GPs: Take Note

"GP's with varying amounts of experience acting like muppets"

Everyone has a GP. We call when we are ill and are normally greeted by a receptionist with far too much power who tells us there are no appointments. If we eventually get an appointment and are still ill enough to need it, we have our 5 minute conversation with the Doc! Invariably they listen to our ailments for a few minutes then write a prescription for some antibiotics, send us for a blood test and/or advise us to come back if the problem persists. For the vast majority of us this works; if it doesn't, the GP will try something else. It's a big guessing game of 'the most likely'. Working for the ambulance service however I get to see a different side to the GP surgery. I get to see them when they need an ambulance. Rest assured it is not every surgery, there seem to be certain ones that attract more ambulances than others. From an EMS perspective a number of GPs abuse the service, the same GPs who are being put in charge of running the NHS. In the 6th instalment in the 'Take Note' series i've compiled a list of don'ts for GPs who like to call an ambulance. By no means am I suggesting I know best, I don't, my 6 months of 'death by power point' is no match for their 7 years at medical school; I do however know the difference between someone who needs an EMERGENCY ambulance and someone who doesn't. Just sayin'! Bearing that in mind, I hope that some GPs read and take note of the following:

• Don't leave seriously ill people in the waiting room.
• Don't call just because it's Monday morning and you are busy. We are too!
• Don't call just because it's Friday afternoon and you want to go home.
• Don't call because it's 18:30 and you want to go home.
• Don't call for chest pain and leave alone in a side room.
• Don't call for 'chest pain' just to get a quick response for your panic attack.
• Don't leave seriously ill people in the waiting room.
• Don't call for meningitis and not treat it. 
• Don't wait for the ambulance to start CPR. It's not beneath you.
• Don't call an ambulance for a patient you have not yet seen or spoken to.
• Don't say "It's above your pay grade". Ever. 
• Don't leave us to guess what is wrong with your patient.
• Don't leave seriously ill people in the waiting room.
• Don't refer to 'medics' and then not refer to medics.
• Don't call because you are running late with your appointments. 
• Don't book an ambulance for a patient well enough to get a lift or taxi.
• Don't call an ambulance and say 'within 4 hours'. That isn't an emergency.
• Don't leave your receptionist to give the hand over.
• Don't leave seriously ill people in the waiting room.
• Don't refuse to come out. If hospital was appropriate we would be there.
• Don't call for a CVA without checking blood sugar! The slurred speech is a hypo!
• Don't call for 'diabetic problems' without checking blood sugar.
• Don't leave a patient on their own when they are peri-arrest.
• Don't call for a panic attack. It isn't an emergency.
• Don't leave seriously ill people in the waiting room.
• Don't talk down to me.
• Don't give me sarcastic answers to my questions.
• Don't leave someone having a heart attack alone. 
• Don't call for someone having a heart attack and not give aspirin or GTN.
• Don't roll your eyes when I ask you a question.
• Don't leave seriously ill people in the waiting room.
• Don't tell me I HAVE to take a patient somewhere they are refusing to go.
• Don't call if your patient has a cold. It's a cold. They'll get over it.
• Don't call the DIB and low oxygen levels then not give oxygen.
• Don't call us for an asthma attack and not treat it.
• Don't leave your asthma attack unattended.
• Don't leave seriously ill people in the waiting room.
• Don't lie to me.
• Don't leave us to guess what room you have hidden the patient in.
• Don't tell us a stretcher is required when you have stairs.
• Don't tell us a chair is required when your patient has a cut hand.
• Don't call us to a head injury and not put a dressing on. 
• Don't leave seriously ill people in the waiting room.
• Don't leave a letter that is completely unreadable.
• Don't call an ambulance for a patient who has refused hospital.
• Don't call an ambulance and not tell the patient we are coming.
• Don't call an ambulance and not tell your patient why.
• Don't send a patient home in their car and then call 999 for them.
• Don't leave seriously ill people in the waiting room.
• Don't call for anaphylaxis and not give adrenaline.
• Don't call for a hypo and not give glucose or glucagon.
• Don't leave a 95 year old with a pulse of 28 alone. CPR is inevitable.
• Don't say it's immediately life threatening when it clearly isn't.
• Don't call an ambulance when one has already been and referred on to you. The patient will still refuse hospital. You need to visit.
• Don't leave seriously ill people in the waiting room.
• Don't ask your receptionist to call an ambulance and not say why.
• Don't say 'MI' on the phone unless you have ECG proof. It's just chest pain.
• Don't send a patient with chest pain home and then call an ambulance there because you are closing for lunch. Seriously. Bad form.
• Oh, and for god's sake, get a bloody defibrillator! If Tesco can have one, a GP surgery can have one.

GPs have a very difficult job to do, they really do. They have to see and treat everyone for every possible medical condition and they are hugely oversubscribed. I do think though, that this is the case because most refuse to work outside of Monday-Friday 08:30-18:30. This causes the Monday backlog and the Friday rush. Outside of those times we are left referring to a skeleton staff of OOH GPs who don't have the time to see everyone. And I did say most! There are some brilliant GPs who do regular home visits, give great handovers and are everything you want from a GP. Maybe if GPs worked unsociable hours as part of their £100,000 salary some of the pressure would be relieved. In the meantime, being sensible about who requires an ambulance would go some way to easing pressure on the already bulging A & E departments. If the GPs are to be in charge of the NHS they'll have to stop looking after themselves and see the bigger picture. Then again, what do I know, I'm just a stretcher monkey and this is way above my pay-grade!

As always, if there is any I have forgotten, leave it in the comments and i'll add!

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

Chasing Geese

"Unknown age, unknown sex, ? fainted"

It was about 2am on the first night shift. The first is always the worst. I'd been up since about 7am and was seriously lagging. No amount of cold air or coffee was helping and despite being busy and having an in-depth conversation with my crew mate my eyes were shutting at an alarming rate. We got sent to the most bizarre sounding church with no other information than ? Fainted. It sounded like a hoax to be honest, the area that it was in wasn't a nice one but regardless of our scepticism, we began the 6 mile journey. I requested more information about what we were supposedly walking into but they had none. The caller was vague and had called from a phone box and there was now no answer apparently. The roads were nice and empty so before long we were approaching the address; as we pulled into the road the location updated.

The new address was 4 miles in the other direction. We queried how someone who had fainted 'outside the church' was now so far away and now 'lying in the road'. No reason was given, we were basically told to get over it and get driving! So we did! After 5 minutes or so we pulled into the new road. Like all sat navs ours has a flag when you arrive at the location, not always exact but normally pretty close; so we sat at the flag, no lifeless body in sight, and called up for instructions.

"Right, the location has changed, just sending you the new one"

Again! Now the location was a fixed address. It was 5 miles away but now we had no sat nav as we had already pressed 'at scene'. One of the many bugs in the system! Out came the map book. Slowly we navigated ourselves to the new address; it was in the middle of an estate, so it took a while to find the actual house. We pulled up outside and looked the place up and down, it was in darkness, in fact, the whole road was in darkness. I wasn't remotely convinced that a)this job was genuine and b)the people possibly asleep in this house had called an ambulance. I decided to share my concerns with control.

"Red base, we are now sat outside the third location, the house is in darkness, it seems like a hoax and I'm not too happy about waking someone up at 2:30am because their address has been given as part of a joke"

"Sorry but that is the address that was given, you'll have to go and investigate"

Call me a wimp but it's quite a nervy business knocking on the door of pitch black houses in the middle of a rough estate. I gave a tentative knock and took a few paces back. I felt reassured when the FRU arrived; he too had been taking part in the wild goose chase across the city. There was no answer and no movement of the blinds. I knocked again, this time with much more conviction. Nothing! I looked through the letterbox and shouted whilst knocking. Nothing. There was no one here, THAT I was sure of.

"Red base, the house is in darkness, there is no answer, can we treat this as a no trace?"

"Negative, we will have to treat it as a collapsed behind closed door, standby for police, over"

"Roger" (said in the most sarcastic tone I could muster)

We waited and waited and waited. 45 minutes later the police arrived. I told them the situation thus far, and that control wanted us to gain entry as this was now a collapsed behind closed door. They were not happy or convinced this was the case and neither were we, but at the end of the day, these decisions are above our pay grades. The officer tried to kick the door in. Based on how this job had gone so far it was no surprise he was unsuccessful. Another 20 minutes went by waiting for the enforcer to arrive with the 'universal key'. A few well-placed acts of violence towards the door and we were in. I say in, I mean hiding behind the police who were in! We searched the place. Nothing! Not a soul! 

(Back to the sarcastic tone) "Red base, we have gained entry, there is no one at this  location, would you like us to treat this as a no trace or is there something else to try"

(prolonged pause)........"Treat as a no trace"

It was a victory for me because I love nothing more than an 'I told you so' moment but in all seriousness almost 2 hours had been wasted on this job. That's an ambulance and a car not available for another job because someone had decided this hoax call was genuine, not to mention the police time wasted too. It was a hoax from the moment it was called. It was never anything but. A constantly changing location, called from a phone box nowhere near any of the locations, the call back not answered, no age or sex given, no real presenting complaint... is it just me who smells a hoax?! This was a wild goose chase from start to finish; it was a waste of everyone's time and as far as I was concerned, not in the public's interest to pursue it to the length that we did. The door will now have to be replaced at a cost to the tax payer and for what purpose? To satisfy the curiosity of a non-clinical manager and amuse a time wasting fake caller who was probably watching from the block opposite laughing away. What a cock-up!

Mexican Standoff

"Female u/k age, feeling suicidal, having bad reaction to cocaine"

In my last post Pass the Donkey the main point was responsibility. Who should take responsibility for a mental health patient suffering a crisis. Police, ambulance or hospital. The long and the short of it was the police should have sectioned but were unwilling and the hospital should have accepted the patient but didn't. Why? A simple but very pertinent question. Why were the police unwilling to go through correct procedure. Well I have found one answer to it. MentalHealthCop pointed me in the direction of this account by a front line police officer. This is their account, unedited and I think goes some way to showing what could be on an officers mind when considering a sectioning.

A Mexican Standoff is a situation where no one can emerge as a clear winner. I think that is very true with mental health care. Certainly the patient never seems to be the winner and as this account shows, finishing on time seems to be much more important to some, than the health and well being of a patient.  To set the scene, it's 5am at the end of yet another gruelling night shift. We all know the feeling, all we want is our bed, but invariably that will have to wait. There will always be one more job to do!

“Here is the full story of the MH debacle and the Mexican Standoff I had this morning with the NHS … Police called by Ambulance to assist them as a well-known self harmer has taken cocaine and has some unusually bad reaction to it. She feels dizzy and sick and it was enough to ask for medical help because it was weirder than her normal reaction to cocaine. I am a good 45 mins away from scene and so firearms vehicle attend. In our force it seems that once you have a gun you lose the ability to think for yourself and (god forbid) the ability to actually use your powers as a police officer … a bit like inspectors!

Helpful firearm officer asks over the airwaves “she says if we leave her she will kill herself. I don’t know what to do so can a local officer please come and help me”. Thanks for that. Try communicating with her for a start!

I get there. Firearms say “thanks, see ya” and leave me to get off and finish on time. Ambulance say – there is nothing wrong with her AND I QUOTE “apart from her her heart rate being a fast from the coke”. They know this frequent flyer and stand with their arms crossed saying can you get her out of the ambulance as we need it back on the road. Roughly translated as – I want to go home and I am tired of her again.

Girl says – if you leave I will kill myself. I now have no choice whatsoever. Oh, and I then remove the razor blades she has concealed in her hands which both firearms and ambulance failed to notice.

So I ’136′ her because I feel that if we leave, bearing in mind her mental health history, her substance abuse and her stated intent, she will make a serious self-harm / suicide attempt. Ambulance says – we are not taking her in, you take her in the police car. Out comes your blog for first time to highlight the first breach (of the Code of Practice).

FIRST standoff – I explain our/their policy of ambulance to 136. I explain this is not a criminal justice incident it is a HEALTH incident: me police; you NHS. Ambulance say we won’t take her unless you sit in ambulance with us. Fair enough – I agree in order to get this progressed.

Get to A&E for the SECOND standoff of the morning – they did not even let us in, we had to stand in the foyer of A&E. I explained the Red Flag (drugs) and why she needed medical assessment. They did not want to do this – roughly translated as I am tired and I want to finish thank you. Still in the foyer of A&E and not even over the bloody threshold I stand clutching my iPhone in one hand (with your legislation and blog) and my police Blackberry in the other with our policy on it re 136. Because the doctor asked our girl 2 questions (being name, DOB) and she did not answer, she declares this patient will not cooperate and asks, “Please take her away.” No monitoring, no communication apart from 2 questions repeated by a stroppy nurse. I say – are you happy she has the capacity? They say yes. I say – how do you know as you have only asked her name and DOB? They all shout at me.

I say “OK, if you are refusing treatment, please sign here and I will remove her, then if she dies in custody or at the MH unit due to cocaine intoxication and a lack of capacity that you haven’t assessed, I can evidence that I have tried to get her medical care and this has been refused.”

THIRD Mexican standoff – I am liking Mexican Standoff for the blog title – please sign here. “No” … we are AND I QUOTE “Not allowed to sign anything relating to treatment unless your Chief Constable asks for it in writing”. I write – refused to sign. They are not happy I have written their names down and shout at me.

My theory is that if you are convinced that you are right, and can back it up – why are you scared of giving your name? Or signing?! They knew they were wrong but they wanted to go home after working all night. Me too.

So, I ask can you please phone the MH Unit which is 50 yards away and ask if we can take this girl there or will they refuse us? Oh no, we cannot phone. Good will tank now running on empty. I am now aching through tiredness and frustration to the point where I may need admittance to the MH unit myself and I’m more than one hour off late already and I’m not done.

I take her to MH Unit who agree to accept her under 136 even though she has had a drink because I have to argue a FOURTH Mexican standoff of ” Custody and cells is not the right place for this lady, she is not a criminal, she is not well and the custody sergeant will not detain here there given the lack of medical assessment so far knowing she feels unwell after taking cocaine”.

All my NHS colleagues went home on time, only me off late. I felt so let down by them that I could have screamed. I nearly lost my cool in A&E and I did share a piece of my mind because they were being SO obstructive. They failed to see that if our girl died from the effects of the drugs – they assume she was telling the truth about what she’d taken – then it would be ME and not them losing their job, unless I did this properly.

So, that is the sorry saga of the shit service provided to MH patients by the NHS this morning. Good night.”

I'm always quick to jump to the defence of my colleagues in green. I am also more than happy to point the finger when it needs to be pointed. I can't for the life of me think what they were playing at. A patient is a patient, regardless of whether or not they are a frequent caller. A patient who by their own admission is having a bad reaction to cocaine is a concern. Threats of self harm aside, this still needs to be medically investigated before anything else is done. The ONLY suitable place is A & E. There are high risks of heart attacks from heavy cocaine use and that is heightened with high blood pressure. I imagine an MH patient feeling panicked and suicidal will probably have a higher than normal blood pressure. On top of that there is a significant risk of seizures and respiratory or cardiac arrest. Luckily this patient had a police officer who put their job role before their bed, to make sure the right thing was done. Why health professionals think that a police cell is the most appropriate place for these patients is beyond me.

There are so many similarities to this job and Pass the Donkey it's frightening. I'd never heard of an A & E department refusing entry to patient brought by ambulance or police. Let alone one who is suffering symptoms of drug toxicity, suffering a crisis and under section. I'm lost for words. Clearly this is more than an isolated incident. It's happening at more than one hospital and needs to be repeatedly reported and addressed. People simply cannot play God over patient care because they want to go home. I am not surprised the police don't want to get involved in a sectioning if this is how they will be treated. The only positive that can be taken from this particular job is that the police officer involved conducted themselves in a way that ensured the patient was put first. Sadly the same cannot be said for the services they came into contact with. I only wish those ambulance and hospital staff could read this and see what impact their actions and inaction are and will have on the health service.

What chance does the NHS have of surviving if it is going to continue to allow such bad practise to occur. Mental health needs addressing, these patients need the same care as any other patient regardless of drink, drugs, mental state or frequency of calling. Maybe the arms folded and 'not my problem' attitude from the ambulance crew and the 'you're not coming in here' attitude from the hospital are adding to the patients problems and inability to fit into society. Not such an open minded, accepting society as we like to advertise is it?!

PLEASE DISCUSS AND SHARE!

This officers account can also be viewed on Mental Health Cop's website in the post entitled Mexican Standoff.

Pass the Donkey - Part 3

"46 year old female, suicidal"

Continued.....

Writing this blog has been a very interesting and worthwhile project, and one I thought I had finished! However, the power and interaction that social media (namely Twitter) brings is debate and opinions from many areas. On this particular job I only sourced opinions from the people and services directly involved on the night; ambulance, police, hospital and of course the patient. What was highlighted was that this job was a 'symptom of a fragmented system'; a system we are all aware of and often vent frustrations against. It was suggested by a number of people that it would be interesting to hear from an AMHP, community MH services or someone with experience in the treatment of mental health. So I did!

Jakki Cowley (@jakkicowley) used to be a practicing mental health and mental capacity advocate. She now has a national role promoting and developing best practice guidance on both Acts (the Mental Health Act & Mental Capacity Act) for advocates and other professionals. With experience in the two key aspects of this job, mental health and mental capacity, I asked her what her thoughts on the job were and what solutions or lessons could be learnt in the future:

"My experience comes from many years working as an advocate, in mental health, learning disability, forensic and acute settings and eventually as a mental capacity advocate.  I now lead on mental health and mental capacity advocacy in terms of promoting and developing best practice guidance, so although no longer a practicing advocate my perspective remains the same – the person at the heart of this process.

I’m lucky and in a privileged position that I don’t have other factors at play when carrying out my job.   I’m there only to find out from the person what they want, what’s important to them, what help they feel they need and how that can be communicated and articulated to others so that their views and wishes are heard and their rights upheld.

In this instance the patient is already known to services.   She threatens self-harm and/or suicide and is known to action these threats.  She’s known to take up a great deal of services time and energy which impacts on how she’s dealt with by all involved.  She’s viewed as a difficult client and that view of her has been set in motion - from the professionals that are familiar with her, those who receive a handover about her ‘difficult behaviour/presentation’ to those she’s never met before - and immediately puts a barrier between her and the professionals involved.  It may not be a conscious barrier, but it exists, she’s viewed as a ‘difficult job to do’.  This leads to a spiralling effect from the private ambulance through to the A & E department and the police call handle centre that means she’s treated as a problem that needs to be dealt with and not a person in mental distress.

But what if she wasn’t seen as a problem?  What if she was seen as a person in distress whose coping mechanisms mean she lashes out, threatens harm to herself but who wants to be heard (she rings an ambulance for a reason even if it’s not apparent).  If she were calmer, polite, rationally explaining why she wants to harm herself, how would she be treated then?  I suspect with compassion.  The issue is the same, but instead the emphasis has become about getting a task done, passing the ‘problem on’, fitting her into a piece of legislation or policy. She has become the least important part of the decision making process. 

@Sectioned_ says it best when she explains she’s in a vulnerable place and needs to be recognised, communicated with and listened to.  Simple yet could make a difference to the process as well as the outcome if she wasn’t viewed as the problem but someone in need and distress who is finding any way of reaching out."

An interesting point was that of not having other factors at play when treating a patient. I think it is often something that hospitals and others services don't understand or comprehend. When the police and ambulance service deal with patients they are often in the public domain and this brings with it its own set of challenges. In this case swigging pints, brandy and wine from strangers' glasses in a packed pub was just one of the challenges we faced. The bystander and the crowd have a lot to do with our decision making process. In a hospital, the nurses of whatever speciality have a cubicle or room in which to treat the patient where confidentiality and due process can be maintained. They generally don't have a sweaty 50 year old drunk man grabbing their arse or the remnants of a Jaegerbomb poured down their neck whilst trying to find out exactly why the patient is suicidal and deserting her wheel chair! A chirpy git leaning over your shoulder saying "I want that one" is not helpful in any way. You also have the onlookers who know best, who all have an opinion and are not shy to share! 

Viewing the patient as a problem is in itself, a problem. Yes, I agree tact and differing approaches are needed but again it comes down to luck. There are 1000's of different combinations of ambulance crews and 1000's of police officers. Some will be willing and open to go the extra mile, some won't be. There are times where I have been faced with 'someone in need and distress who is finding any way of reaching out' but if reaching out means I get verbally abused, spat at, punched, kicked or vomited on, then that is where the 'reaching' will stop; I'll be reaching for my radio and requesting police, and so starts the cycle again. As much as we all want to do the right thing, circumstance, guidelines and personal safety all get in the way. That is the flaw with pre-hospital care. We are in unknown, uncontrollable, often volatile environments, with not only the care of our patients to worry about, but the risks they may pose to unaware members of the public.

Jakki continues:

"The Mental Capacity Act in this instance doesn’t apply as she’s assessed to have capacity.  However if she was assessed as lacking capacity and it was deemed in her best interests to take her to hospital, consideration would need to be given to the use of force and/or restraint and whether it was necessary and a proportionate response to protect her from harm.

However section 136 of the MHA was the therefore used and the place of safety in this instance was a hospital. But it doesn’t need to be.  Local policies and procedures should consider a range of options that may be more appropriate and have a less detrimental effect on a patient.  Whatever their presentation, consideration should be given to the impact on the person’s mental health: will the place of safety exacerbate their distress for example; what environment would ensure a mental health assessment runs more smoothly, would a relative's home be a more temporary appropriate option?  

To end, given this is a complex case with a person with a long history of presenting to services, has her mental health AND her capacity been thoroughly assessed and is there a need for a multi-agency safeguarding meeting to progress the case long term so that all agencies are working together?  Also, given the numerous professionals involved, should she be given the option of having an independent advocate?"

The most frustrating observation from doing this project is that all of the services seem to be singing from the same hymn sheet; the ambulance, the police, the hospitals, the mental health services and the patient all want to work together to find the best outcome. It's a shame we are just the people doing the work. It's a shame we are the ones in contact with the patients. It's a shame politics and budgets play such a huge part in patient care. The concept of 'failure demand' is painfully evident in all facets of mental health care. There is a huge failure to do what is needed, and what is done is not being done properly. That is what let this patient down to a point. None of the services she interacted with on this occasion can be free from blame, likewise, neither can she. Her actions, albeit triggered by cause and a lack of appropriate care and management, put us in a no-win situation where the police are our only option, as only they can restrain and section. Not at all ideal for any party involved, but everyone did what they had to do to cover their asses as Laptop Cop eluded to. I have no doubt her behaviour is a symptom of her mental illness but we can only act on what we see in a moment. We knew her on this occasion but another crew may not, and without any prior knowledge of her history, her actions cause a barrier to be put up between her and those who are there to help.

If all services were allowed to work together, like we all clearly want to, then change can and will occur. Maybe if more people could see that through social networking different aspects of the health services are indeed trying to understand each others' roles better and then perhaps that could be transferred into improving patient care. At the end of the day that is what we are all here for; the patient. How can anyone expect a patient to buck a trend, make positive changes and take steps to get better if the very services there to help them won't do the same? Just sayin'!

I'd like to thank Laptop Cop, Mental Health Cop, @jakkicowley and Stewart Thomas for their input on this project and a special thank you to @Sectioned_  for sharing her feelings and experiences from the patient's perspective. EMS and police blogs can be very one sided I feel that, in this post especially, the patient's view was the most crucial. I recommend all their blogs and Twitter accounts for anyone interested in policing, health care and mental health.

Pass the Donkey - Part 2

"46 year old female, suicidal"

Continued........

When we arrived at the hospital we were not greeted with open arms; in fact, quite the opposite. For the first time in my career the charge nurse refused to accept the patient. He didn't 'want her nonsense' in his department. As far as he was concerned she had been discharged from A & E and was not his responsibility. Obviously I didn't take this lying down but at the end of the day I have no power at all so we went and waited in the corridor like naughty school children until someone above my pay grade could decide what to do next. Obviously there were implications for our patients current mental state. I can only imagine what it must feel like to be taken somewhere you don't want to go and then be refused entry the place you have been assured will look after you. She did not take kindly to this rejection and despite the corridor being full of other ambulance crews and their patients she continued to scream, shout, swear and abuse. It was frankly embarrassing and something the hospital has a responsibility to avoid at all costs.

I felt it was important to get the hospitals view so invited Stuart Thomas, a charge nurse in a busy city hospital. I asked him how he felt about regular patients, suicidal patients and what he would do in this situation if presented to him and if there are circumstances in which a hospital refuses patients:

"From a nurses point of view, there isn't really a question of whether to accept hand over or not, the patient 'claims to be suicidal' so the patient stays to be assessed for suicide risk and medical clearance with an aim to refer to mental health services. Standard practice for any mental health patient. 

Capacity needs to be assessed and documented, if they have capacity then at least if they leave, your partially covered. 

So the treatment of the patient in question, isn't really an issue, it should happen, it needs to happen and clear discussion about the management of this patient should be carried out with the mental health team. 

What's more concerning in this case is the aspect of staff safety, without knowing why the police were called it's difficult to assess however standard practice can be carried out, nurse in two's, remind staff to look after personal safety, clear exit points for example. Request security to be nearby to maintain staff safety. If the patient kicks off then police get called, senior review and look at other options (section by mental health team or prison or sedation...but not too much or the mental health team won't be able to assess) 

What people often forget with frequent callers is that every episode should be treated separately, with respect and dignity, something I pass onto staff constantly. 

This case when broken down is simple and clear cut. Easy to manage with the right input."

Clearly, for the second time in an hour, the proper procedure was not followed and again we were left in a situation where I was unhappy and the patient was getting more and more aggravated. As we couldn't stay with her indefinitely and as the hospital would not accept her I had no choice but to call the police back. After 5 minutes we got the following message:

"No units to send, we will not be attending unless requested by the hospital. We have already attended this CAD"

So now we were stuck a corridor with nowhere to go and no plan ahead. I then asked the patient to get off our bed and sit on a chair. She refused. I'm guessing it was her chance to fight back and in a way I don't blame her. We had effectively been playing the kids card game 'Donkey' where the object is to make sure you are not left with Donkey at the end of the game. That was no different to this situation, as crude an analogy as it is, to look at the mental health patient as the donkey. As an ambulance service we want either the police to take charge or for the hospital to take her. The police didn't want to get involved as it would tie up officers for hours and the hospital didn't want to know because then they would have the responsibility. We were stuck with the 'donkey' with no one to pass it to. A cruel analogy yes, but despite knowing what should be done, no one seemed willing to do it on this occasion. We sat in that corridor for a further 2 hours, totalling 4 for the job. When she got off of our bed and used the hospitals toilet she became their responsibility so we left. Not ideal for the patient but what could we do? It is therefore only fair to get one more opinion on this. 

I'd like to introduce @Sectioned_ who has been a patient who's experienced the our ailing mental health system and has had dealings with the police, ambulance and hospital from a patients perspective. I asked her what it is like to be a patient in a similar situation. What is the mindset? Where no one wants to know, being forced to do things you don't want to do and having doors closed on you by the services supposedly there to help:

"When you’re suffering extreme emotional distress, let’s face it: you’re not at your best. You may not be great company or easy to deal with. That’s because you’re in pain. Not the bleeding-from-the-head-put-on-the-oxygen-mask kind, but pain nonetheless. And you want that pain to stop. But you don’t know how to make it stop. And you don’t necessarily pick the best options for making that happen because you’re not in an especially “resourceful” state of mind. (At least not in a helpful way: after all, swigging from strangers’ pints is a pretty resourceful way to get drunk and blot out the pain … but it’s never going to end in a good way.)

Whenever I’ve dealt with emergency services personnel, they’ve arrived at a time of crisis. Of course they’re human beings, good and bad; but in a crisis they interact in institutional ways, according to training, codes and protocols. They’re there to do a job, which is to somehow resolve the situation that presents itself to them in the moment.

They’re not there to fix your life. They’re not your mummy. They don’t love you. Similarly they’re not the housing benefit office that’s just written to say your benefit’s being cut; or the doctor’s receptionist who didn’t give you an appointment right away; or the hole in your pocket that meant you lost your purse. But it’s all these sorts of things and a million others that will be pressing on you in that one moment to contribute to your emotional distress.

Sometimes when you don’t know how to deal with these emotions you end up feeling completely worthless. Totally messed up. That you’re a burden. That people would be better off if you were dead. And that you’d be better off dead.

But here are the emergency services standing in front of you, trying to get you to do something you don’t want to, like move here, sit there, when all you want to do is cry out in pain. The priority of the emergency services is not to make your pain go away. Though they might well see you as a pain to be resolved, one way or another. 

This woman needs help with how she copes with her life. She needs coordinated mental health, physical health and social care services; pre-emptive measures. Each time she calls on the emergency services, it's an example of "failure demand": a demand generated by the failure to do something or to do it right ("Failure demand" is a concept invented by occupational psychologist Professor John Seddon and introduced to me by @MentalHealthCop.). It’s not about who’s going to transport her, or whose bed she sits on. These practical problems, which the emergency services are tasked with solving, are merely symptoms of a fragmented system that’s clearly been passing her around between different services for long enough for her to be seen as a right royal pain in the nether regions."

I decided to do this blog out of frustration. Frustration the patient didn't get the treatment she was entitled too. Yes, she drains resources, yes, she is often abusive and yes, she is an extremely difficult patient for us, the police and the hospital to deal with, but this does not negate anyone's responsibility towards her. Stuart Thomas summed it up perfectly. 'Easy to manage with the right input'. I think the one thing that is apparent after gaining a variety of opinions is that a lot depends on who you get. Like in every job there are good eggs and bad eggs. There are people at the start and end of their shifts. There are people who have passion about certain areas and not about others. There are good people on bad days. Luck has a lot to do with it. What that proves I don't know, but I think it does highlight the need for more communication between services, mental health teams AND patients. The patient's voice often goes unheeded but is one which I feel should carry the most weight. I think this is much more pertinent in mental health as we are not adequately trained to deal with it and therefor don't understand their mind-set and what does and doesn't help. If there was an open dialogue and agreements between services in place this job may not have escalated like it did. Personally, if the PRIVATE ambulance hadn't kicked out a vulnerable adult onto the street I probably wouldn't be writing this blog in the first place! Just saying! *cough NHS Bill


To be continued........


Part 3 - Click here