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. 

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?

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. 

Policing Violent Healthcare

It is with great pleasure that I can welcome back Inspector Michael Brown, highly revered police blogger of Mental Health Cop and award winning Tweeter @MentalHealthCop to guest blog on Trying My Patients. His work on mental health policing has won him acclaim across the country and is highly regarded as 'the go to guy' for all things mental health. Enjoy!


***WARNING: This post contains some graphic descriptions some may find distressing ***

"23 year old female, self harming"

The area where I worked as a sergeant had a hostel on it for women. The people who stayed there had various backgrounds, most of them troubled. It included domestic violence victims in need of temporary accommodation; those rehabilitating from substance use / abuse as well as being used as a 'step-down' facility for people with mental health problems. You can imagine the police service were there most days for a range of reasons.

I went there one New Year's Day with a probationary police constable I was working with - she'd won a "shift with the sarge" and it was my evening assessing how she was getting on now she was 'independent' of her tutor constable. It was a night shift, just after midnight that we were called to staff asking for help with a resident who was self-harming. The name of the woman was given to us over the air, because she was a "regular user of police services" owing to her propensity to get drunk and self-harm and she became foul and abusive when was she did. She was already 'banned' from one Accident & Emergency department in the city because of her relentless abuse of medical staff and she was flagged on the ambulance systems as someone who should always attract police support. 

We turned up quite quickly. I'd remarked to my inspector just before being despatched that the evening had been quite dull so far - as 01/01 night shifts often are - and flippantly stated we could do with a 'decent job' to keep us all awake. The inspector had stared at me the way I often now find myself staring at ignorant young sergeants!

We were ushered by a member of staff through the corridors of the hostel and into her room. We walked into what first looked like a blood bath: she'd cut her arms to shreds - she was incredibly drunk, bleeding heavily and muttering whilst banging her head off the wall. The cuts were not superficial. You could see the flesh cut centimetres down and the skin was widely split across the wound. Staff had attempted first-aid and to at least get dressings covering the injuries. She'd pushed them away and hit one of them, determined to hurt herself more. They sort of looked at us as if to say, "Over to you." We hadn't been told that ambulance were on their way, so just in case, I asked again.

She was scratching at her wounds, as if to pull them apart - I noticed a knife and a razor blade on the bed, red sheets soaked in blood. I did what all good sergeants do and patronisingly said, "Let's see how you handle this, then!" and let my probationary constable try talking to her. She did really well - the fact it had no effect whatsoever was nothing to do with any lack of empathy or effort to engage: it was almost certainly going to fail. I remember saying, "Let's just get the weapons away" and we each took hold of an arm whilst we passed the implements to staff.

We sat, holding her arms, getting covered in blood to the wrists waiting for ambulance. They turned up after about ten minutes. They tried what we'd already tried and failed and were also shouted at and abused for trying to get covering dressing on the wounds. It was explained again and again that she would need to go to hospital and it was me doing the telling after what seem like ages of trying to persude. This only seemed to make her more agitated. I found out later that the woman had a history of being sexually abused, had serious PTSD and personality disorder problems and she had real difficulty with men, especially male authority figures. Great! - nothing much I could immediately do about being a uniformed male police sergeant built for rugby with a special line in not messing about!

She was still bleeding, but the paramedics had said there wasn't a lot they could do. We tried to lift her to her feet, but she pulled away. Her arms were slippy because of the blood and she was frantic. She was going to have to be handcuffed otherwise we couldn't move her. Watching paramedics trying to just wrap something 'round her arms after we'd handcuffed her to the rear and she was starting to get violent wasn't happening ... she was just going to have to be shifted as is.

I remember looking at the paramedics and without speaking we were each thinking, "She's going in your vehicle, isn't she?!" Both of us looked horrified at the idea. "Come on, mate - she's drunk, injured, mentally ill and restrained by the police." No - they weren't having it. She was too violent to be conveyed in an ambulance and this wasn't for discussion apparently! Today, I'd have said, "One of you get in the police car then!" but as an ignorant young sergeant it didn't occur to me. So she went in a police vehicle without paramedics who resumed to something else - Costa Coffee, I'd imagine - wiping their hands of this healthcare situation and off we went to the nearest A&E.

Turns out, it's the one she was banned from. The receptionist looked at us and tried to start saying "No" but I said, "Come on, she's handcuffed and restrained by two police officers, she's bleeding and we can't move her miles to another A&E -somebody's got to see her, surely?!" It was like gatecrashing a party - you were in, but you knew you weren't really welcome. No coffee offered this time, as it often was in A&E. They cleared out a cubicle of its trolley and 'stuff' and placed a thin mattress on the floor. The woman had become more hysterical as she'd arrived in the bright lights of A&E and started head banging. Two other female officers from my shift had arrived and they took control of her whilst we got our breath back. She was finally able to be safely searched by two female officers, who'd had change to get "gloved up" and more razor blades were found.

After about an hour she was seen but she spent the whole of that hour trying to headbang and being restrained to stop her doing so. It was an hour of fighting police officers so who knows what kind of physiological strain she was subjecting herself to. I'd now be saying various other things to nursing staff, about NICE Guidelines and my fears and restraint related injury, but at the time I had no idea about these things. She spat towards the Doctor when he arrived and abused him severely so we were shortly afterwards ordered to leave the A&E department!! No healthcare at all. "Get her out!"

As the four of us, placed this poor soul back in a police vehicle - this time a caged police van for the safe transport of disturbed detainees, often mistaken for a 'dog van' - we had two choices. We try another A&E or go to police custody. I thought about asking the grumpy custody sergeant that night whether he'd like to detain a physical injured, mentally ill, untreated intoxicated detainee?

Another A&E it was: a four mile drive off our division to the area where I'd worked as PC. It felt like familiar territory as I'd almost lived in this A&E for four years. The woman was placed in a side room and actually became somewhat calmer, escorted by the two female officers who had come to help. My partner that evening and I started to think about getting ourselves cleaned up from blood and spit and I was asking this young officer whether she'd had her HepB jab from her GP - police officers don't get routine HepB, you have to ask your own doctor - she hadn't! "I strongly advise you ..." etc., etc.. Got to look after your cops.

The woman went on to get assessed under the Mental Health Act and was sectioned sometime late on the 02/01 after many hours being guarded by the cops and resented by the NHS.

But it was as we stood discussing HepB that the evening took a really interesting turn: A nurse tapped me on the shoulder and asked, "Officer, could you just speak to this woman, she's been shot!" I saw a young woman holding up her hand and you could clearly see a gun shot wound. it was Sophie Ellis, Charlene's sister. At that stage I had no idea who knew what about the incident so had to treat it as me being the first police officer to know ... well, I had asked for an interesting evening and my inspector said, "I told you to keep your mouth shut!"




To read the Mental Health Cop blog check out his website! Well worth a read! It's the one-stop-shop for all things mental health.

The Irony in Crisis

"29 year old female, suicidal, having a break down"

Not wishing to sound like a broken record, mental health is a huge part of what we deal with, yet in terms of training it's what we get least of. I suppose it draws a parallel to the cost mental health has on the NHS compared to the funding it receives. Being able to talk to patients suffering a wide range of disorders is something you either a) have b) get with time and experience or c) never have. I like to think I'm somewhere between A and B with still a lot to learn. My abilities aside, I still have to treat these people regardless of what I know about their condition or mental fragility. 

It was about 8pm when we got the job so traffic was an a minimum and we were on scene within a few minutes. As we entered the road we got a message sent from control.

"Patient now on window ledge, husband thinks she will jump, police on route"

As we pulled up at the house a man came running towards us from the property. I guessed by his mannerism that he was the husband but he got so close to the door I couldn't open it to find out. I had to usher him back just to open the cab door! We grabbed our bags while he frantically spoke (I'm sure he was talking faster than his lips were moving). The gist of it, was his wife was a paranoid schizophrenic and a manic depressive and was suffering a crisis because she had forgotten her morning medication. She was now locked in a room and 'threatening to jump'. We have no training whatsoever in talking down people wanting to jump but I've seen The Negotiator, how hard can it be.....?! With much intrepidation we headed up the stairs. The door to the bedroom was indeed locked, so I knocked. 

"Hello, it's the ambulance service, can you let us in so we can talk?"

To my surprise the door swung open and we were invited inside. On top of her apparent suicidal thoughts she was having a panic attack, never helpful in any situation so that's what we dealt with first. Once she was calm and able to speak in full sentences we found the root of the problem. She was scared of being taken away again. That fear is very common in mental health patients and often due to bad experiences where forceful removal and restraint has been used previously. My thoughts on this and restraint are best left for another day, but they were our patients main worries and cause of crisis. It was clear she needed treatment, be it at home or in hospital. A & E was the last place I wanted to take her and last place she wanted to go. She denied being suicidal and said she was just very depressed and her missed medication had caused her to hear voices and freak out. She wanted to talk to someone. Obviously, I was there, but my knowledge of what to say is hugely limited. She needed a professional. She needed a Crisis Team.

As luck would have it she had the number for her old crisis team. I say old, because they had discharged her a week previous saying she didn't need ongoing treatment. Hmmmmm. Anyway, I phoned them expecting either a constant ringing or a patronising message followed by equally drab digitised music. I was wrong on both counts! The phone was answered within seconds! A lovely, helpful lady who was familiar with the patient gave me a full history about her. I asked if a crisis team could come out to see her. She said they only do home visits until 9pm and as it was now 8:45pm I didn't argue. I asked for advise, wanting to find out what options were open to us and whether she felt our patient would benefit from hospital. She told me that she should be seen, if not tonight, in the morning and suggested she spoke on the phone with an AMHP. Brilliant, this was going well! 

"Shall I pass her over then?"

"I'm just about to see a patient, if you call back in 10 minutes, we'll have a chat with her and see if we can find space to admit her here"

"OK, brilliant, thanks for your help, do I just ring this number again?"

"Yep"

"OK, speak to you soon"

I told my patient the plan, she was happy, I was happy! Maybe crisis teams are not all bad! I started doing my paper work while my crew mate did her OB's, just to make sure there was nothing untoward going on. There wasn't. After 10 minutes I phoned back.......no answer. I phoned again......no answer. I phoned a third time.......eventually a guy answered the phone. 

"Hi, it's Ella Shaw from the ambulance service, Jane told me ring back in 10 minutes so she could talk to my patient and arrange an admission"

"Janes gone home"

"Erm.....I spoke to her 10 minutes ago, she told me to call back"

"Yeah, she left 5 minutes ago"

"Well is there someone else my patient can talk to?"

"No"

"So what are we supposed to do?"

"I don't know, that's up to you"

I spent a few livid minutes demanding names etc and ranting away but it was pointless. On learning the news that no one was free to talk to her, our patient started having another panic attack. She uttered the words 'I might as well kill myself' and 'suicide' amongst others, which until now, she had convinced me that she wasn't. We had no choice but to take her to A & E. The prospect of this started a chain reaction we were powerless to stop. She refused, we said she had to, the police arrived, she freaked out about being taken away, she became violent, she was put in handcuffs, she was sectioned and taken to hospital, screaming and shouting the entire way. The very same person who I had spent 45 minutes with discussing her dream of becoming a midwife or a pathologists assistant. It was heartbreaking. Yet again, another mental health patient let down by the system. Let down by the services there to protect her. She didn't need sectioning, she didn't need handcuffs, she just needed to talk to someone. What will happen about this? Nothing. Why? Because ultimately no one cares enough to fix it. There is nothing more frustrating. Yet again, a patients welfare is dictated by a shift time and the misfortune of time of day. What's the bloody point? A crisis team should do just what it says on the tin. Be there wherever and whenever a patient is in crisis, come rain or shy, regardless of whether it is a convenient time of day. Until these 'crisis' teams (and crisis is not meant to be ironic) are accountable for their failings, nothing will change. They are not all bad, but like everything in the NHS, if it is well run and done properly, we as an ambulance service rarely get to see it. Instead we just end up hitting our heads against the wall passing the patient from pillar to post. Is that what the NHS is for?!

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!