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.

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

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 Three Stooges

“43  year old female, chest pains”

This job set the tone for what would turn at to be a very familiar night shift. I exhaled in frustration when I saw the address. It was one of the many regulars on our patch. She was a wine-drinking alcoholic; she always called for chest pains, always went to hospital and was always rude and obnoxious. Tonight would prove to be no different to the norm. We stomped up the concrete stairwell, navigating our way past the vomit on the stairs. Lush! Her door was wide open like it always is. We walked down the landing to her bedroom like we always do and found her lying on her bed smoking a fag like we always do. Then followed a very familiar conversation.

“Hello again”

“Alright luv”

“What’s the problem tonight?”

“I got chest pain”

“Same as before?”

“Yeah”

“Can we do an ECG?”

“Yeah, go on then”

We do the ECG and all her obs. They are all normal like always. 

“Shall we pop you up to hospital?”

“Yeah, I need to see a doctor.”

"Still got the pain?"

"Nah, but it should be checked out."

So, without any fuss he all walked (she staggered) arm in arm to the ambulance. We drove to the same hospital as we always do, where I gave the same handover as I always do. On to the next!

“37 year old female, suicidal, taken an overdose, police on scene”

We all say that the first job sets the tone and shifts have a theme but they really really do and I don’t know why! This address was also well known to us. It was the residence of the most abusive drunk in our area. I say abusive, she abuses the police and most ambulance crews but for some unknown reason she loves me! We pulled up next to the police car, which seems to be a permanent fixture outside her flat. In the hallway outside was one of the coppers.

“Good luck, she kicks off every time I go inside”

Sitting there in her underwear and dressing gown, she swigged vodka while smoking a roll-up. Her face lit up as soon as she saw me.

“Heya babe, tell the pigs they can go and you don’t need them”

As much as calling the police 'pigs' wasn’t acceptable, in all honesty, their presence was only going to make things worse and I knew they’d be only to happy to leave.

“I’m happy to deal with this, I know her well, she’ll be fine with me”

They were only too happy to leave and were gone near enough before I'd finished the sentence! It was the same story, drinking vodka to excess, self harmed her forearms, refused hospital and then there was a 45-minute battle to convince her to go. Sometimes she wins and sometimes I win. Tonight I won. Hospital was the plan and all we had to do first was go through the charade of collection her ‘valuables’ (vodka) and hiding them so they can’t be stolen. After completing this ritual we headed off and handed her over to the less than enthusiastic nurse. 

We left the hospital to go and get fuel and hopefully a Wild Bean coffee and a pre-packed sandwich. It really is 'gourmet on the go'! Well actually it wasn't because we never made it. We were flagged down by a member of the public for what appeared to be an unconscious man in the street.

“u/k male, unconscious, running call”

We called it in and were sent down a CAD number. It shouldn’t have surprised me that he was well known to us. I had picked him up yesterday about 200 yards down the road. In fact, he was being picked up 3-4 times a day, each time by an ambulance and each time taken to hospital. The problem is, each time, the hospital sober him up enough to be able to walk and then either sit him in the waiting room until he walks out or discharges him. He walks up the hill to the shops, buys more booze, drinks said booze and passes out again. The hospital are not willing or able to invest time in fixing the problem & we have no ability to anything else with an unconscious drunk person other than take them to hospital. The cycle will continue until he stops drinking or dies. The latter seemed most likely. 

Tonight, he was lying at the bus stop next to his empty bottle of scotch. He was face down and had wet himself. I often wonder what he was like before this. What kind of life did he lead? What family does he have? What friends did he have? Now there appears to be no one. The only people around him are the members of the public who call 999, the ambulance crews that take him to hospital and the nurses that kick him out. What can we do?! We scooped him up off the floor and onto our bed. We did the usual obs and then drove the half-mile to hospital. We got the usual looks of distain from the nurse and rolled him onto the bed. To be fair to the nurse, we had just brought in three abusive alcoholics in as many hours, but still……not our fault!

Alcohol is something that the NHS does not do well, a bit like obesity. We only treat in the short term when it is too late. Very little is done when warning signs are there. Accessing services is far to difficult and it is a lot easier to just give a bag of fluids and let them go than find out the cause and refer to the appropriate places. It’s a shame, if they invested in prevention rather than cure, the long term saving could be huge. Shame no manager or politician is ever that long sighted.

Off we went for fuel, this time we made it. The sandwich was rank and the coffee was a poor substitute to Costa but beggars can’t be choosers! After the start to the shift we had had it was a necessity! We went off and did a few more jobs to a different hospital and at about 2am came back to our area. We handed over our drunken teen to the staff and booked them in. I walked through the busy waiting room and what did I see?! All my regulars sat in a line on the bench together! The Three Stooges! That image summed up how the NHS treats alcohol and mental health. A sad sight but one that amused me! 

“Evening all!”

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?!

Left Behind

"34 year old male, ? Collapsed behind closed doors"

This job gives you a lot of strength in many ways. I suppose it's fair to say it's good for character building.  Over the years I have found myself in various situations, where when I look back, I think 'how did I hold it together?' I often feel that the job has desensitised me to a lot of things. It has to. Everyone has their own coping mechanism and ways to deal with different situations. The much vaunted 'gallows humour' is something that all emergency services use. Perhaps after seeing the same thing over and over again, it just doesn't matter any more. There are some jobs however, that don't come along every other day or even every other month. These are the jobs you remember. Everyone remembers their first cardiac arrest, their first dead body, their first baby delivered etc and today was no different. As far as a day goes, it didn't feel right. I was just on edge, no idea why. When the call came down I knew it would be a serious job. We get  'collapsed behind closed doors' ever week but this just felt different. We headed round to the address to find two women standing at the front door. 

We grabbed our stuff and headed over. It was the patients partner and mother. They hadn't been able to get through to him all morning, afternoon or evening. It was now 10pm. His car was outside the house and they could hear his phone ringing inside. The police had been requested but we had no ETA so we decided to try and get in ourselves. The door had been locked from inside so forced entry was our only option. My crew mate stepped up and gave the door a kick but she just bounced back off the door. I then had a go. After three kicks, the door swung open with a deafening bang as the brass door knob crashed into an iron radiator. The sound billowed through the hallway. The goal was to get in and we had achieved that but now a feeling I'll never forget engulfed me. I had a pitted knot in my stomach and was very apprehensive about going in any further. The hall was pitch black and the house felt cold and motionless. I shouted as I gingerly walked forward. All I heard back was silence. The light came on and lit up the downstairs. My crew mate entered the only closed door but the room was empty. Upstairs it was then.

I looked up and braced myself. I don't like exploring dark, empty houses at the best of times but today I was really nervous. It was a split staircase, and as I went up the first few steps I could feel my heart pounding. I pressed the light switch on the wall beside me and a single bulb illuminated the stair well. As I turned halfway up, I saw my crew mate and the two woman starring up at me with a look of expectation. I continued up, the stairs creaking with each movement, and as I got to the penultimate step my breath was taken away. I had looked to the right down the dark landing and six feet from me, poorly lit was a silhouette. It was the silhouette of our patient. I was the silhouette of him hanging, motionless from the loft hatch. I still see it like I do a photo. A moment locked in time that will stay with you, haunt you perhaps, forever. We cut him down, the tragic and gut-wrenching pain that his loved ones were experiencing was palpable. It's not a nice sight for someone who is used to seeing some pretty horrible sights. For someone who isn't, I can't to imagine what that feels like. We laid a blanket over his body and went downstairs to where his family had gone. 

For us we could immerse ourselves in protocols. The guy had been dead for hours so we called the police to confirm an unexpected death, we filled out our paperwork and our Recognition Of Life Extinct form for the coroner. It all seems very scientific but it's a way to remove yourself from what the natural human reaction is to do. Cry. Seeing a relative cry in mourning is enough to put the lump in my throat and make me well up. They are horrific situations and no amount of training would make a difference. What do you say? What can you say? There is no way to powder coat what had happened. The evidence was there for them to see. It wasn't just knowing their partner or their son was dead, it was knowing how desperate he felt before his death to do what he did. Those feelings are what will haunt them just as much as seeing him hanging there. Every suicide effects many more people than the ones you see. There are always the ones who are left behind. The ones who feel that pain every day. The ones who still have to live their lives. Alone. That is the tragedy of suicide. 

He had a 3 year old son. He will never know him, but will know how he died

He had a 1 year daughter. She will never know him, but will know how he died.

He had a sister. She will always hurt because her little brother didn't come to her for help.

He had a brother. He will always feel that he should have done something more.

He had a mum. She will always feel that she failed. 

He had a dad. He will always feel like he failed.

He had a partner. She will always blame herself and raise their children alone.

He had many friends. They will all ask themselves why they didn't notice. 

He had depression. He couldn't confront it, or if he did, he couldn't turn the corner

NB: My final bullet points were inspired and partly taken from @chocolatewig blog post Life After Suicide with her permission. Felt it highlights the tragedy well.

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!

Failed by the system........

"43 year old male, brain injury, feeling suicidal"

I have very little empathy for most of our regular callers, normally it is an attention thing or poor management of a chronic illness. I had similar feelings for Mr Smith but after the first 10 or so meetings I realised he needed empathy, and he needed help. Mr Smith called a lot of ambulances. Sometimes as many as 5 a day. More often than not he went the 600 yards to hospital but sometimes he stayed at home. Mr Smith suffered from schizophrenia which is a mental disorder characterised by a breakdown of thought processes and by poor emotional responsiveness. It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganised speech and thinking, and it is accompanied by significant social or occupational dysfunction. I believe he also had some learning difficulties. His usual complaint was feeling suicidal, stating he wanted to jump in front of a train. He claimed he had had a traumatic brain injury aged 11 but there was never any evidence to suggest this. Every attendance to him followed a similar pattern. We took him to hospital, the nurse sent him to the waiting room and he walked home where he would then call another ambulance. You can see the cycle.

Regular callers are very frustrating. It's a waste of resource and when they are so prolific in their calling the expense is huge. In one calendar year Mr Smith had 478 ambulances at a cost of over £250000 to the ambulance service. Unfortunately this is a bi-product of the system we are in. As previously discussed the care pathways for mental health patients are poor at best. The nearest mental health unit to Mr Smith knew him well but wouldn't allow us to convey him to them without him being assessed in A & E first. On the rare occasions where he did stay in hospital long enough to be assessed, the unit would discharge him to be 'treated at home'. The problem with mental health in A & E is that there are not only very few staff trained to assess him but there is usually a very long wait. Certain nurses knew if they left him for long enough he would just leave. To be honest, myself included, no one really took his threats of suicide seriously. He didn't seem the type. There was no history of self harm and he'd been threatening it for so many years it didn't seem likely. Regardless, he wasn't getting the treatment he desired or needed. He was being let down by the system in a never ending loop of hospital admissions and self discharges and no one who could buck the trend was willing to do so.

It's a far too familiar sight with mental health. No one wants to know. Even the mental health units generally are not interested. They certainly aren't helpful. They make admitting a patient as hard as possible for us and the police. They have so many rules and conditions that must be met before they'll consider even laying eyes on a patient. Because of this the cycle continues. If i'm honest I didn't really know what Mr Smith wanted. He never really said. I tried talking to him, I tried referring him onto every service I could. I filled out frequent caller referrals, vulnerable adult forms and flagged his address. I tried to argue on his behalf to immediate assessment in A & E but everyone has their priorities and he was never going to be one of them. He only ever called from his home. He was never rude, always polite and therefore never had anything to do with the police. The police have more powers than us and can be very useful with mental health and enforcing assessments but this was an avenue which was never open to us. He always agreed to go voluntarily and as such, was never in a position to be held against his will. Unfortunately about 4 months ago a crew not familiar with Mr Smith attended his home. I imagine he told them the usual and he was taken to the hospital. Once at hospital the nurse sent him to the waiting room. 20 minutes later he walked out. 20 minutes after that the following call was sent to a local crew.

"'One under', male jumped in front of Intercity train. ? Life status"

Like he always claimed he would, Mr Smith jumped under a train. From what I have heard he would have died instantly. The train was travelling in excess of 90mph, he didn't stand a chance. Or did he? He had a chance twice on that particular day. Twice he was taken to hospital and twice he was ignored. I suppose it was only a matter of time before he did it. He'd been let down by the system that is there to help him, and he was let down because he was submissive. He didn't complain about lack of treatment. He never raised his voice. He just quietly walked away unnoticed every single time. The cynic in me would say that now he is dead, that is a huge financial burden lifted and it's what he wanted. In reality, I felt crap. He didn't need to die, he needed treatment and help but it was treatment and help I wasn't able to provide. It was treatment and help 'the system' wouldn't allow him to have. I'd like to say that would be little consolation for his family and friends but he didn't have any. All he had was us and we failed him.