A Home to go to........

"41 year old male, seizure, will be met at station by staff"

It was rush hour on a Thursday evening. It was already dark and we had only just started. We got the shout to one of our local underground stations about two miles away. Normally a seizure on a train is indeed a seizure on a train. Today was no different. We arrived at the station after a few minutes and with the help of a very friendly station supervisor bundled all our stuff down the steps to the platform. To save on repeat journeys we brought the chair and life pack just in case. If he refused treatment as is common with epileptics we could leave him in the station and if he was in a bad way we could get him back up to the truck quickly. Most of the passengers had piled off the train to get some fresh air or find alternative transport. We were waved over to one of the middle carriages by a group of them. The closer we got the more I became aware of an argument going on. Indeed there was, between the driver and a passer-by. I say passer-by as for all intents and purposes he was but to me he was a colleague. Off duty but rendering aid. Very nice to see! This is what I heard as I got to the doors.

Paramedic: "Quite frankly I don't care about your train, this man is fitting and until he has a) stopped and b) the ambulance arrived nobody is moving him"

Driver: "We all have homes to go to as well, this is my train and we need to get it off the platform, it's causing chaos" 

Paramedic: "I don't care"

Driver: "You idiots think you are so special, I don't care who you said you are, get him off the train."

Me: "This man isn't moving anywhere until I say so and until then I would like you to leave for patient confidentiality reasons. If there is a problem I will get the police"

Driver: "Look at you all fucking sticking together"

With that, he stomped off down the platform to a hail of abuse from various other passengers. Can anyone actually be that uncaring and selfish?! It appears so. Would he drag off a dead body? Probably. Would he wake up a drunk instead of calling us? No! 

Our patient had stopped fitting and was beginning to come round. After about 5 minutes he was back to his normal self and gave us his full epileptic history. This seizure followed his normal pattern and he did not want to go to hospital. We were checking him over so we could send him on his way. The driver was by now loitering again at the door and sheepishly asked how long we would be. 

"We'll be done when we are done"

My bluntness had the desired effect. He stomped off again down the platform telling someone over the radio that the obnoxious ambulance crew were dragging their heels as part of a power game. Maybe we were, maybe we could have removed our patient a few minutes sooner. On the other hand though, maybe he could have shown some compassion and respect. Maybe he should have just let us do our job. Maybe he should think very carefully before criticising us when he works for the greediest bunch of lazy, good for nothing scroungers this country has in its workforce. It really does make me livid.

My feelings about tube drivers are no secret. The way they repeatedly hold our country to random sickens me as I've pointed out in Tube Strikes: The Cost of Greed and this day was no different. It only went to reaffirm my feelings about them. The public will only put up with their nonsense for so long before there is a serious backlash. It took one search of Google for 'Tube Drivers' to find 5 negative stories about them on the opening page.

• MP's Condemn Tube Drivers
• Tube Drivers Strike
• Triple Pay Demands from Tube Drivers
• Tube Workers Reject Pay Offer
• London Held to Ransom

They are not held in high regard by anyone. I wasn't able to find any positive stories about them which speaks volume for contempt in which they are held by the public. There was no purpose to this blog other than to make myself feel better and showcase  the moral fibre from which they are made. I do feel better now! I just wish one would have the guts to comment and stick up for their actions. Bet they don't........

I've added a video of a song about the London Underground by the parody music due Amateur Transplants (Adam Kay - @amateuradam & Suman Biswas - @amateursuman). This song has amused on on many occasion so hopefully it does the same to you. Genius!

"London Underground"

Safe and Well?

It is with great pleasure that I can introduce MentalHealthCop as a guest blogger.  After a question was posed to me by him on twitter my instant reaction was 'here goes the #no. 2 emergency service trying to palm work off on to us'. However, in the intrest of fair play we agreed to answer the same question on each others blog with a mind to provoke debate from service users and health care professionals alike. Whether we come to the same conclusions I don't know, you'll have to check out his blog for my response!

Why do the ambulance service not undertake “safe and well checks?”

I should explain, I operate a 'rule of thumb' that 'RAVE risks' are the cue for the police to become involved in supporting or temporarily leading health and social care matters, to mitigate risks and keep people safe. It is an operational mnemonic for 'Resistance, Aggression, Violence or Escape'. A far from perfect model, but helps to point the police in the right direction.
Health and social care functions, we'd all agree, are best left to people who know what they're doing, but where they would be exposed to risks, the police should either support them or temporarily lead a situation, until the risks are managed. Once mitigated or found not to exist, the police should begin to disengage and let the professionals take over.

For those who've not read my blog: I've been interested in how we police incidents involving mental health issues since I joined the police and as I've become more involved in it, I've found that frontline police officers like clarity around when a 'mental health job' is a police responsibility.
Egon Bittner (criminologist) said, "There is nothing which could not become the proper business of the police." Of course, this is not the same thing as saying that everything IS the proper business of the police! So where's the line; and who draws it?!

The start of my conversation is usually, "Is there a RAVE risk?" If not, using the police needs to be balanced off against the potential to stigmatise and criminalise the person concerned and it needs to be considered against other police priorities, because we are a finite resource and currently getting smaller.

This is important: the police are frequently accused - as am I personally - of perpetuating the myth that people with mental health problems are violent, when this mostly nonsense.
The police have a certain level of frustration with issues involving mental health: when one is asked to recover an AWOL patient from their home address, despite a Code of Practice saying that this should be done by a mental health professional (who does have legal authority to do so, regardless of what they may tell frontline cops who know no better!) it feels like the existence of the police as a generic 24/7 social service is being taken advantage of. That said, sometimes this frustration is inappropriately placed for if that AWOL patient has a history of aggression and violence, it may be quite appropriate for the police to do it.

So where's the line and who draws it?! And how do you bring about finality to that debate if it emerges that the police and the NHS have drawn their 'battle lines' at different places, leaving a gap between their expectations of each other?

So who should do a "quick safe and well" job? Such checks are often necessary and for a range of reasons: mental health services for community mental health patients who may have failed to attend an outpatient's appointment; general hospital patients or those who have attended A&E who left before treatment or self-discharged before proper explanation of the medical risks involved; other agencies such as education or children's social services asking the police to do checks for children absent from school or not seen.

So in theory, ambulance services could do it for the health situations as they are part of the NHS. For that matter, community mental health teams could do it and Crisis Teams could do it out-of-hours. The NHS is an employer of over 1 million people, working 24/7 and the numerous ways of addressing this issue. So why the police?

None of the scenarios necessarily involve what the public may regard as core police responsibilities: prevention of crime; detection of crime; protection of life and property and maintenance of the Queen's Peace. Especially in those first two scenarios - there are obvious links to health. If health action is required; if explanation of health risks is necessary, surely there can be no question that health professionals of one type or another would be are better suited than a police officer with a first-aid certificate? "But what about [RAVE risks]?" OK, the police should support this to keep you safe, but it remains a health issue at its core.

So I ask, if orientated around health concerns, why not ask the ambulance service to do it? I am being deliberatelyprovocative: apart from their obviously being part of the National Health Service, they are not necessarily any better placed to do this than the police. However outrageous it seems to me (and it does), the ambulance service have no more access to out of hours GPs, community mental health or health services than the police. I once heard a senior social care director within mental health shouting at an ambulance service mental health lead who wanted to do better for patients, "You will NEVER have direct referral access to crisis teams!" Not even, apparently, if the ambulance service knew they were dealing with a person who was currently open to that director's mental health services. I wouldn't have believed it if I hadn't been there. You would rather have a patient coerced by the police or taken by the ambulance to A&E - not a great place to be mentally ill - than have your Crisis Team respond to a mental health crisis involving a current patient?! Bonkers.

Where a safe and well checks leads either emergency service to find a person who is mentally ill in a private dwelling only three things can result:

• Whether Police or Ambulance - if a person found safe and well; messages can be passed or warnings conveyed but if they are capacitous and are left there or taken to A&E or back to hospital.
• Ambulance only - person found; not safe and well and especially if uncooperative and / or where capacity is questioned, the get called and then neither agency have a legal power to do anything about it at all (unless Mental Capacity Act can be applied, which will be rare.)
• Police only - person found; not safe / well and ambulance get called to this health situation and then same predicament: no powers to intervene.As such, NHS Commissioners need to plan for demands we KNOW we will face: how do you respond to spontaneous mental health crisis in a private dwelling where there is no criminal offence? Parliament says, healthcare professionals leading to MHA assessment by an AMHP / DR, if need be for admission under s4 MHA.

We know that the police and ambulance service will be managing these things tonight - regardless of what day you're reading this. The answer is not necessarily 'police' or 'ambulance' and sending these professionals to safe and well checks creates exactly such a scenario. Even if you send them - maybe send the police to the RAVE risks, and the ambulance to the other jobs - they will still need necessary pathways available to them.

So it emerges asking for a "quick safe and well" is too simplistic a description of a fairly complex problem that neither police nor ambulance are necessarily best placed to solve. And so this post is not for paramedics and cops: it is for NHS Commissioners and Service Managers and for inpatient nurses who ask for this to be done.

To read DiagnosisLOB's thoughts go and have a look @MentalHealthCop website!

Peace..........

"41 year old female. DIB. Lung cancer patient"

In health care, no one really wants responsibility. We are bottom of the food chain and from us, upwards, there is a long line of people to pass the buck onto. We pass the buck to a nurse, who passes it to an HCA, who passes it back to a nurse. The nurse in turn passes it to a House officer (junior doctor) who passes it onto a Senior House officer who passes it to a Registrar. If the Registrar doesn't know what to do he passes the buck onto a Consultant; top of the food chain. If they don't know what to do, you'll probably die. Sometimes however, this marvellous system of avoiding blame is scuppered by someone not going to hospital. The problem here is that if the GP has been to see them and wants them to go to hospital he or she will phone an ambulance. If the patient refuses you end up with the buck stopping with the lowest level of the NHS. The only place we can turn is our illustrious Clinical Support Desk. However, those who have had contact with our CSD will know they have a phrasebook consisting of only three phrases:

1. That's a decision you'll have to make.
2. I'm afraid that's a grey area
3. Please hold the line..................That's a decision you'll have to make.

Needless to say, when the buck stops with us there is nowhere to turn making these jobs some of the most difficult to deal with.

This particular job was a case in point. We were sent to a private residential address where the GP had already visited. He had assessed our patient and been told by the family that our patient did not wish to go to hospital and would not go to hospital. Needing to pass said buck, we were called. Whether he thought we could convince her to go or just didn't want the responsibility of leaving someone struggling to breathe I don't know but the end result was the two of us entering Amy's bedroom armed with our bags and a smile. Amy had lung cancer. The very late stages of the disease. The disease that had manifested itself throughout her body. A disease that can attack anyone without cause. She'd never smoked, lived a healthy life and worked hard. Where is the justice? She was in palliative care, at home, with her family at her side. When we walked in we were introduced to her two daughters and her husband. Her mother and father were also present. It was a very sombre affair.

"Please don't take her to hospital, she wants to die at home, please" 

"We won't take her anywhere she doesn't want to go"

As I said that, Amy took hold of my hand and gently squeezed it. She didn't have the strength to speak but mouthed 'thank you' to me. She was struggling to breath, her resp rate was high and her SpO2 was very low so with her permission we gave her some oxygen. We spent a while talking to her family while checking her over and it was a very humbling experience. They were such a lovely family, at peace with the inevitable but had called the GP because their mother / wife / daughter was suffering. She was on a syringe driver for pain and everyone was just waiting for her last moments to come. I felt like an impostor that didn't belong there. This family needed to say their goodbyes in private but we couldn't leave our oxygen with them. Obviously when Amy was comfortable we could leave but in taking the oxygen away I didn't want to be the cause of her passing. I phoned clinical support and got a combination of answer 2 & 3 from their book of knowledge. We agreed that we'd go and do our paperwork then come and get our oxygen before we needed to leave. I told Amy what we were going to do and in a moment that I'll never forget she closed her eyes with a smile. As she opened them a tear trickled down her cheek. Being left at home with her family was her only wish and we were able to give that to her. In all honesty we should never have been there but that's the system. 

We sat in the ambulance for a little while doing our paperwork, it was a very sad job and one that frustrated us. It wasn't the fact we were called knowing there was nothing we could do, it wasn't that the buck was past. It was the fact that we'd intruded on a families precious last hours and had to stick around so we could tick all of our boxes and cover our asses. For every job there is a paper trail. One that is scrutinised by our service and what our performance is judged on. That was frustrating. We went back in to get our O2 and leave a copy of our paperwork. I was halfway up the stairs when an unmistakable sound engulfed the landing. It was the sound of sobbing, the sound of pain, the sound of grief. In the fifteen minutes that we had been gone Amy had passed away. Passed away with everyone she loved, and who loved her, at her bedside. Her suffering was over. We sat on the stairs for twenty minutes feeling rather numb. Her husband came back out of the room, tears pouring from his face, yet he was smiling. He was happy his childhood sweetheart could hurt no more. I entered the room to confirm death so I could fill out our Recognition Of Life Extinct form. She looked asleep still with the half smile on her face. She was at peace. I felt the lump in my throat so decided just to grab by bits and make my excuses. I'm sure there is some procedure I didn't follow to the letter and a box I didn't tick but I don't care. There was nothing for us to do and we had no place being there now. I left the paperwork on the dining table so the family could make the arrangements they needed to. Us? We went to go and do another job.

A special relationship......

"22 year old male. Unconscious and bleeding heavily"

A weekend in the city wouldn't be the same without drink, drugs, violence, vomit, blood and blue lights. More often than not, all the above are on the first job of the night. Today was no different. We were on station but our shift hadn't started yet. In a garage that holds 8 ambulances and 8 cars, our truck sat alone & being a Sunday night there was no management around and no admin staff. It was just us doing our VDI when the phone rang. We had already spoken to control to give our fleet number and skill level so they knew we were there so we had to answer! It was a begging phone call pleading for us to start early as there was a Cat A call and no other resources to send. Obviously we obliged, so not really knowing if we were missing anything we shot out the garage. It was only 3 miles we had to travel but doing that at 18:00 on the day of a Spurs vs Arsenal match and heading to Tottenham causes bit of a tricky drive. That aside, we arrived about 15 minutes later to a sea of blue lights. In the road was a guy lying on his back surrounded by police. As I stepped out the vehicle I could see a considerable amount of blood on the WPC's hands. The closer I got, the more blood I could see on all of their hands. What a mess!

The guy had been stabbed numerous times in the leg and once in the stomach and he wasn't in good way. He was pale, sweating and very drowsy. The police were applying fantastic pressure to the wounds so I took a moment to come up with a plan whilst listening to a vague handover. No one was exactly sure of what happened but what they did know was that a large crowd of 'anti emergency service' youths was gathering and were shouting abuse at us and the police. I called for HEMS back up or an FRU. In fact I believe I actually said "send me anything". If ever there was a reply which summed up David Cameron's reign of terror on front line services this was this:

"Sorry, we a spread thin. HEMS are tied up and there is nothing else available at the moment. We've got A & E support running from 13 miles away but until then you'll have to make do. As soon as something comes up I'll send them. Sorry guys"

Still think cuts to emergency services is wise? Hmmm! I wanted someone who could assist in major trauma. No disrespect to A & E support but they are not even aloud to do an ECG or give Calpol. They would be as useful as a chocolate teapot. It was us and the police. I started cutting the guys clothes off. He was panicking but we were far to pre-occupied with his life threatening injuries to be able to talk to him. Cue the police. Not only are their 12 officers trying to keep the crowd back, trying to protect us from some missiles that were being thrown but were applying pressure to wounds, opening dressing, passing us kit and constantly re-assuring our patient. No instructions needed. They just did it. The main source of bleeding was his groin. It was an arterial bleed and was taking all of my energy to apply the pressure needed to slow it down. My crew mate was placing orange cannulas (wide bore cannulas for trauma) in both his arms and drawing up fluids. It was a real mess. 

I was aware of two things. Firstly, the crowd was becoming angrier by the minute and things were getting rather volatile between them and the officers who were now almost making a cordon around us. Secondly, our patient may well die where he lay if we didn't move soon. Again, without prompting the trolley bed appeared. The police knew we had no hands to do it our self. Normally we'd use a scoop or sheet to lift someone but with the number of bodies we had at our disposal it was just a case of lift and run. We got him on board and put in the blue call to the trauma centre. As we were about to leave an FRU turned up. He dumped his car and at our request, drove the ambulance. In the back was me and my crew mate and three cops. The three who had saved our patients life. We arrived at hospital and bundled into resus. The guy was transferred and hospital staff took over from us. Off we went to the blood bath that was our truck. There was blood everywhere, everyone was saturated but it was a good job done by all. 

This job itself would have stood up well as a blog in it's own right but for me it was a great example of the special relationship between the ambulance service and the second best emergency service; the police! (sorry guys, couldn't miss out on the banter). No matter what the job is, there is a respect and admiration between the two of us. We wave as we pass each other on the road (take note fire brigade) and there is always a welcoming look of relief when one of us arrives at the others scene. This was a perfect example of two public services working well together for one purpose. The police come under a lot of stick and put up with much more abuse and violence than we do and normally shrug it off as being part of the job but that isn't good enough. They are a fantastic bunch of people who do the toughest job in the most difficult of circumstances. This country is lucky to have such an outstanding force and the sooner that is recognised by the mindless minority the better. This guy WOULD have died, I have no doubt, if the police hadn't done what they did but it won't gain them any respect or thanks from the idiots who abuse them. It wasn't their job. It was ours but they did what they had to do. I wrote a letter of thanks to their police station, only knowing their shoulder number. I hope it got to them. That's the funny thing. There are so money different police and so many different ambulance crews, most of the time we are working along side officers we have never met yet the respect and professionalism never wavers. Time after time, we call them when there is even a hint of danger and they come running. I'll always be in their debt and as such will always be more than willing to give my call sign, even on the ninth time of asking. Bless 'em!

Care Homes: Take Note

"Care homes of various standards acting like muppets"

Care homes. The word 'care' isn't meant in any way to be ironic however we have all been to 'that care home'. As sad as that is the standard in care homes is generally poor. That's not to say there are not good ones, there are, however normally where I say the good outweigh the bad, I don't think this is the case. Good care homes seem few and far between and to say you get what you pay for isn't exactly true. It's more pot luck. The care given ranges from excellent to sheer negligent and for the latter we end up having to alert social services through vulnerable adult forms. It's horrible to see the elderly who have spent a lifetime serving the country and paying taxes left in squalor because the care staff don't give a crap. Invariably there are two sides to every care home. The side that the relatives see during visiting hours and the graveyard shift. During the day, patients are paraded in social areas, full of Amitriptyline and polite, English speaking nurses tend to their needs in full view of anyone who pops by. At shift change they are replaced by a bunch of miserable mis-fits who don't care one iota about the people they are supposed to be looking after. OK, I'm generalising massively and tarring the good ones with a bad brush but in all honesty the good homes rarely call us so I we don't see them. They care for their patients as they should and as a result their patient rarely go to hospital. When they do, they are clean, we get a handover, a full history with matching paperwork, an escort and a smile. Sadly we are more likely to get a seriously ill patient, be greeted with a grunt, no handover, no paperwork, no history and no escort. Our patient is likely to have soiled themselves and been left to suffer. These are the homes I want to Take Note. These are the ones that need investigating. These are these are the homes that should face the strictest sanctions. So, with that in mind to avoid a confrontation with us and avoid an inspection from the local council, social services and the police the following should be noted and followed:

• Don't leave your patient lying in their own faeces.
• Don't tell us they were fine an hour ago when they've been dead for 6.
• Don't put your patient to bed after they have gone into cardiac arrest.
• Don't negate to start CPR because "We are short staffed"
• Don't negate to start CPR because "I forgot"
• Don't call yourself a 'care home' if you're not going to care
• Don't put coded doors on every corridor and look annoyed when we knock.
• Don't call 999 just because your patient fell over. Check them first.
• Don't allow a catheter bag to fill to bursting point.
• Don't allow a colostomy bag to fill to bursting point. 
• Don't put tea in the mouth of someone who is dead to cover your arse.
• Don't call yourself a 'care home' if you're not going to care
• Don't wait until your patient is septic before calling us. 
• Don't leave your patient uncleaned for days on end. We can tell. We can smell.
• Don't look at me blankly when I ask what room we need to go to.
• Don't look at me blankly when I ask what is wrong with the patient.
• Don't look at me blankly when I ask for a medical history. 
• Don't call yourself a 'care home' if you're not going to care
• Don't look at me blankly when I ask for a medication list.
• Don't look at me blankly when I tell you the patient has been dead for a long time.
• Don't hide from me. I will find you. 
• Don't call us because you want less patients on your night shift.
• Don't leave your care home staffed by all non-english speaking nurses. 
• Don't call yourself a 'care home' if you're not going to care
• Don't refuse an escort to hospital when they have paid for an escort to hospital.
• Don't forget to feed your patients.
• Don't wait 15 minutes to call us for someone who has gone into cardiac arrest.
• Don't lock the patient who is in cardiac arrest in their room and wander off.
• Don't kiss your teeth at me. 
• Don't call yourself a 'care home' if you're not going to care
• Don't refuse to give me your name. 
• Don't tell me it wasn't your job for whatever question I ask you.
• Don't lie to me. 
• Don't let relatives come in and watch us doing a resus.
• Don't let other residents stand and watch us do a resus. 
• Don't call yourself a 'care home' if you're not going to care
• Don't leave your residents sat in the same chair for 15 hours a day. 
• Don't tell me you're a "residential home, not a care home" as an excuse.
• Don't take me to the wrong patient.
• Don't give me the paperwork and medication of the wrong patient. 
• Don't call us and then wait 15 minutes to let us in the building.
• Don't call yourself a 'care home' if you're not going to care
• Don't tell me a patient who is hypo had a BM of 10, 20 minutes ago. 
• Don't drop your patients.
• Don't blame your patients. They are in your care.
• Don't be rude or dismissive to us.
• Don't blame everything on dementia.
• Don't call yourself a 'care home' if you're not going to care
• Don't wait a month to change your patients bed sheets. 
• Don't forget humans need water. We can tell if you forget.
• Don't be a carer if you don't care.

This are not me or ambulance crews being pedantic, these are basic human rights. Treat others as you'd like to be treated. Some of the places we visit are verging on inhumane and the sooner something is done to prevent this third world squalor the better. Every single one of the above I have witnessed and can only comment on what I see. Like I said, I don't see enough of the good homes because the patients are well cared for and rarely need an ambulance!

Click the Take Note photo at the top to see the other posts in the series!