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. 

OCD, Trees & GPs

"50 year old female, GP visited, states patient wants to kill herself by starvation, states patient's partner is assisting her suicide attempt. To be taken to the nearest A & E"

Well this job was pretty self explanatory. A GP (one that'll soon be in charge of the NHS) went round for a rare home visit, he couldn't get her to agree to hospital, so booked an ambulance. He did that in the full knowledge that if she refused hospital, with the information he had given us, we were now responsible for her! He knew she would refuse but it's easier to pass the buck. C'est la vie!

It was a baking hot summer's day, we had spend the morning broken down, sitting out outside the sweltering ambulance eating ice cream! It was a small victory! The second our vehicle was fixed, this job was sent to us. We headed to the address and went in to the building. The patient was lying in bed, only her head visible, the reason she wanted to kill herself was because she was fed up with her Obsessive Compulsive Disorder. She couldn't leave the bed without a 1 hour ritual which made going to the toilet the hardest and, I imagine, the most frustrating of tasks! So, the suggestion of hospital was not one she remotely considered. She refused all observations, any treatment and any transport. She just wanted to be left at home to die. I have seen a lot of patients with OCD but her's was severe. While I sat there talking, I observed the struggle she faced to do the simplest of tasks. She opened a brand new pack of 10 cigarettes wearing latex gloves. She removed a cigarette, cut the tip off with the scissors she removed from a sandwich bag and lit it with a match. She was then unable to smoke the remaining 9 as the pack was already open. Expensive habit!

Our problem was the age old one of capacity. In legal terms its a 'grey area'. The first question on our capacity assessment tool is 'Is the patient free from any external pressure?' Unfortunately we had already been told by the GP that she wasn't. The partner is of the opinion that starvation is a pain free way to die and as our patient was bed bound, by not feeding her, technically he is assisting the suicide attempt, thus preventing her from being free from the aforementioned external pressure! Sigh! We talked and talked about hospital and how we could make it easier for her. We agreed to 'sterilise' the ambulance by covering a seat in plastic bags, we fetched a 'sterile' infection control suit for her to wear and after a few hours we were making progress. She was out of the covers and had the suit on her legs. Then the partner returned:

"She doesn't want to go to hospital"

With that, all our good work was ruined. Within seconds she was back in bed, head poking out above the covers. We requested the police and one of our officers, as by this point we had been on scene for 3 hours and there was no end in sight. While waiting for the  grown-ups to arrive some family and friends of the patient arrived 'to say their goodbyes'. Please note, she was not about to die, nowhere even close, but the fact she wanted to die meant I was not happy leaving her, especially in the 'care' of her partner. Once the police arrived we had a lengthy discussion about what to do. A sectioning seemed the likely option. Being in her own home meant we were limited to what section we could use. We went back inside to discuss said sectioning and stumbled upon all 9 people who were now in the house singing 'Kum ba Yah' complete with guitars and drum. It transpired that the big tree outside the property was being felled by the council the following day, so they are all meeting up to sing it a song and have a group photo with it. Yes, a group photo, with a tree! Hippies!

Trying to arrange a sectioning on a Sunday afternoon took hours. Eventually it got to the point where all we needed was her GP, the one who phoned us! We had the police, we a had an AMHP, we had an OOH GP, all we needed was hers. Bare in mind we had now been on scene for over 7 hours. My shift finished 3 hours ago, we hadn't had a toilet break, we were more than a tad annoyed by now and then the following conversation occurred:

Ring ring...

"Hello"

"Hello there, my name is Ella Shaw from the Ambulance Service. Is this Dr Smith?"

"Yes, how can I help"

"Well, we are with Miss Jones, who you requested go to hospital earlier"

"Ah, OK, yes I remember"

"Well, we are trying to arrange a sectioning. We have the police, an OOH GP and AMHP on scene, we just need your signature so we can take her in as you requested."

"I'm sorry, but i've got plans this evening, afraid I can't help you."

What?! Have you?! Dont we all?! What a complete waste of time, we had spent most of the shift there, as had 2 policeman and all because the GP couldn't be bothered to do his job in the first place. The outcome was that the patient stayed at home, our officer in my opinion copped out and gave her capacity to refuse. He asked the police to take the partner out of the property and re-assessed her capacity. He came to the conclusion the external influence was now gone. It wasn't, it was standing outside 20 feet away. We were left bewildered and utterly frustrated. The doctor on scene didn't believe she was in immediate danger so a section 135 would be arranged the following day. At least she would get treatment but that didn't help alleviate my foul mood. 

This job did highlighted the issue of OCD. It was the first time I had seen it in such a debilitating way. When people think of OCD this think of excess hand washing, obsessed with tidiness, flicking a light switch on 'X' number of times before entering a room but it is much more varied and severe than people may be aware. It is an anxiety disorder characterised by intrusive thoughts that produce unease, apprehension and fear. The symptoms can vary from excessive washing and extreme hoarding to alienating nervous rituals. It is a mental health disorder that is far more common place than people may be aware and is now the fourth most common disorder to be diagnosed. It is now diagnosed  nearly as often as asthma and diabetes. Very rarely is OCD a stand-alone problem. It is often accompanied by depression, generalised anxiety disorder, anorexia, Asperger syndrome and frequent panic attacks amongst others and like all the above, it requires treatment. Our patient had gone without treatment for many years and the consequences were evident in the way she was now suffering. Like with most mental health disorders early recognition and early treatment is the best way to produce a positive outcome. No one wants to enforce a sectioning and no one wants to drag someone out of their own home for treatment but it is a necessary evil. To prevent this, services and referrals need to be more readily available and easily accessibly. I'm sure i've said that before! Why bother though, it's only OCD eh?! Hmmmm!