed, under trained and underfunded system, the safety net is always A & E. However, combine deep cuts, fed up staff and lack of training with winter pressures and a waiting room full of time wasters and the basics are simply overlooked. 

There was no RAID (Rapid, Assessment, Interface and Discharge) or other liaison service made available or seemingly in place to allow a quick assessment of him. There was also no apparent risk assessment. After only 5 minutes with the guy and a limited knowledge of the Pierce scale of suicidal intent, I had him at a high risk of significant harm. His medical history and presentation alone raised enough Red Flags to warrant a rapid assessment. Instead he was left to his own devices in a waiting room of a busy hospital. Hardly the place for a vulnerable, suicidal young adult to be left. This job highlights the woeful inadequacies of mental health care from top to bottom of the NHS. When will this improve?! 

So, mental health care in the NHS. Discuss.

Coffee, Lizards and a Mongoose

"49 year old female, head shaking"

Sometimes you have simply awful days, other times you utterly fabulous days. Admittedly the latter is a rarity but I'm glad to report that today was one of them. A shift can be made or broken by the person you are working with. 12 hours in what is effectively a yellow tin can, can be an utterly trying experience with a total arse. On the flip side, 12 hours working with a certain few people can not only fly by, but also be great fun. After a hearty breakfast we dragged our weary and tired carcasses into the ambulance to trundle out into the 6am darkness. Joy. Deep deep joy.....

The day followed a pattern. Job, eat, coffee. Job, eat, coffee. Etc etc. After a plethora of patients who had either not needed an ambulance or not needed carrying to the ambulance the shift was almost at an end. We pulled up outside a rather bedraggled looking building of flats. Sure enough, we were needed on the top floor and with a rather vague history or 'head shaking' we rang the buzzer. 

'Who is it?' 

I wanted to say 'It's the King of Siam' or 'It's the second gunman from the grassy knoll'. You phoned an ambulance 4 minutes ago, we had sirens blaring as we pulled up outside the house and now there is a ring on the doorbell. It really isn't too hard to fathom. Anyway, despite what the inner sanctum of my psyche was telling me to say, 'ambulance' was all I mustered!

We plodded up the 6 flights of stairs and knocked on the door of the flat.

'Who is it?'

Really?! *insert sarcastic responses*

'Ambulance'

The door slowly opened and a lady stood in the doorway with a rather blank expression on her face. She invited us in, and disappeared off into her lounge. We duly followed. She started to tell me what was wrong but I couldn't concentrate. I was transfixed on the bizarre surroundings I had found myself in! Most people, myself included have some kind of theme to the decor of a room. Perhaps it's a colour theme, a feature wall, ornaments to match the furnishings. Maybe it's minimalistic, futuristic, antique. We trawl through catalogues stealing every good idea we can, in the vain attempt to pass off as our own inspirational masterpiece. However, a shrine to lizards isn't something I've come across at the Ideal Home Show. 

Yes, a shrine. To lizards. Models, photos, paintings, books and masks. I can assure you she was no herpetologist but she clearly had a penchant for reptiles. The drawings were bizarre and definitely not anatomically correct! The centrepiece to the room was a huge cage of sorts, inside was a lizard of some description. I was transfixed! It was one of the most bizarre things I've ever seen! 

It transpired that the patient had a mental health history and this 'head shaking' was something she had presented with before. The GP was aware and she didn't need to go to the hospital. Whilst checking her over I asked about the lizards.....

'They are my sons. He thinks that he is an alien. Maybe he is. I'm not sure.'

How does one respond to that? Either the fact that he thinks he is an alien or the fact his mother a) doesn't seem concerned about this fact and b) is under the impression it was a possibility! By this point my crewmate had disappeared from sight. I knew she was bound to have a beaming smile on her face and be seriously struggling to maintain any kind of composure. It was taking every bit of concentration on my behalf not to laugh. I know there are clearly underlying mental health problems but it's impossible not to find some of the things we see amusing, even if there is a sad tale running parallel with it.

Back in the ambulance, doing the paperwork, we had our laugh.  And we laughed hard. As is often the case, conversations tend to evolve based on our patients. In this case lizards in particular. From lizards we ended up discussing how the mongoose lives on lizards. Then it was what the plural of mongoose was. Was is mongooses? Mongeese? So many questions to answer! Apparently if I was a lizard, I'd be a Gekko. Why, I'm not entirely sure but despite my best attempts at pushing for something with 'dragon' in the title I was put in my place. We really are a weird lot!

A short while later, the time came for me to return to the lizard den with the paperwork. 

'If you're not back in 5 minutes, I'll send in the mongoose.'

She didn't even look up. 

I bloody love days like today! We really are a random bunch!

Grey Areas

”67 year old male, ? overdose, acting aggressively”

Despite the offer of police assistance we declined and said we'd be happy to investigate first and then request police only if necessary. I felt that with 3 of us on hand we should be able to manage by ourselves! As I've written about previously, it saddens me to attend suicidal elderly patients. They are given anti-depressants and sedatives like smarties. It almost feels like they are given them just to shut them up. Rather than address the cause, let's just make them sleep more, eh?!

We pulled up outside and were met by the patients daughter. She told us that he didn't know we were coming and that he wouldn't be remotely pleased to see us! Regardless of health problems I really wish people wouldn't do this! It makes our job infinitely harder and sets us off on an uphill battle from the get go! I understand why people do it, the emotional tug of loved ones is hard to ignore, it just makes them much harder to treat when we do arrive.

Sure enough, we were greeted with a steam of expletives. Reading between the lines, I think the essence of what he was saying was "Go Away". I am, of course, paraphrasing! He was indeed confused and overly aggressive, nothing like the way he appeared in all his photos. Apparently, he had taken an overdose of pretty much everything he had. We weren't sure exactly how much and of what, but he did need medical help, that was for sure. His family had rung the GP, but the minute they said 'overdose', the GP rightly called us.

At this juncture, where a patient is refusing treatment, but is, in our opinion, in need of help and may lack the capacity to refuse, we would assess him under the Mental Capacity Act (2005) to determine whether he has the capacity to refuse. It involves a form and some questions. The upshot is, the patient needs to be able to explain a rational and reasoned decision and withhold information given to him. If he fails, in our opinion, them we have the right to treat him against his will. It is a crude tool that is often mis-used but in a patients own home, is all we have available to us, short of the GP arranging a mental health assessment and a sectioning. That, doesn't happen quickly, by any stretch of the imagination!

Now, all I've just said, we did. We assessed his capacity, for what he had done. Every question we asked him he replied something like:

"Fuck off, get out of my house, you're not taking me to prison."

I didn't take it personally, clearly something was going on. There was a twist however. Under normal circumstances I wouldn't have thought twice about taking him to hospital for treatment. The issue was that he was a palliative care patient with weeks to live.

Is it morally right to force someone to have treatment in hospital when they want to die at home? There was a DNR in place and this mental deterioration was likely due to the cancer. Surely his previous wishes of non-treatment should be adhered to?! That said, we weren't here for his cancer or even his mental deterioration, we were here for the overdose and that was something that could be treated without conflicting with the wishes of the DNR. Yet again, we were stuck in a grey area, a mine field of mental health uncertainty! I certainly wasn't comfortable with putting him through the distress of being physically forced into going to hospital. And the likelihood was, if we had to take him, then it would be the police who would have to physically drag him out screaming. It isn't how I'd want my friends and family to remember me. 

We decided to call the GP back. Luckily, after eventually bypassing the GP reception security and interrogation I was put through to the locum doctor. She didn't know the patient and it would have been very easy for her to pass the buck and be of little help. Instead, she was excellent. She agreed hospital was not the right place and offered to come out and assess him. Due to his aggression and refusal of treatment, even at home, we requested police. This wasn't necessarily a police job, it was health related, and even though mental health is a huge part of police work, this still wasn't really their remit, but we felt their presence was necessary for the safety of us and the GP. Within half an hour, everyone was there, and with the assistance of the police, he got assessed by the GP. 

She decided that based on what he had possibly taken, he could stay at home. She offered to come back later and check on him and if further treatment was required she would call us back or arrange a home assessment. We thanked her, thanked the police, and we all left.

THIS is how healthcare in the NHS should work. THIS is how mental health should be treated and THIS is how the police should be used with regards to mental health. An outcome that is in the best interests of the patient. An outcome which is as least restrictive as possible and utilising the police when they are needed and not because the words 'mental health' appear. The NHS can work, inter-professional working can work and work very well. There is no need for us to stretch each others resources when it isn't appropriate. The patient got the best and most appropriate treatment, taking into account his physical and mental well being. Perhaps if other areas of the NHS can see things like this as a model for GP led treatment then things will start to improve. 

Closed Doors

"83 year old female, collapsed behind closed doors" 

It was a long winter. The dark seemed to last forever, the cold seemed to bite eternally the feeling of being cooped up seemed never ending. But hey, this is England. If we can't bitch about the weather, what can we do. The reason I mention it, is because I feel it may have contributed to the events that followed. 

'Collapsed behind closed doors' is an unnerving situation. A lot of the time you have no idea what lies beyond the door, thus serving its purpose! Still though, day or night, doors must be kicked in to get to someone who may be dead or alive on the other side. Today was the same uncertainty and the same vague details. All we knew was that there was a lady, behind a door, that her daughter couldn't get to. 

We were met at the day by the worried looking daughter. She had been out all afternoon and when she'd got back her was in her room, door locked and not responding to the knocking. She also 'never locked her room'. We went thought the motions of knocking and shouting but to no avail. My crew mate called control and requested the police. Meanwhile I was trying to peer through the key hole but couldn't make anything out. It was an old house and the doors weren't perfectly straight so the was a small gap at the bottom. I laid down and put my cheek to the floor. In that single moment my heart rate doubled and I could feel the adrenaline pouring through my body. About 3 feet from the door, lying facedown on the floor was our patient. 

"We need to get in now!" 

My crewmate took a sizeable shoulder barge at the door but just bounced off it. He the kicked, and kicked, and kicked some more. After about 5 hits the door swung open. I rolled her onto her bad, her eyes were closed, she wasn't breathing, but she was still warm. She was linked up to our machines and there was signs that her heart still had some activity going on. Due to that, and the fact the distraught daughter was screaming for us to do something we started the resus. We called control back and said that this was now a working resus and we needed more resources. 

After 1 shock her started beating again, unfortunately, this was short lived and within a minute or so we were doing CPR again. As the resuscitation moved on it became apparent we weren't going to be successful. The a bin was put next to me by my crew mate. Inside the 100s of tablets she had presumably taken. A glance around the room left reveals a suicide note to her daughter. It was unanimously agreed after we'd exhausted our protocols to cease our efforts and confirm her passing. 

Her daughter was beside herself with grief and guilt. I sat in the kitchen with her whilst she read the letter over and over. I also read it and it really was heart breaking stuff. She had lived a full life, a life of adventure, a life of many tales, but that was a life she had shared with her beloved husband. She explained she simply couldn't live without him anymore. She had her enthusiasm for life had died with him and she could no longer go on being a burden on her daughter. When you read words like 'seeing you grow into the woman you have become fills me with immense pride and joy' was touching to read but little comfort to her daughter. 

I don't know why, but I suppose I associate suicide with younger generations but depression is all to common in the elderly. It's often dismissed as part of being old and the anti depressants are handed out like smarties by GPs. Behind the tablets though the real people. Real people who are not coping with the loss of independence. Not coping with the loss of life long soul mates and not coping with having to impose on their children's lives. As she said, her enthusiasm had gone, and if you take that away from

any of, all that is left behind is apathy. In her mind she wasn't living the life that she had always stood for. The joy and adventure had gone. I suppose she realised that she didn't want to live her final years with apathy and sadness. It did make me think. When the time comes, do I want to go on my own terms when it's right for me. Probably. 

I have no doubt it was a decision that she agonised over for a long time. I'm sure she was well aware of the pain and hurt she'd cause her daughter but it was what she needed to do, for her. At 83, who is to argue when she says 'that's my lot'. 

"Nobody grows old merely by living a number of years. We grow old by deserting our ideals. Years may wrinkle the skin, but to give up enthusiasm wrinkles the soul" 

           - Samuel Ullman

A Mental Assumption

"28 year old female, sectioning, psych team on scene"

Sectionings are rarely as straightforward as they may initially appear. For starters, rarely are the team of people required actually there and more often than not, we are left waiting hours for people to arrive. Now factor in the fact that by its very nature, a sectioning is removing someones liberty and in this case, removing from their home address. It is of little surprise that most of these patients don't want to go to hospital, let alone go quietly. This is where the police are normally brought in. In fact, realistically, they are brought in when the word 'mental' is used in conjunction with an ambulance. but I'll get back to that. 

In a break from the norm, when we pulled up on scene to find that we were in fact last to the party. The approved mental health professional (AMHP) was there with the police and all the paperwork, signed by two doctors required to make a Section 2 legal was there, I's dotted and T's crossed. The police were there as the patient was being aggressive. The patient was suffering from severe post natal depression, and had been for a perhaps 4 or 5 months since her last baby was born. She had become more and more detached from her family, her moods were changing, she wasn't eating, washing and seemed totally unable to look after herself. When she started being incontinent and being seemingly apathetic about it her husband called in help. The GP (who didn't visit initially) arranged for her to be assessed by the AMHP who wanted her admitted to the mental health ward. The patient refused. The two GPs visited, agreed, left, and here we are.

We entered the house and were led through to the patient. She had an extremely vacant look in her eyes, her lips were pursed and she was acting in a bizarre, almost manic fashion. When she spoke she sounded drunk, but we were assured she doesn't drink. As is required, we checked her over and a few things just didn't seem right. He short term memory seemed to be poor, she was complaining of a headache and her skin was red hot to touch. She didn't have a temperature but I had that feeling that anyone who has worked on an ambulance has had. Something just isn't right. 

"I think she needs to go to A & E."

"No. She's going to the mental health unit for treatment. It's been arranged. You are here for transport." the AMHP snapped.

"And I think she would benefit from an assessment at A & E first."

"No."

Well that told me I'm only an 'ambulance driver' after all. The transport. I shared a look with the two police officers there, which as far as I was concerned gave me carte blanche to do what I wanted! Police and ambulance work together so frequently you just know that they will do anything we say and we would do anything they say. If I say A & E, they will support me! Without any fuss we got her onto the ambulance. She certainly had a decreased Glasgow Coma Score(GCS - a scale used to measure a patients levels of consciousness. A GCS 15 is normal. A GCS of 3 is completely unconscious) and after a quick examination it was clear she was dehydrated. Her blood pressure was also low. The AMHP was still outside the ambulance on the phone, still under the impression we were off to the mental health unit.

"Pass me the cannula roll will you?!" 

"Ha, he's gonna kill you!" (by cannulating and giving treatment she then HAS to go to A & E!)

"He'll need to get over it, she needs fluids and needs to be in A & E, this isn't PND, something is up."

"I agree!"

The police watched on as we cannulated and drew up fluids. 

"A & E then?! Do you want to break the news to him or shall we?!"

Because in a sick way I enjoy some confrontation I offered to break the news and unsurprisingly he was livid! He bleated on about all his wasted time and efforts at which point I interrupted him….

"Surely, what you want, like us and like the police is what is best for the patient?"

*mutter mutter, AMHP goes to his car, head shaking and tutting all the way*

By the time we left, we were that concerned by the patients rapid deterioration that we put in a blue call to the nearest hospital. On arrival I gave a handover to the doctor who promptly bleeped neuro to come and have a look. 

To cut a long story short, this was one of the rare occasions that we found out an outcome. A few days later I was told that the patient had a scan shortly after arrival and was diagnosed with an extremely rare and serious brain tumour. She was transferred to a specialist hospital and had surgery that night. The long term prognosis isn't that great. The problem was, as has happened to me before, it is so easy to get tunnel vision on a medical diagnosis that once set upon a treatment path, it is hard to stop it. In this case the fact she had just had a baby, and had had PND in the past it was assumed it was the same again. The early symptoms fitted with that diagnosis and so did the latter ones. Perhaps when the doctors visited she wasn't as bad as she was with us. Needless to say, there could have been a very different outcome.

Mental Health. Yet again it rears its ugly head again. The elephant in the room of health care and policing if you will. We all know it's there, we all know it's not dealt with properly yet everyone, until recently, has just hoped it will go away! If we bury our head in the sand, perhaps when we re-emerge and one of the other agencies will have dealt with it. Nope! It's still there. In Lord Adebowale's report, published this week, looking into the handling of mental health incidents by the Metropolitan Police, it highlighted a number of key areas for improvement. Most notably to me was the fact that far too many patients were being transported to either police stations or other places of safety without proper medical examination.

This shows why 999 services have to be careful about the risks they can be managing and think for themselves. Lord Adebowale sees a greater role for the ambulance service in responding to mental health emergencies irrespective of whether the police are in attendance. I think this should apply even if mental health services are in attendance, because I know from experience that basic physical health examinations are not as common as they should be.

Parity of esteem is mentioned in the report for physical and mental health - delivery on this is going to have to include not being too quick to assume things about patients with mental health histories to the neglect of their physical health. 

For further reading on the content in Lord Adebowale's report I recommend two posts by Mental Health Cop.  'The Adebowale Report' and 'My Reaction to Adebowale' both give a great insight into the reports contents and its impact and recommendations on police and the NHS. 

Invisible Wounds

"Female u/k age, tired, mental health problems"

"What's been going on?"

"About a year or so ago I witnessed something horrible. The death of a young man. I suppose, in the days / weeks that followed I expected to see his face in my thoughts. On the night itself I think the adrenaline kept me going until I got home. I just laid there on my bed and absorbed it all. I'd just watched someone die in the most horrific of circumstances and was helpless to stop it. Could I have done more? It was a helpless feeling that I just couldn't shift. His face. It was there all night. As the days past I thought about him less and less. I don't remember when his blood stained face stopped appearing in my dreams but within a month I'd say he was gone."

"So what's changed?"

"I found out his name. I was shown an online article about his death. I suddenly felt I knew who he was, what he was meant to be, what he had lost. His blood stained face came back. I'm plagued by flashbacks on an almost daily basis. I can't get his face to stop invading my dreams. It's weird though, now I almost take comfort in his presence. I can't imagine a day where he isn't present."

"And have you talked about this to anyone?"

"Sure, I've spoken to the people that were there and others. I feel like I'm the only one bothered by this. It's an overwhelming isolation which is eating away. Maybe it's just sleep I need. I can't remember the last good nights sleep I had. I've always had a problem sleeping but now it seems worse. After hours of trying I eventually get to sleep but once drifted off I'm awake again with an alarmingly predictability and the circle starts again. And again. Sometimes I just wake. Sometimes it's a nightmare. I picture his last moments again and again. Not from where I was though. It is as if I was watching it on TV. And I'm not looking at him really. I'm looking at me. It always ends the same though. His bloodied face, distorted, mutilated and swollen, lifeless. It's just......there."

I was clear just from looking at her eyes that this was taking it's toll. She looked drained.

"I have seen things that should upset me since but they don't. Maybe I'm hardened to it. I just feel numb. I try and keep busy to take my mind off it. The more tired I am the more I try and avoid thinking about how tired I am. I know if I think about sleep I'll think about him."

"What about your friends and family? Do they know?"

They do and they don't. They say they do yet I feel vilified for being irritable. Despite how I'm feeling they always have something trivial which is much much worse. Either that or I'm given happy clappy cliche advise about 'staying strong' etc. My mood swings back and forth and I try to only interact with them when I in a good place. It's just easier that way. I'll be fine, I'll get over it, I'm just tired."

"There is help available." 

A smile appeared on her face. Clearly I wasn't in on the joke.

"Yes I know, therapy, drugs, a sick note etc. No thanks. Can't be dealing with a disciplinary and P45 too! Work is a good distraction but they don't take kindly to mental frailties! Honestly, I'll be fine! Just venting!"

*          *          *          *          *

The 'patient' was me. The 'guy' was patient from '3am' (read). Post Traumatic Stress Disorder (PTSD) is very very real. It's often associated with the military due to the sights they see and the environment they are in. However, it is becoming more and more common, or more and more freely admitted in the Police and the Ambulance services. I have it, or had it, I'm not really sure. I'm also not really sure if it is ever something that goes. Maybe it is and it just hasn't gone yet. Maybe it is gone and what is left will stay. I don't really know. I wrote this post because of one I read on the One Police UK Facebook Page. It really hits hope what PTSD is all about. 

Despite what the PR department will say, there really is no provision within the emergency services for dealing with it. I tried accessing the 'free counselling' service that is offered and if anything just trying to make an appointment made me worse. Actually saying  'I have PTSD' was of huge importance, as cliche as it is. Not in the sense of standing in a circle and saying 'My name is....... and I have.....' but to admit that your mental health is affected is quite a big thing. Especially when until that point, you only ever had to deal with other people's mental health. In the ambulance service, the closest you come to your employers knowing something is wrong is going off sick with stress. And lets be honest, that only stands to give you a reputation for 'someone who goes off sick with stress'. i.e. chancer, faker, pulling a fast one, playing the game, abusing the system. It's true. That is how you will viewed by management. 

Admitting weaknesses isn't something that is done much in an environment full of black humour and bravado. Mess room banter probably wouldn't cope with someone saying 'actually no, I see his face in my sleep every night'. You just play the game. Put on the brave face and only confide in the ones you think won't judge your weakness. Let's be honest, it doesn't give much confidence in a new crew mate when a simple head injury causes you a panic attack. There a triggers everywhere, it's about learning to spot them and avoid them. Sadly, this job doesn't let you avoid seeing words like 'fall from height'. These are the invisible wounds that PTSD leaves behind.

The problem we and police have is it doesn't stop. There is always a new memory around the corner. '3am' has effected me. It was the last job of the shift, the last shift in a run and I had seven days off to dwell on it. Maybe PTSD in the emergency services is more about timing rather that the event. I have seen things that a more tragic and more disturbing since but they don't effect me. Part of me wishes that they did. 

Another traumatic death or a dead child. Maybe the one memory that stays is protecting us. If every traumatic sight we saw effected us in the same way we simply wouldn't function. There is very little time to process information. Very often I have written about seeing something which most people would see as probably the most traumatic event in their lifetime, only to go to another call five minutes later. Maybe this is why

PTSD isn't going away, it is a fact of life and although some efforts are being made to treat it and make it more accepted, until it is fully embraced and tolerated by employers little will change. Let's be honest though, the reason why it isn't widely tolerated as a genuine reason for sickness is money. We can't have our police officers and ambulance staff on long term sick can we! There are targets to be met.....

Don't forget to vote in the MAD Blog Awards 2013. I'm a finalist in the Best Writer category and all votes will be appreciated! VOTE NOW! Voting closes midnight tonight!

Does The End Justify The Means?

"36 year old make threatening to jump of balcony. HE IS VIOLENT"

Oh goody goody gum drops! Some mental health to end the shift! It'd been at least two hours since we had dealt with some! This time however, there was a little more gravity to the situation (excuse the pun). These 'jumping' jobs could literally be anything. I could be a Holby City'esque dramatic scene where we spend ages waiting while the patient is 'talked down'. It could be a cry for help where the patient has no intention for jumping and moves away from the balcony when asked. Or, it could be a major trauma waiting to happen and we don't know whether to leave our bags downstairs or go upstairs. The latter would be the least appealing and by far the most stressful but as always, it's a mystery until we arrive. These are things we think about on route to jobs like this. You need a plan for each outcome so you're not caught off guard!

We pulled up behind the police cars that were already there and looked up! Sure enough, about 4 stories up was a man leaning up against the railings of a balcony. About 20ft away were the police. Do we go up, do we stay down?! We went up and joined the police. The patient was shouting that he was going to jump and said he was fed with everything. The conversations between him and police went back and forth for a little while. Apparently this wasn't the block of flats he lived in so if he could be coaxed away from the railing s136 could be used to get him to a place of safety. Suddenly, without warning he ran! He ran down a stairwell, across a covered walkway and into the adjacent  block of flats! We all followed. By the time we caught up with the police, they were inside a flat. 

Inside was our patient sitting on his bed. His mood had changed from utter despair to one of anger and he would not be reasoned with. The police were explaining that he had to come to hospital to he indignantly replied:

"No I bloody don't!"

The 'yes you do', 'no I don't' playground argument went on for some time but at no point did he budge from his stance that he was going nowhere.

"You have no right to take me anywhere without a warrant. I'm in my own home, you need a court order to get me out of here."

He knew his stuff, the only power to remove him here and now was ours if we could prove that he lacked capacity under the Mental Capacity Act. His life wasn't in imminent danger now he was in his flat despite what had occurred previously. That was at least by the letter of the law. I went through the motions knowing full well that he would pass! And he did! He was able to rationalise his decision, he was able to retain information and he was able to explain in clear language that he didn't want to go to hospital and why! It is a frustrating part of mental health law. The only power available to the police was a s135 magistrates order that would need to be applied for by an AMHP to force someone to have a mental health assessment. We were stuck! Or were we......

We had a discussion with the police outside regarding what to do. No amount of pleading would make him come to hospital but the copper who seemed to be running the show said:

"We'll have to 136 him."

Alarm bells started ringing in my head! I'm no expert like @MentalHealthCop is but I know this can't be right!

"But he's in his own home so s136 is useless here."

"No, he was in a public place when we arrived so we can still remove him."

He said it with authority but I wasn't remotely convinced. Time to bring in reinforcements! Ah, the joys of social media and the professional connects Twitter gives us! Time to ask the expert! So, I texted @MentalHealthCop for some tactical advice!

Just what I thought! Needless to say I got bantered on Twitter for interrupting the rugby but I'll take that! It was what I thought but needed to be sure before I let me thought be heard. Before the times of Twitter there would be no immediate contact with people from other professions and I think it's great that it can be used in such a positive way. 

So, back into the flat I went. 

"Section 136 can't be used, he's exercised his liberty to remove that option. We'll need another plan. I know he's vulnerable and we've all heard him threatening suicide but I don't see there is much we can do now he's here."

"We are sectioning him, we are just waiting for the van to arrive."

Clearly I wasn't going to be listened to so we stood outside with our tails between our legs and watched the illegal kidnapping unfold. It wasn't a pleasant thing to watch, distressing to say the least. Seeing someone restrained in their own home, removed against their will and screaming for all and sundry to see was not in the patients best interest by any stretch of the imagination. He was already in a very fragile state, how will this impact on his future treatment? I don't know how the police involved documented and justified their actions but they certainly won't have said they sectioned him from inside his own dwelling. We watched as he was loaded into the van and my crew mate travelled with them while I followed. 

I know that the patient needed hospital, and as it was he was taken (albeit under an illegal section) to the mental health unit but it is NOT a case of the end justifies the means. Or is it? The mental healths laws and police powers that are there, are there for a reason. Breaking these rules only goes to put further barriers between patients the services available to them. This patient will never have trust in the police. I trust the police and I know this was one decision made my one policeman but a patient wouldn't see it like that. He knew his rights and he knows his rights have been illegally removed. Unfortunately, it will be his word against the police and who would believe a depressed, schizophrenic with a long history of crime and drug use. Rules are rules and laws are laws. He has been punished previously for breaking the law. What example does it set when the people who uphold the law are technically breaking it? The flip side is that in this instance the police were doing what they felt was right and were trying to act in the patients best interest. 

This job will also damage the image of the ambulance service in this patients eyes. We were party to it, guilty by association if you will. Sure, it's only one patient but that's not the point. Mental health is a challenging thing for all services to deal with. Like I have said many times before, working together and having an open dialogue with all services is essential but each service has its own responsibility to adhere to the rules, apply them within the framework that already exists and always act in the patient's best interest. The latter is where the grey area engulfs us all. Who really knows what is in a patients best interest? It will always be personal opinion and that will never change. You tell me, does the end justify the means?

I'm just a Fire Starter

"25 year old female, mental breakdown, setting fire to her room"

This had all the ingredients to be 'one of those jobs'. By that, I mean a job needing diplomacy, co-operation from mental health services and patience. It may also need police and fire, the latter of which I could happily do without! Mental health jobs kind of excite me in a weird way. I know that it will be tough to deal with, I know I will end up getting frustrated and wound up by the lack of options available to me and ultimately I know I'll probably end up blogging about the shoddy mental health care that patients have access too! Then again my fascination with mental health and psychology makes me gluten for punishment!

We pulled up outside to see a police car parked up. As we got out Trumpton pulled into the road, sirens blaring, causing curtain twitches galore to appear in their windows. Bear in mind it was 2am. There was absolutely no need for sirens on residential streets, but that's 'pet rescue' for you. As we approached the front door one of the coppers came out. 

"Evening ladies, she's upstairs, I'll send Trumpton back to bed!"

It's as if he was reading my mind! I headed up the stairs and followed the noise that was coming from one of the rooms. It was a halfway house for people recently discharged from the local mental health unit and there was an office at the end of the landing with a rather fed-up looking woman sitting inside. She just pointed at the room where the noise was coming from with a shake of the head. 

The police explained that she had been discharged for the mental health unit about 6 hours previous and had been 'freaking out' ever since she arrived here. She had been setting fire to documents and her mediation and was doing so because the voices in her head were telling her to do so. I made various attempts to talk to her without success. I like to think I can talk to mental health patients, some can and some can't. Normally I am able to, but sometimes patients either won't engage at all or will only engage with people who have gained their trust. In this case, she wouldn't engage with anyone. Stupidly I turned my back to talk to my crew mate and a water bottle came flying across the room and got acquainted with the back of my head. No cut, no lump, no harm done, but still.....uncalled for!

The police were savvy enough to know that jumping on her for assaulting me would have been of little benefit so it was ignored. She was scared, unsettled to say the least and was surrounded by police and an ambulance crew. We were all there to help her but I imagine it didn't feel like that. She said she wanted her case worker and that he was back at the mental health unit. As far as we were concerned, that's where she should be and as she had only just been discharged the plan was to take her back. With that suggestion she frog marched herself out of the room and downstairs towards the ambulance. I simply followed! That was easy!

Once on board we convinced her that it was in her best interest to let us check her over medically so that the unit would have no qualms about accepting her. She was medially fit as far as I was concerned. No alcohol in her body, no unauthorised drugs, no injuries, nothing! Excellent! Off we went, police in toe! 

So, there we were, 1 x patient, 2 x ambulance staff, 5 x police officers and 1 x mental health worker from the half way house. All 9 of us bundled into the lobby of the mental health unit. Behind the security glass that would rival most banks was a collection of staff. We were ushered round to the door to hand over. I explained what had happened and why we were her. Her response:

"She's not coming in here."

"Why not?"

"She's been assessed and discharged. There is nothing wrong with her mentally. It's just behavioural problems and attention seeking."

"We are called to a young woman, discharged from a mental health unit hours previous who states she is hearing voices and is setting fire to her room. She has anti-depressants and anti-psychotic medication. She clearly does have some kind of mental health problem and that is why we are here."

"Well she doesn't. I assessed her myself, we aren't here to sort out peoples behavioural problems."

"But you are here to help sort out voices in someones head."

"She doesn't have voices."

"She says she does."

At this point, one of the coppers took over.

"We believe she is suffering a manic episode, the employee at the mental health half-way house agrees. If she doesn't have any mental health problems why are you putting her in a building for people recovering from mental health problems?"

After a brief pause..... "She'll have to go to A & E first. We can't accept her until she has been cleared by A &E"

"A minute ago you said you couldn't accept her because he hadn't got anything wrong with her! We have brought her here to you, this is the most appropriate place for her and the fact you discharged her less than 5 hours ago, to me, makes it a failed discharge. I suggest you re-assess her because your initial lack of diagnosis has been found wanting."

Another brief pause...... "Bring her through."

HURRAH!!!! Oh the joys of a mental health unit! To be fair, I knew it was never going to be easy! With my blood pressure suitable raised and my mood suitable lowered we trundled off to the ambulance so I could have an expletive filled rant in private! Good times!

The Sixth Sense

"38 year old female, ? assaulted, ? pain after C-section"

I think it's fair to say that everyone who works on the front line of the ambulance or police service develop a sixth sense regarding the general public. You can tell when something isn't right, you can tell when someone is ill and the police can tell when someone is up to no good. It didn't however, take a well homed sixth sense to realise something was amiss with this job. It had come from the police and every bit of information we received had a question mark in front of it.

'UPDATE: ? Intruder in house, ? Partner on scene, sounds distressed'

'UPDATE: ? Baby on scene, ? sexual assault, police now on scene'

It all just seemed a bit odd! There was snippets of information but no real presenting complaint or firm idea of what we were walking into! Nothing new there! We pulled into the road and headed up to where the police car was double parked.

As we approached the front door, it swung open. One of the coppers was standing there and we shared the police / ambo look! The look that says 'Hi, how are you, glad your'e here, this is a load of rubbish, I wish I was at home, why do we do this job?' in one half smile, slight nod of the head and a aura of resignation! We walked down the hallway to the other copper in the living room. Again, we shared the look!

'Hi guys, this is Jayne. Jayne had a baby 2 weeks ago and today is scared that someone is going break into the house and try to get her pregnant again.'

With a rather smug, gloating look he backed out the room leaving me to do the questioning. Jayne was sat on a chair, rocking back and forth slightly, her strawberry blonde hair was tangled and messy and she had a very intense look in her eye. I introduced myself and my crew mate and asked how we could help. She responded in kind and introduced as to her 'partner' Eamonn, who was sat in the arm chair on the other side of the room. He seemed totally unmoved by the whole situation.

Jayne went on to explain how she had given birth to Layla 2 weeks previous, by cesarian section. Lying in a moses basket next to Eamonn was Layla. All of the commotion hadn't made her cry, she just laid there, eyes glued to the ceiling. Apparently, for the last day or so Jayne had become convinced that someone was trying to break into her house to impregnate her. She had a real look of fear in her eyes but constantly tried to reassure us that she 'wasn't mental'. It's always awkard to ask about mental health history but I had to. She denied any and said she only suffered with mild depression. On cue one of the coppers handed me a discharge summary from the local mental health unit. A quick flick through revealed that Jayne was a medicated paranoid schizophrenic who frequently suffered from manic episodes.

It was of little surprise but when questioned about it she vehemently denied it, telling us they were wrong. She said she had been bullied by the psychiatrist and they had a vendetta against her. She said the reason she was so upset today was because Eamonn was angry that other men were trying to break in and impregnate her. I told her that I was sure that he wasn't angry but she snapped back 'well he's not talking to me'. He had nothing to say to the accusation. The whole room felt the air of awkwardness at the silence that ensued. We didn't know what to do or how to act. Family disputes are often difficult to be stood in the middle and this was no different. Eamonn's apathy was overwhelming. He had no response to her accusation and just stared blankly towards us.

"Would you prefer it if Eamonn wasn't here? Or maybe come to the ambulance to talk in private"

"Yes, take him away she snapped."

With that, one of the coppers walked over and picked up Eamonn under his arm and walked out the room. As Eamonn's leg hit the door frame he let out a squeak. 

Oh......didn't I mention?!

Eamonn was a blow doll.........

With Eamonn gone, Jayne got up and walked over to Layla and begun stroking her face. I couldn't bring myself to play along with the charade of talking to the 'My Little Baby' doll and suggested we went to the ambulance. She refused and said she wasn't going anywhere as she needed to protect her house and her family. There is no training for this type of situation for us or the police. You just have to improvise, adapt and overcome. Jayne clearly needed help desperately but being in her own home our hands were tied in the short term. Section 136 was useless and Section 135 would take time so it was the old fashioned good cop / bad cop routine with me playing the role of good cop! She didn't have capacity as far as I was concerned but there were less restrictive options available to us. Her life wasn't in imminent danger so we didn't really have the option of removing her against her will. It would also cause her more distress and we didn't want that.

I explained that I wanted her to come voluntarily to get help and talk to someone. She said no. She said she wanted her baby back. With that she pulled up her top and revealed a wound. It was a healing wound from a cesarian section. Her notes hadn't revealed anything about a pregnancy or a baby. 

"Where is your baby Jayne?" I said with real concern!

"They took her?"

"Who took her?" The copper said.

"Social services."

With that she handed me her hospital notes from the maternity unit. Twelve days ago she did give birth to a baby girl called Layla. She had been having frequent psychotic episodes since her partner, Eamonn, had left her and the baby had been taken away due to Jayne's inability to care for her. Clearly though there was no one caring for Jayne! Something as traumatic as having your child taken away would leave anyone distressed but for a paranoid schizophrenic already suffering manic episodes was a recipe for disaster. She certainly wasn't in a position to be left alone at home! What were they thinking?! 

Luckily for us, the fear of being put in handcuffs and taken away meant after some convincing she was willing to go to the mental health unit voluntarily and seemed keen to get some help. She refused point blank to go to A & E saying she'd rather die, so we decided to present to the mental health unit uninvited and deal with the staff when we arrived! 

As was expected they kicked up a stink about her needing to go to A & E first. They also wanted to know why she wasn't under section! It is as if they have never read the mental health act! After much arguing they eventually accepted her. Being reminded by the police that their choice to discharge her are a two night stay was a) irresponsible and b) the cause of us being here, swung it our way. We left Jayne in their 'care' hoping desperately that she would get the help she needed.

This job had two sides to it. The funny and the sad. It's extremely hard to keep a straight face when introduced to a blow up doll and a 'My Little Baby'. What do you say to that?! We certainly had a good giggle about it afterwards and I have no doubt it would be the talk of the mess room at the police station! It certainly was in ours. Some situation you have to laugh at purely because it's how our much vaunted black humour works. It's how we all rationalise the stuff we deal with. We are also well aware of the upsetting side to this job. The woman who's husband has left her, who went through the trauma of giving birth and having her child taken away. Having that mother and baby bond destroyed. Then the pain of being shipped back to her house. The house she shared and had expected to raise a family. The house with the babies bedroom as the constant reminder of what had happened. Pure torture. That alone would be enough to tip the most stable of people of the edge. She had been abandoned by the system, left to fend for herself and unfortunately for her, she had only been able to find solace in a blow up doll. This job was a stark reminder of just how much work is needed to bring mental health care up to the high standard of the rest of the NHS. 

Stressed Out

You'll find that normally, when I'm talking about the Daily Mail, it's under the heading of the 'Daily Fail' and I'm generally less than complimentary about their flawed research and criticism of people who should be getting praise. This time however, their article about sick leave for stress in the ambulance service is mainly factual and really highlights the issue. Obviously, the headline calling us all 'ambulance drivers' made my blood boil but that rant is for another day! So, the article in full.....

The number of sick days taken by stressed-out paramedics has soared by 40 per cent in two years. 

New figures released by ambulance trusts show they took 43,680 days off because of stress during 2011-12 compared with 31,268 in 2009-10. 

The number of ambulance workers suffering from stress has also increased by 42 per cent during the same period, from 728 to 1,035.

Union bosses say the widespread closure of hospital A&Es and rising numbers of 999 calls has taken its toll on ambulance crews, who are breaking down under the stress of the extra workload. 

Research by The Mail on Sunday has revealed 33 casualty units across England and Wales have either already closed or are under threat of being closed or downgraded.

The number of 999 calls has also risen by more than ten per cent in a year for most ambulance trusts across the country.

Adrian Gilbert, Acting General Secretary for the Association of Professional Ambulance Personnel, said: ‘Ambulance staff are run ragged on shifts and it’s no wonder the number of staff off for stress has increased. 

‘They are coming in to do a 12-hour shift and instead it has gone on for 14 hours. You have got hospitals closing A&Es across the country and this means ambulances are having to go farther afield.

‘So instead of a five-mile journey to the nearest hospital, it can sometimes be a 25-mile journey.

Threat: There are growing concerns that closures and increasing numbers of calls are having an affect on drivers, as research shows that 33 casualty units across England and Wales have either already closed or are under threat.

‘If there are three or four vehicles out of the area, it means the ambulance crews who are still in the area are being run ragged.’ 

The new figures come after a Freedom of Information request to England’s 12 ambulance trusts.

Last week Shadow Health Secretary Andy Burnham revealed ambulances were being forced to wait with patients outside A&E for more than five hours – because of congestion inside.

It is a massive problem and one which can't be ignore, however, I don't think it's as simple as blaming it  on being run ragged. There are a number of factors involved in the high and rising amount of stress leave taken, some that won't change and some that will. 

As eluded to in the article working conditions plays a huge part. 14 hours without a recognised break is a major problem and as highlighted in various news articles about crews being on rest breaks, there is no easy solution. Well, there is, give us breaks! Playing devil's advocate though, for so long, the ambulance services have become accustomed to have the staff available all shift, that if you suddenly take them away, there would be a huge shortfall in resources. 

Being at work with no breaks, alone, isn't the cause of stress but the culmination of things that are done to make our days harder all add up. Waiting for hours in the corridor in hospitals is frustrating. Not our fault or the hospitals but for the hospitals to ban ambulance staff from drinking tea or coffee and refusing to allow us to heat up food in their microwaves means we are left with only cold food and drink for 14 hours when it's minus 3 and we have to wear short sleeved shirts!

Then there is the job related problems. Arriving at scene 3 hours after someone called an ambulance and getting the ear bashing. Chasing your tail for hours on end with cancellation after cancellation, being refused to be stood down to go to the toilet despite not being at a hospital for 5 hours. Being made to transport patients with the fuel light on because you've had 4 requests for fuel turn down. Having your activation times monitored, being harassed to make yourself available quickly at hospital and being badgered when you have spent to long on scene with a patient. Then there is being rushed out at the start of the shift without all the kit you need and the guarantee of NEVER finishing a shift on time. EVER. On their own, they are no real biggie but when it's ALL happening every single day, combined with some of the horrors we see, the abuse we take and the emotional turmoil we can be involved with, it is of little surprise so many are off sick. Or even worse, throwing the towel in all together.

Finally, there is the issue of sick leave in general. The ambulance service has a tradition of high sick leave. No surprise when we are around sick people all the time and don't eat properly but also because of the way sick leave is managed. There is a huge fear of being off sick because of the disciplinary procedures that are in place. If you are off for a week with Norovirus in December and then in January you get another bout of D & V and are off for another day, you start the disciplinary procedure. Another other time off in the next 12 months and the disciplinary process will be escalated. I was hospitalised whilst at work a while ago and came back to a rather threatening letter in my pigeon hole. This is just one example of many which I think go a long way to causing people to work on regardless until they are burnt out. The other issue this policy raises is that of people playing the system. Across every service there are the people who are off for long periods every year, often with stress, and do so year in and year out. Stress is something that can easily be faked and allows people to be off for considerable time with little consequence. The ambulance service has become a victim of it's own management strategy which targets the wrong people.

With all factors at play the amount of sick days will continue to rise year on year. Like everything within the NHS there is too much focus on cure rather than prevention and because of that, it's the staff that are targeted for multi-agency failings and this in turn leads to a workforce of disillusioned, down trodden, tired people. 

http://www.dailymail.co.uk/news/article-2272517/Stressed-ambulance-drivers-43-680-sick-days--40-rise-years.html#axzz2Jp4ocYMu