No seriously, leave it with us!

"34 year old female, under section, delusional, ready now"

It doesn't take long for mental health to rear its ugly head again. It didn't take long into the shift either too, 07:03 to be precise before we were off to a sectioning. In a change from the norm we were transporting from the A & E at one hospital to a specialist psychiatric hospital. There were no immediate safeguarding issues as she was in a place of safety so, in theory, it should be a simple load and go. Who am I kidding?! It's mental health! 'Simple' is never a word that is used around the transferring, admitting and sectioning of mental health patients. There is always far too much red tape, hoops to be jumped through, dragging of heels and differences of opinion, to make the simplest of things simple. Besides, where is the fun in having a fully accessed, ready to transport patient, complete with escort and a willing receiving unit?! Boring! We arrived at the hospital to a full welcoming party; lots of smiles, waves and enquiries after our health and wellbeing... OK, that's a lie; a miserable looking matron pointed at bed 1 and said 'she's in there'. That's more like it! 

Our patient had been in hospital for 32 hours. There were points where she had been on the verge of discharge but due to relapses in her psychosis she had 'flipped' and become volatile and violent again. To calm her down they loaded her with diazepam in the hope she would be lucid for transport. It appeared to have worked! She was lying on the bed, asleep, husband by her side, and the AMHP who had been with her for 14 hours and on duty for 23! THIS was encouraging. We put the beds together to make the transition across an easy one. Her husband woke her, she looked at him, she looked at the nurse, she looked at us, she looked at the bed next to her, she looked at us again... then the shouting began. Not so lucid after all. After 20 minutes or so we had made no progress. No hospital staff had attempted to help us, the exhausted AMHP from the hospital we were taking her to was trying her best but failing. The patient's husband was shouting, the patient was shouting (in another language now) and then she got up and made a dash for the exit. We initially tried to stop her but the husband said she was going to the ambulance and the AMHP seemed keen to get her on board. We went with it and that is exactly what she did. 

We now had a patient, under section, in the ambulance complete with belongings, notes and the husband. Where is the AMHP?! In her car. This concludes her involvement! It appeared we had the parcel, the music had most definitely stopped! NO NO NO NO NO NO NO! I went back into the hospital to remind them we were supposed to have an escort. I was told she wasn't their patient and there were no staff or security to send. Brilliant. I went back to the ambulance where our 'calm' patient was now trying to escape from the ambulance. She was not safe to transport in this way; we had no means to restrain her, nor the man power. We requested the police. This is the message we got back:

"Sorry, this is not in our remit; the hospital will need to provide an escort / security for the transfer"

I get it. Yes, that is what they are supposed to do but they haven't. This is not the hospital asking the police to be the escort, this is me, the ambulance, the police service's best mate if you will, asking for assistance. I went back into the hospital to say they had to provide security for us as it wasn't the police's remit. This was the response I got:

"We only have passive security here, if you need an escort the other hospital will have to provide it, not us"

I'd already been told by the AMHP before she foxtrot oscar'd that this was wrong and her hospital (15 miles away) had no one to send, nor was it in their remit. Back in the ambulance, my crew mate was assisting the husband to restrain the patient manually as she was lashing out, punching the windows and threatening suicide. This was starting to feel like a wholly inappropriate, possibly illegal situation. Do we actually have the power to restrain? I'm going with 'yes', as I was restraining her for my own safety, but it does beg another question: is the AMHP legally allowed to leave, abandoning a duty of care, especially to a vulnerable patient who's needs clearly reach beyond two girls in green?! Hmmmm! I made another request for police, as yet again they are the only people I can realistically turn to. This was the response I got:

"We will not be attending this CAD, it's a hospital issue"

Seriously, what are we supposed to do? The patient is now in our care, although the 'being in our care' was a contentious issue. The patient was under section and as such is in the care of the AMHP, but this care was apparently delegated to us (whether we wanted it or not) right before she scuttled off to her car. Unfortunately, had we not wanted to convey, her legal obligation to stay could not be argued with as she was now screeching away in first gear, grinning into the rear view mirror! Back to the matter in hand. The hospital wouldn't assist us, the police wouldn't assist us and our control had told us not to convey if we don't deem it safe. That is easy enough to say, but we can't walk away now; we can't leave her in the back of the ambulance, and letting her run off would make her a danger to herself and others. Why on earth were we in the back of an ambulance trying our best to calm down and restrain a patient in the first place?! This is not what we signed up to when we accepted the job! Remember me saying 'simple transfer'?! Why were the words 'violent' and 'aggressive' not mentioned when requesting an ambulance? Where was the risk assessment? Basically, there wasn't one, or if there was it was written on a tissue in the AMHPs pocket. I imagine it read something like this:

"Call ambulance, say hello, run away."

I'm hoping you now sense the sarcasm in the title! Sensing the delay and confusion over her 'imminent' transport she became violent; she scratched us, bit us and spat in our faces. The three of us, including her husband, were holding her, tears running down her husband's face. I requested police again, this time citing a crew emergency off the hospital premises. This was the response:

"Unit on way, ETA 2 minutes"

At last! Is that how it works?! We have to actually wait until we are bleeding for it to become a police issue? OK, I know that isn't the case but being stuck in a grey area, the police, hospital and ambulance all work within their own policy frameworks. Why, where mental health is concerned, is there not clear procedures in place for the transporting of mental health patients? In terms of restraint, who is best placed to do it? Us? The hospital? The police? I know there are vehement oppositions to restraint, and I only see it as a last resort, but in this case it was a necessity. Does a hospital A & E have the means to restrain for a journey to another hospital? Apparently not! Are the police the most appropriate body to restrain a patient during transport? Apparently not! That's the issue yet again, when it comes to mental health, no one really knows who is supposed to do what! By definition, mental health is a health issue; one that in my opinion should be treated and dealt with solely by the NHS. In reality, it is also a huge part of policing but surely an inter-hospital transfer is not part of policing? Maybe it is; maybe prevention of an assault is prevention of crime! I know for a fact the police will say that the mental health teams are more than equipped to deal with it, and theoretically they are (see this post by Mental Health Cop explaining his stance on what the police should be doing). The problem is they don't play ball, and when they don't play ball, something has to give. Personally, if an ambulance crew requests police to their location then that is what they should get! Thoughts?


I'd love comments / thoughts from police, ambulance staff, hospital staff, AMHPs and anyone who has an opinion on these issues! Get talking!!

Nan Down!

"81 year old female, fall, unable to get up"

Falls are a huge part of what we do. Very rarely is there a shift where we don't do one or more. In terms of time it is a massive drain on resources due to the sheer number of falls and time spent on scene assessing them, treating, and /or referring them. As a job I love them, and in terms of the bigger picture, there is no way to reduce the amount of calls. We are an ever ageing population and if anything, the number of elderly fallers will continue to rise. 

Today we were met at the reception by the Warden who showed us round to the apartment. As I entered my head was turned by the Aladdin's cave that was in front of me. The place was full of knik-knaks and I mean full! Every inch of wall space was taken up with shelves, cabinets or photos. There were collections of crystal owls, frogs, spoons, thimbles, teddy bears, miniature houses, Kinder egg toys, McDonald's toys, cigarette cards, coins, stamps, the list was endless! A lifetime's collection in her tiny apartment, and it was all dust free! We found our patient on the kitchen floor, propped up by a cupboard and sporting a beaming smile.

"Hello my dear, what's happened today?"

"Pardon?"

"Hello there, what's happened?" I said slightly louder

She shook her head and beckoned me down to her level. I knelt down beside her and tried again.

"What's happened today?!" I said by her ear.

"I'm just pulling your leg, no need to shout, I'm completely deaf" she said with an air of amusement in her voice.

I had a little chuckle while she laughed away! I grabbed a pen and paper and started writing questions for her: Any pain? Are you dizzy? Do you want to go to hospital? etc. She seemed a very happy lady and just wanted putting back in her armchair so she could get on with her puzzle! We obliged, helped her up off of the floor and helped her to her chair. She was all smiles and had the most infectious laugh. She laughed at everything! Whilst my crew mate was doing her OBs and I was doing paperwork, she continued with her wooden puzzle; I couldn't help but join in! She squealed with excitement as I found a piece, I even got a little clap. She insisted we had a cup of tea and some biscuits with her so that is what we did. For half an hour we sat there doing a jigsaw, drinking tea and eating shortbread whilst writing down questions and having her answer them. Between the three of us we made a sizeable dent in the puzzle but not one in the paperwork! 

As much as this job needed two people to pick her up off the floor, she also needed the company; maybe not physically, but emotionally. She told us no one ever takes an interest in her puzzles. I suppose having a conversation with someone who can't hear you can be frustrating but no more so than for her. A huge part of our job is dealing with the lonely. A lot of time they call simply for company and time is not something that we have a lot of. Today, however she got the conversation and entertainment she needed. I'm sure the big wigs in the Ivory Tower would have preferred we just picked her up, scribbled our paperwork and rushed off to the next job but there has to be a balance between the human element and the target driven machine that is the NHS. I love these jobs; I could do them all day every day. I moan a lot about the drunks, the abuse, the minefield of mental health, heavy lifting and time wasters amongst plenty more; one 'Nan down' and it's easy to remember why we do what we do. In terms of targets the job was probably a complete failure; the call had been held for a few hours, we travelled from a fair distance away and we were on scene for ages. For me it was a success; patient was happy, treated at home, I was happy, and I got tea and biscuits! That is how the success or failure of a job should be judged!

Unsocial Networking

"Does social networking make you unsocial?!"

This week I read a blog titled 'Are you a secret blogger?' by Big Fashionista. It got me thinking a lot about blogging in general and the social media that surrounds it. The question was about who, in your life as a blogger, really knows what it is exactly you are doing? Obviously, the people closest to you are your family and friends but in terms of your blog, the reality is, they aren't.

When I came into blogging it was all new to me. Social networking consisted of having a stagnant Facebook page with a timeline full of people I went to school with but, in reality, couldn't give a crap what they had to say and I'm sure the feeling was mutual. I took the plunge and started my blog with no expectations. After 16 posts in the first month I had reached a measly 212 blog hits, most of which were me. Nothing to write home about, but then again I wasn't really telling people, not because it was private, but I didn't know how. Then I started to understand how Twitter worked and to be honest, everything changed. 

For someone not au fait with computers, Twitter was a strange concept to get around. So... let me get this straight, I tweet, re-tweet and mention and in return I get mentioned? You hashtag things, things trend, you follow people and they follow you? Clicking my first 'follow' button I felt a bit like a stalker to be honest! Anyway, despite my scepticism my blog started to get read; people would talk to me about it, leave comments and engage in conversations and debates. I followed more people and more followed me. Inevitably relationships are formed; you find that you have 'friends' in this online world that know more about you and what you do than your 'real friends'. I have put both of them in inverted commas because I don't really know what context either should be. I suppose it depends on your definition of a friend. I would say I am closer with a number of people on Twitter than I am with people I have known for years and socialise with regularly. Social media and networking is a very powerful machine and for me it has changed my life for the good. That's not saying it is without it's flaws. Twitter and the blogging community can still be like the school playground; there are bullies, backstabbers and those who just don't like you and will not hold back telling you so. There are trolls who will always leave negative comments no matter what you write. There are those who think they know best and have a right to try and belittle what you write. It is no different to every aspect of life, except, like many of your online friends, they to have no face and can hide behind that. Luckily these people are in the minority and if anything it spurred me on!

My blog is now a huge part of me. It is my hobby, my place to vent frustrations and share my troubles at work. Writing is almost like a second job! It is no different to me playing two rounds of golf a week, spending hours in a pub or sitting motionless watching all the soaps on the box. It is something I am immensely proud of and take great pleasure in writing, so why is it that my friends away from Twitter and work take no interest? If I was doing something that was on TV I have no doubt they would want to know more. Instead, I am writing and talking about my writing to people who do care. People I have never met, yet people who ask how I am and genuinely seem to want to hear the answer. As these people are the ones I connect with, it is these people I spend my time talking to. Unfortunately, that isn't done by have a traditional conversation sitting in a pub or a coffee shop. There are no lunches, dinners or regular social gatherings. It is all online and in a world of smart phones it is done at the end of your fingertips. Many a message, email and tweet is shared, many a comment left and it is all very engaging but not so much for the family and friends watching you do it. I have often been accused of always being 'attached to that bloody phone'!

If you are to believe the Daily Mail article, using iPhones and iPads make us bad parents. In fact, overuse is verging on neglect and a culture of 'passive parenting' has engulfed our society. Like everything, it's about finding a balance. It's also well worth ignoring everything that the Daily Mail says! One thing I can relate to though was in an article about withdrawal symptoms from smart phone. I do find myself strangely addicted to my phone. The 'phantom vibrations' they talk of are something I have experienced and it really does show the reliance I have on my phone. Could I go 24 hours without checking my phone?! No, probably not, but when asked that, I thought, 'could they go 24 hours without doing their hobbies and talking to their friends?! It's all about what is deemed to be socially acceptable. If I spent all the time that I blog and talk on my phone running, going to the gym or playing Xbox no one would batter an eyelid. My housemate says he might as well have a conversation with the back of my laptop and in general, the excessive use of my phone or laptop annoys people. What I don't understand is from the moment I open my laptop at no point does he engage in conversation with me, yet I am the unsociable one? Is it still the mid-90's stigma of computer geeks and 'dotcoms' that people don't understand? If people talk to me I talk back! I find it hard not to reply to messages though, not to check my emails and maybe that is something I should learn to do better.

Where is the line drawn between your social life and your online social life? Does being sociable online make you unsociable offline? Does being unsociable online make you more sociable offline? I don't really know, but as a blogger, I don't think I'm alone in saying when I am not blogging or am away from my computer or phone I miss it. I either want to write, promote my blog or chat to people in the blogosphere. It is after all something I have watched grow from scratch to what it is now. Can social networking exist alongside a fully functioning, full time, working family and social life or will there always be detesters to the online world? 15 years ago I would have probably said they can't but it's 2012. Having online friends is much more socially acceptable and year on year the two worlds are edging ever closer to being one.

Thoughts on a postcard please......

The Collapse

Yesterday I read a blog by Inspector Gadget titled 'The Collapse of the ambulance service'. As I read it, I nodded along and to be fair I couldn't argue with a lot of what was said. It sang very true. However, as it was written by a policeman, it very much looked at the issues from the police view point. And why wouldn't it!? Like everything though, there are multiple sides to an argument and different perspectives to be had. If you asked ten different bloggers to blog about the same subject you'd have ten completely different blogs at the end, all with their own personal slant and identity. I could have easily written a post called 'The Collapse of the police service' but instead I will just say my thoughts on the issues highlighted from the ambulance point of view.

I can't disagree with anything that was said. I have experienced police waiting for ages and ages for an ambulance, often with patients that do need us. Working in a city, the distances travelled are smaller than that in 'Ruralshire', but it is all relative. We may not cover three counties, but the higher call volume has the same effect on resources. At busy times, rather than travelling 2 miles we are travelling 7, and at the times of day when we are needed the most there always appears to be less units available. The government's cuts ARE killing the ambulance service, not necessarily from cutting numbers of front line staff directly, but by limiting the opportunity to employ new staff and a huge void is being left by the dozens and dozens of staff leaving each month. As a consequence, the shortfall results in a reliance on private ambulance services and volunteer community responders to help fill the gap. At busy times it does feel like we are on the verge of collapse. Calls being held for hours, general broadcasts asking for crews to help with waiting jobs, messages asking for staff to work on, offers of overtime every day of the week; it's never ending. Yet the work we are doing still seems the same; time wasters, drunks, sniffs and colds and *cough cough* police jobs.

Yes, whilst the police are frustrated with being called to 'perceived risks' because a patient at an address once had a knife 3 years ago, or an occupant once looked at a crew funny, we also have our frustrations. I can see their point, a lot of the flagged addresses need reviewing, but at the end of the day we are not equipped to deal with the risks that may or may not be there. We have no training in dealing with situations which turn sour, unless you count a half day course in conflict resolution. We also have no means of personal protection; no CS spray, asp, Taser etc, and no legal means of restraint. We also don't have the back up in sheer resources the police seem to have. It's a running joke that when we request police for an assault the 'no units available' on the previous job turns into 4 cars and a meat wagon for the most innocuous of jobs. But who am I to say what resources should and shouldn't be allocated? I'm always grateful, but is there now an expectation that ambulance crews should put themselves more at risk to save police resources?! I know the Daily Mail think we should! A crew was recently maligned because a patient died whilst they were waiting for police. If I get a message saying 'patient is violent' I will not go in without police. If the police take an hour to arrive, so be it.

We do call the police routinely for a number of jobs like domestic violence and assaults, but shouldn't that be the case?! They sound like jobs that police should be doing. It is crime after all! How about all the ambulances the police call for chest pains in custody, cuts and bruises post arrest and a variety of other calls where someone with a 'first aid at work' certificate could deal with it? Do these require an ambulance from an already stretched service? Yes, because no one wants the blame when the shit hits the fan. That's why the police rely on us and why we rely on them. If we get attacked because the police didn't show up the finger will be pointed and if someone dies because we don't show, the same finger is pointed. There have been times where I have waited hours for a police response. 'No units to send' is the answer we get, and it is the same answer we give them when all our ambulance crews are queued up at the hospital because there are no beds to offload our patients on to. Starting to see the chain? Hospital full, ambulances tied up waiting to offload, police tied up on jobs waiting for ambulances, ambulances stuck on jobs waiting for the police who are waiting for an ambulance, basically everyone is stuck and no one will budge, because we won't do the other one's job and can't! 

Maybe this is why police and ambulance have that 'special relationship' I have discussed before. There is a mutual respect for the jobs we are doing; we are sharing the same frustrations and the same difficulties, day in, day out, with no end in sight. Inspector Gadget calls it 'The Collapse of the ambulance service', I say it's 'The Collapse of the emergency services'. Well, the 2 that count anyway. While police are fighting crime and bitching about the ambulance control room, and while we are saving lives and bitching about police control room, the fire brigade are pumping iron, practicing "getting onto the truck the quickest" & having well paid second jobs. When they do wake from their slumber, they go on mass (25 fireman) to rescue a seagull from a pond. Yes, that happened, read this! Nothing will ever change; under the current government purse strings will only be pulled tighter, and no matter what government is in charge the police and ambulance service will both continue to cover their own arses whilst being run ragged! To quote Mother Teresa:

"We the willing, led by the unknowing, are doing the impossible for the ungrateful. We have done so much, with so little, for so long, we are now qualified to do anything, with nothing."

A sentiment that rings true for all of us. On a serious note though, if you can get shares in ‘Bluelight services’, then do so now. If I earned decent money, I would!

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?!