Emergency Service

Well, it's that time again. Time to introduce Inspector Michael Brown, author of award winning and acclaimed blog, Mental Health Cop. Normally, I drag him out to discuss all things mental health. However, this time, my narcissistic side, just couldn't resist sharing his words with the masses. Namely, because one of the tails of heroism he refers to is me, and to be brutally honest, I dig that shiz! It's also confirmation that the ambulance service is indeed the BEST emergency service.

So, with all the fanfare it deserves, and a dosage of pomp and circumstance, I present to you, 'Emergency Service'! 

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I sometimes remember to marvel at some of my colleagues and did so again over the Christmas period – ordinary men and women doing an extraordinary job, away from their friends and families whilst we were at home – (it was my turn to be off!) Their pay has been frozen for the last few years with their pensions being eroded compared to those they were promised when they joined up; there is comparatively little or absolutely no training for some of the functions that they are expected to undertake in their role; and sometimes they are patronised and misunderstood by senior members of Government who don’t really get their role at all.

CRIME, SAFEGUARDING AND PERSONAL BRAVERY

A while ago, one of them was at a job where a man had attacked his partner with a knife and the man was known to have a risk history that flags up whenever you attend the address. Back up was a distance away and consumed by an instinct to protect the woman and get to her aid, she went in to that unknowable environment on her own. What she did what she got in there meant the man fled with his knife, the woman was safeguarded from any further threat and it could be declared safe for paramedics to roll the ambulance up to the door. The man was arrested a short-distance away, but that early evidence meant we could prove that he *was* holding a knife during the incident. Crucial evidence, nicely preserved by a brave professional witness who put herself at risk.

You’ll remember this blog was prompted whilst I was off work this Christmas: I remembered what it was like working on the frontline last year – Christmas Eve in particular was a real bender of a shift and resources were so stretched that by about 3am (on Christmas Day!) I was first on the scene of a stabbing. A man so badly injured that his wound was an open chasm in his neck and there were half-pints of blood all over the pavement. I was soon joined by another set of blue flashing lights and before much else could happen, my colleague and I were rolling on the floor with this bloke, fighting him to let us apply pressure to his neck wound so he didn’t bleed to death in the road. We both got knocked about a bit, but nothing serious and wondered afterwards whether this man was as high-as-a-kite on cocaine? But the ambulance crew and more officers turned up and off he went to hospital.

Earlier this year, we had a very mentally distressed lady in police custody – a person in a condition of some particular agitation and obviously very unwell. As various medical professionals have suggested we should, I remember asking the custody nurse whether we could be sure that her basic obs indicated nothing was seriously physically wrong with her – was she actually safe in police custody? The nurse checked the custody record medical forms and admitted she didn’t know. She agreed she should do them again to be certain and saw what I was getting at. Was her heart rate OK, her blood sugar, etc., etc.. The nurse being there with all of her gear, you’d hope and think that a nurse would be able to reassure someone perhaps to a greater degree than someone in uniform that they wanted to check them out, to help make sure they’re OK? This lady couldn’t see that and I patiently watched two of my colleagues spent 90 minutes of constant patient and compassionate conversation turn this into a position whereby the obs could be done and we could relax that she was not potentially seriously medically ill, as well as distressed.

EMERGENCY SERVICE

I could go on and on – the point I want to make here is thatnone of the colleagues I’m referring to above are police officers.

They were all paramedics from our ambulance service. 

It was a paramedic first-responder that intentionally put herself at risk where a man had taken a large blade to his wife, to safeguard her and she unintentionally contrived to be able to provide evidence against him that helped convince the court he was a dangerous liar; it was a paramedic who got physically stuck in to a man who was bleeding heavily but fighting not to be helped; it was two paramedics who came into police custody and spent 90 minutes patiently persuading one of the most vulnerable, psychotic and distressed people I have ever met, to let them care for her.

I could still go on and on – the story of the paramedic in London who continued to provide care for a drunk man just after he’d been hit over the head with a fence post by that man; the paramedic in Suffolk this Christmas who ran into a burning building before the Fire Brigade could arrive to rescue a trapped woman and immediately give her respiratory support; the paramedic who accompanied three officers into a building where there was a risk of a gas explosion in order to assess a man inside – all were hurt when the building exploded, a risk that they knew they were taking.

It is my genuine privilege to work alongside these people – as we do every single day. Despite the very obvious differences between policing and pre-hospital healthcare, there are many overlaps and at the core of it all is dedicated public service at times like Christmas or during family birthdays and other events. It is my view that paramedics are paid peanuts for what they do and they are probably more messed about and taken for granted with the rubbish that is thrown at them, than we realise. The stories of people ringing 999 for an ambulance because they can’t be bothered to walk to hospital or see their GP; the Home Secretary contriving to refer to them as “ambulance drivers” in apparent disregard of the training and qualifications they must have and the media quick to pick up on paramedics not diving into a lake but aren’t mentioning the one who ran into the burning building.

It just beggars all belief that they aren’t considered an emergency service – I have certain views about that!

The practice guidelines for paramedics is a telephone directory sized book and it has four pages of information on about mental health, some of which is wrong! It probably isn’t as widely known as it should be, how many paramedics will say that they want to be able to do more for people in mental distress – they want to access NHS referral pathways, have options for removal to care settings that are more appropriate than A&E and be trusted to take pre-hospital clinical decisions. Let them serve us better, because they want to do it and are currently blocked from trying. We trust these people to get to grips with our heart attacks and strokes and to know what to do when time is of the essence – surely we can open up the mental health pathways and trust their clinical judgements?

So I want to circulate my admiration for my colleagues in green and help build awareness of the stuff they do for you and for all of us each and every day.

We would notice if they weren’t there to do it for us, trust me on that.

Twas The Night Before Christmas

Christmas is that time of year where you get to see your family and friends and be merry! You get to over indulge, share gifts and sit at home in the warm, watching your kids enjoy the magic that Christmas brings! Being Christmas eve, they have the excitement of leaving treats for Santa and his reindeer. It's the time of year where we all have our own traditions and I think that is what we all look forward to most. Well, by we, I mean those who are not working. Christmas this year consisted of 12 hour late shifts so I would be enjoying none of the above. It's one of the sacrifices we make to do this job. In all honesty, I hate it. Every single minute of it. I don't want to be at work in the slightest and it is part of the job I didn't think about when applying. There is only one thing worse than being stuck on an ambulance over Christmas, and that's being stuck on a car. Yes, I want you ALL to get the violins out and throw sympathy in my direction. And chocolate. An absolute tonne of chocolate. Anyway.......

Full of joy and Christmas spirit (not Baileys), I headed out of the garage to my first standby point. After only 5 minutes of sulking I was heading through the Christmas eve traffic on way to my first job. 

"52 year old male, chest pain"

The words ' Chest pain' don't provoke any emotion in me anymore. As someone who works on the car it is my most common job. More often than not there is no chest pain at all. It is probably the most abused term within ambulance triage. People know chest pain will get an ambulance immediately. If they cough and it hurts, chest pain. Panic attack, chest pain. Headache, chest pain. Got a cold, chest pain. Rib injury, chest pain. I could carry on forever. Within about 2 seconds of seeing a patient I know if it is proper chest or not. 

I pulled up at the address and headed in. Due to the patients age it was feasible it was genuine so I took everything I might need. I headed up the stairs and into the bedroom. There he was, lying on the bed. I knew instantly he was having a heart attack!

His skin was ashen, he was pouring with sweat and had central, crushing chest pain that came on at rest, which was radiating into his jaw. A classic cardiac story with a classic cardiac look was as good as a blood test and ECG! Sure enough, within minutes I had the ECG in my hand and it was one of the biggest heart attacks I've ever seen! The type of heart attack know as a 'Widow Maker' and elevation on the ECG known as 'Tomb Stoning'. I think you'll agree, both are ominous descriptions!

I requested the ambulance on the hurry up and then explained to the patient exactly what was happening and what was going to happen now. I gave him a variety of drugs to help with the pain and as soon as the ambulance arrived we were gone and off to the heart attack centre. The cardiologists were waiting for us and he was wheels straight into the cath lab. As we were transferring him he went into cardiac arrest. 

He was shocked immediately and was back with us within seconds. We had an anxious wait while the doctors prepped him for his angioplasty. He arrested a further three times during the procedure but eventually the clots were removed, stents fitting and the good news was passed to his family that he will be fine. Job well done by all!

Back in my car, I recommenced my sulking and the hours ticked by slowly. Apart from the first guy, no one needed hospital. I made referral after referral and with about an hour to go was clock watching until midnight. Then I could wish myself a merry Christmas and go home. Or not.....

"63 year old male, cardiac arrest, CPR in progress"

It wouldn't be Christmas without a cardiac arrest! I pulled up on scene seconds after the ambulance, grabbed everything I could and headed in. Sure enough, lying on the floor was our patient. The relatives were still doing good CPR so the crew had got them to continue. The patient had vomited so his airway was soiled and that became the priority. We suctioned and secured the airway, got the pads attached and shocked him. 

The crew was one of my good friends so working together in a situation like this was easy. No egos to deal with, we each just did our think. IV access was obtained and subsequent shocks were given. 

"I've got a pulse!"

Back in the room!! We set about stabilising him. His heart was in a very unstable rhythm so we couldn't move him quite yet. It was only now that I realised the sheer volume of family that was in the room. There must have been about 20 of them. This is why I hate working Christmas. I don't like to be part of the reason peoples christmas' are destroyed. I don't want to be there when people die. I don't want to have to give bad news to people during a supposed joyful time. 

We did his ECG and it showed another massive heart attack. Back to cath lab we shall go. We got him off the floor and into the ambulance. The hospital was alerted that we were coming and we left. On the journey the patient begun rejecting the airway. On one hand this a good thing, because he's getting function like his gag reflex back. On the other hand, a vomiting patient with a soiled airway is difficult to manage in a moving ambulance. Unfortunately, he started vomiting again so we had to remove the airway. He still wasn't breathing sufficiently on his own so we inserted nasal airways and between the two of us, ventilated him until we got to hospital. 

Same old routine, arrive, handover, to the cath lab, angioplasty, blockage cleared, stent fitted, high 5's all round. We had missed midnight but we there were smiled a plenty in the back of the ambulance. It was now Christmas day, we were late off and covered in vomit but none of us cared. I suppose we gave the best Christmas present that family could ask for. Puts my sulking into perspective really doesn't it?!

With the ambulance cleaned up and paperwork done we headed back to my car. I waved the crew off and started to head back to station almost 14 hours after I started. At least the shift was over!

"General broadcast, all mobiles. Need an ambulance and an FRU for a cardiac arrest. Can any unit please press Green or come up on priority. I repeat, we need an ambulance and an FRU for a cardiac arrest. Can any unit please press Green or come up on priority. We currently have no one to send."

I was one mile away from it and it was Christmas. Fuck it! 

"Red base, I'm currently returning to base x-ray but if you have no one else you can send it to me. I'm feeling festive!"

"You're a legend, on it's way to you now"

"64 year old male, cardiac arrest."

Here we go again......

To cut a long story short, we got him back (again), massive heart attack (again), off to cath lab (again), angioplasty (again), blockage removed (again), stent fitted (again). Happy family (again). What are the chances?! 

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UPDATE March 2014:

One of my biggest gripes about this job, is the lack of follow up of patient outcomes. We may get people back from the dead and get them to hospital 'alive', but very often, that isn't maintained. Obviously going into cardiac arrest is a HUGE event for the body and survival relies on a number of factors, none more important than early CPR. Without that, there in no chance at all. IF, there is early CPR then there is still a huge set of circumstances that will lead to survival. An ambulance quickly, quick defibrillation and then being taken to the right place for definitive care. Even then, the is such a long road ahead before discharge that the chances are slim.

In the ambulance service, we generally count a successful resus as heart beating on arrival at hospital and as we rarely find out the outcome of the patient journey, that's where our thinking stops. I left these patients on Christmas Eve, pleased that we had done our bit and given their families some hope to cling onto, but that's all it was, hope. No one knew how their recovery would go, least of all me, and to be honest, since writing this post, I hadn't given them a moments thought. Just writing that makes me feel a little cold and heartless but such is life!

That is, until I had the most extraordinary day! I turned up at a familiar address on a 'chest pain'. I couldn't place it, but as soon as the door swung open I recognised that family! It was my first patient from that day! He was discharged three weeks later, had lost a lot of weight and was on the mend! He thanked me for saving his life, but wanted another favour! An ECG and a trip to hospital and I was more than happy to oblige! I was so chuffed! You never hear the good news and it makes such a difference! High fives all around!

Anyway, at the end of my shift, I returned to my ambulance station to find a letter in my pigeon hole.

"Dear Ella, 

It is with great pleasure that we send this letter to you as recognition of your hard work  on 24 December when you attended a 63 year old male who was in cardiac arrest. We are delighted to inform you that thanks to your efforts in resuscitating this patient, they survived and have since left hospital."

Now THAT, is one way to send me home in a good mood! Two out of three ain't bad! I like to think the third one survived but perhaps I will never know. Here is hoping! At least two families definitely had a happy christmas! 

A Force To Be Reckoned With

"41 year old male, hit by car, injuries unknown"

The traffic was already at a standstill so it took me a good few minutes to get to the scene of the crash. As I pulled up I could see some colleagues already doing CPR. I did not know it was this bad! I jumped out the car, grabbed some bags and headed over.

"Hello guys, what going on?"

"This guy has been hit by a car, he was unconscious but breathing when we arrived but stopped shortly after. We started CPR and ventilations."

"OK, you OK to carry on CPR?"

"Of course, not a problem."

"What do you want me to do?"

"Can you grab the spinal collars and the suction unit please?"

"Yep, no probs."

I set about attaching the pads to him. He wasn't in a rhythm that can be shocked so we continued working on him, best we could in the circumstances. The rain was absolutely bucketing it down, the three of us soaked through to the skin.

I suctioned his airway which was filling with blood, he wasn't in a good way. I needed to put in an airway but couldn't do it on my own.

"Can you suction here for me?"

"Yep, say when you want me to stop."

"Will do, give me one sec.......OK now."

I pushed the airway into his throat and started ventilating. It was a bubbly initially but air was going in. Unfortunately, the chest wasn't rising properly.

"You got any more gloves on you?! Mine are covered in blood!"

"In my back pocket! Take over CPR will you?!"

"Sure, thanks!"

Once gloved up again I got my cannula roll out and decompressed his chest. I got assistance securing them down and then moved onto the cannula. Amazingly at the next rhythm check we had a very faint pulse. That freed up another pair of hands at least.

"Let's get his legs raised, just use one of those bags. In fact, can you also grab some blankets, try and keep him warm and dry as much as possible. Well done guys, that's great stuff!"

It had only been 10 minutes since I had arrived but it had seemed like an age. Eventually, the ambulance arrived and between the 5 of us we got him onto the bed and rapidly off the to trauma centre. I don't know whether he'll live or not but he'd been given the best possible chance.

That chance came about not because I was there within 8 minutes of him being hit, and not because the ambulance came and we got him to hospital. He has that chance because 2 people had done an incredible job. An incredible job in extremely difficult circumstances. Those two people were police officers. They happened to come across the RTC within minutes of it happening. Not only were they there quickly but they treated him extremely well. They recognised he'd stopped breathing and started CPR early. They didn't have a Bag Valve Mask that we have. They had a micro thin face shield and blew air from their lungs into that of a stranger. They basically kept him alive until I arrived. Once I was there they acted as an ambulance for me. Irrelevant of uniform they did what they had to do to save the life of a member of the public. This is our police force.

This is the same police force facing cuts after cuts. The same police force that has lost tens of thousands of officers. The same police force having their pensions reduced. The same police force who get maligned on a daily basis by all of the gutter press. The same police force who are expected to work in the face of abuse and violence on a daily basis. The same police force we all rely on when the shit hits the fan. The same police force who's morale is at an all time low. 

I for one am fed up of reading the snippets of misinformation reported. We should be proud to have the best police service in the world and I'll be shouting from the rooftops at every given opportunity. We work alongside side them every single day. We rely on them for our safety. We rely on them to investigate crimes. We rely on them to do just about anything to keep the public safe. Well today I relied on them to keep a man alive and they did. We have an amazing police force. Let's not forget that, through all the politically motivated propaganda we are forced to read. 

I wonder of the Daily Mail will report on this. I shall be sending it to them!

The Capacity Games

As I walked into the room he was laying face down on the bed, arm hanging over the side and bleeding heavily. A constant stream of blood was trickling out into the ever increasing pool on the floor. He was seemingly unconscious and very pale. I applied some significant pressure to the wound in the bend of his arm whilst trying to find out what had happened. It turns out that he wasn't unconscious but just playing dead. Within a minute or so he was up and talking, full of bravado and attitude. I applied a pressure dressing to the wound and bound it up relatively tightly. 

In terms of numbers he was OK. His pulse and blood pressure were stable and was showing no signs of shock despite the blood loss. That said, he needed to go to hospital. Clearly this was a cry for help and I wouldn't be happy leaving him on his own. For a suicidal self harmer however, he was surprisingly up beat. Very chatty, very well spoken and extremely knowledgeable about mental health law. He quickly made it very apparent he was not going to be going to hospital under any circumstances and was well aware that currently the ball was in his court. I had hoped some well chosen words and my power of persuasion could have made inroads with him but he was as determined as he was smug. 

Plan B then. If I couldn't force him to go to hospital, then I had to bring the most relevant bits of hospital to him. I discussed options with him and we settled on getting an out-of-hours GP to visit to ensure the wound was clean and appropriately dressed and then contact a mental health crisis team who WILL visit within two hours. Well, that's what they are supposed to do! He was happy with the plan, his dad was happy with the plan and seemed in good spirits. I wasn't happy with the plan but that was probably fed by the compulsion to do something for someone in crisis and not getting my own way. The patient had capacity so this was the best I could do! At a stretch the fact he was drunk could effect his capacity but I was able to have a more than rational conversation with about the pros and cons of staying and going and depute my disagreement with his opinion, it was after all his opinion and ultimately, his choice.

*REMEMBER THIS MOMENT* At this point, no ambulance had arrived, so I phoned control, to tell them that the patient was refusing treatment so no ambulance was required. 

"We also have the police running on this CAD, would you like them cancelled too?"

"Rog, patient is compliant and isn't being aggressive. Cancel police."

"Rog, thank you, red base out."

I explained to the patient and his dad that I needed to go and get my paperwork and phone various people to arrange the referral. I needed to speak to our Clinical Support Desk, the GP and the Mental Health crisis team and that could take a little while to get the ball rolling.  What I did assure them of, was that I wouldn't be leaving until I knew exactly when someone would be coming.

I went down to the car and started my phone calls. Midway through my first conversation there was a knock on the window. It was the dad looking rather panicked.

"He's done it again, I can't wake him, it's bleeding everywhere."

*face palm* 

I hung up the phone and rushed (Ambulance Run - above average walk) into the house and back upstairs. As I got to the landing I could hear the blood pouring onto the wooden floor. He was now lying on his back, other arm hanging over the edge of the bed and blood was literally pouring out of him. He was white as a ghost and unconscious. Again, I applied pressure and held his arm as high as I could. I was now in an extremely awkward situation. *REMEMBER THAT MOMENT* 

I was on my own with a bleed I was struggling to control. I had cancelled the ambulance and considering I had already waited 40 minutes and one never arrived, the chance of getting one instantly was minimal. I had also cancelled the police, who in this situation could be of great use!

"You see the radio on my belt, twist it off, hold down '*' to remove the key lock, then hold down '#' (priority) for me."

His dad followed my instructions and within a couple of seconds the radio started ringing. 

"Hold down the button on the side for me."

"Red base, patient has cut himself again, I need the police and an ambulance as a priority, I'm struggling to control the bleeding." 

"Rog, will do that for you now, nearest ambulance is some distance away, sorry!"

"Right, take the key off my belt loop, in the boot is a big black bag with 'Paramedic' written on it. Bring me that bag please."

Off he ran (Non-ambulance run - Actual running - Weird phenomenon). I managed to apply a pressure dressing to the arm which seemed to do the trick. This time bound even tighter than the first! On his return I got his dad to hold the arm in the air, allowing me to do other stuff. His blood pressure was in his boots so I got a cannula in him (for the medical lot, an orange in the back of the hand, sadistic git that I am) and started running some fluids through. The patient gradually became more coherent and was soon back and telling me to go away and leave him alone. Unfortunately for him and luckily for me, the leaving alone option was no longer viable.

First to my aid was the police. They helped me with everything I was doing and also attempted to convince the patient that now hospital was a must. He was having none of it. 

"You can't section me, I'm old enough to make my decisions and I'm not going to hospital. There is nothing you can do to make me go."

"I think you'll find we can."

"What powers are you going to use to take me from my own home, a place of safety, right here and now. You can't do anything legal and you know it."

The poor copper looked a little stumped and unfortunately had no answer for him which somewhat undermined his authority.

Although the patient had apparent capacity to refuse treatment, on balance I now felt I had reasonable grounds to use the Mental Capacity Act to enforce treatment. As far as I was now concerned he lacked capacity to make an informed decision and didn't appreciate the severity of his injuries. Unfortunately for the patient, he came up against someone with greater knowledge of mental health law than him. I was able to quote section 4(B) of the MCA at him and outline why the deprivation of his liberty was necessary. My rationale was because my proposed treated was wholly or partly for the purpose of giving life saving treatment to him and that, as the medical professional currently in charge of his wellbeing, I was well within my right to ensure he got treatment.

I explained all this in quite a self gratifying speech which left the patient looking rather deflated!

"Aaaaahhh, you just got schooled on the law by a paramedic, aren't the police supposed to know more?! Embarrassing!"

I felt a little awkward but luckily the copper took it on the chin and seemed happy to follow my lead and confirmed to the patient that I could do what I was saying. I also backed that up by telling him that under section 6 of the MCA he could be retrained by the police to ensure said life saving treatment happened and to prevent further harm to himself or us. Faced with three people who were much more well read on mental health law than he was, he quickly got on board with what was going to happen and became compliant. 

When the ambulance arrived he came voluntarily and was most apologetic to all of us. His initial reluctance to go to hospital was easily explained......

5 hours earlier......

A 23 year old guy who suffers from bi-polar and depression, who has a history of self harm and suicide attempts, is feeling particularly low. He is feeling suicidal and wants some help. He tries but fails to get hold of his crisis team. They simply don't answer the phone. Because of these feelings, he has been drinking heavily but being self aware enough to know that he is likely to do something stupid, he self presents and his local A & E. He tells the triage nurse he has been drinking and is feeling very low and suicidal. He said he just wants to die. 

The hospital is very busy, majors and minor are full and the waiting room is at bursting point. The triage nurse listens to a young guy tell her he has been drinking and apparently takes no notice of his medical history and wish to die, so puts him in the waiting room where he waits.....and waits. After 4 hours he got up and left. His cry for help had been ignored by mental health services and his local hospital.  He got on a bus and went home where he carried on drinking. And drinking. 

He then smashed a glass, picked up a shard and rammed it into the crook of his arm. He then called his dad who was downstairs, to tell him what he had done. His dad phoned 999.

"My son has self harmed, he is bleeding from his arm quite heavily."

"OK sir, help is on the way."

"23 year old male, self harm, serious bleeding, access OK"

Luckily I was only round the corner so was on scene within a minute or so. I grabbed all my stuff and headed up the path for my first mental health of the night......

A patients outcome, positive or negative should not be based on luck. Luck that I was close by. Luck that his dad was in the house to find him bleeding when he did. Luck that the bleeding was stopped and he was quickly treated. This should be the basic of mental health care. There are services in place to not only treat this demographic of patients but to safeguard the risks that are associated with their conditions. A patient in crisis and at significant risk of harm should have instant access to their crisis team. Time and time again mental health services are impossible to access outside of 'Mon-Fri 9am-5pm'. It just isn't good enough. With the glaring failings in an understaffed, under trained and underfunded system, the safety net is always A & E. However, combine deep cuts, fed up staff and lack of training with winter pressures and a waiting room full of time wasters and the basics are simply overlooked. 

There was no RAID (Rapid, Assessment, Interface and Discharge) or other liaison service made available or seemingly in place to allow a quick assessment of him. There was also no apparent risk assessment. After only 5 minutes with the guy and a limited knowledge of the Pierce scale of suicidal intent, I had him at a high risk of significant harm. His medical history and presentation alone raised enough Red Flags to warrant a rapid assessment. Instead he was left to his own devices in a waiting room of a busy hospital. Hardly the place for a vulnerable, suicidal young adult to be left. This job highlights the woeful inadequacies of mental health care from top to bottom of the NHS. When will this improve?! 

So, mental health care in the NHS. Discuss.

The Curious Incident With The Jaffa Cakes

"78 year old male, DIB, daughter gave him a box of Jaffa Cakes."

Yep. Jaffa Cakes. Depending on what system ambulance services use to triage calls, they either use AMPDS or NHS Pathways. Call takers follow a series of questions and the answer lead onto another. Eventually you get a determinant, a diagnosis and a level of response. Or in this case, crucial information regarding confectionery.

I love Jaffa Cakes. Probably too much. It is impossible to have just one. Utterly impossible. I think I could easily live on them. They have it all. Now, as much as I love Jaffa Cakes, I did wonder why this information was deemed pertinent. There were a number of scenarios that went through my head:

1) He was given Jaffa Cakes and he doesn't like them. This caused a blind rage, resulting in a heart attack and subsequent DIB.

2) He was given Jaffa Cakes and he LOVES them. This utter joy took his breath away causing carers to think he had DIB.

3) He ate ALL the Jaffa Cakes so quickly that he forgot to breathe and now is struggling to breathe. 

4) He ate ALL the Jaffa Cakes and a Jaffa Cake or part of a Jaffa Cake went down the wrong way causing coughing and subsequent DIB.

5) He choked on a Jaffa Cake and isn't now breathing effectively. 

6) Someone took away his Jaffa Cakes, causing a panic attack and subsequent DIB. 

7) He had COPD and due to being distracted by Jaffa Cakes he forgot to take his medication. Now he has DIB. 

8) He was concentrating so much on his Jaffa Cakes that he didn't look where he was going. He tripped, fell down some stairs, punctured his lung and now has DIB.

9) He has run out of Jaffa Cakes and is now having a panic attack. 

10) He has DIB for an unknown reason. The Jaffa Cakes have absolutely nothing to do with it. 

Well, with all these questions running through my head it was probably best that I went to see the patient. 

No one was waiting for me at the care home so I found myself wondering the corridors saying 'Hello' at sporadic intervals. Eventually I was found and taken to the patient. Upon entering the room I instantly spotted an open pack of Jaffa Cakes. Unfortunately I didn't notice any DIB so that immediately discounts all of my predictions. There he was, lying in bed, not really communicating because of his dementia and there was me standing next to him looking confused. 

"What's the problem today?"

"He has a temperature and his blood pressure is really high. Like really really high."

"I was told something about Jaffa Cakes?"

"Yes, his daughter gave him two packs of Jaffa Cakes. He ate ALL of one pack in one go!"

What a lad! So, that cleared up the Jaffa Cake mystery for now. As scandalous as it was that he ate an entire pack of Jaffa Cakes, it didn't seem totally relevant to my examination. Surprisingly  his blood pressure was absolutely normal, as was his temperature. Back to the drawing board!

The crew arrived a few moments later. For the regular readers, it was the girl who threatened to send me a mongoose a few weeks ago. Her face said it all. She wanted to know ALL about the Jaffa Cakes! She also wanted a Jaffa Cake but she'll strenuously deny this accusation.

"As of yet, I haven't found anything wrong with him. Apparently he ate a whole pack of Jaffa Cakes. I don't think he shared."

Whilst doing his ECG the daughter arrived. The daughter who provided the Jaffa Cakes in the first place! I assure her that at this current moment we couldn't find anything wrong with her dad. I also had to ask about the Jaffa Cakes!

"He ate the whole pack!"

This really did seem to be the sticking point with everyone involved here. We had a man, who is normally bed bound, who by all accounts, had eaten a whole pack of Jaffa Cakes. Then someone phoned an ambulance. It really was a shocking state of affairs. Is this a police issue?! I mean it was a WHOLE pack of Jaffa Cakes and he didn't even share!

The crew sat him up and within about 20 seconds he had projectile vomited everywhere. By this point I was well and truly out of the line of fire, so happily stood at the back of the room by the door watching the clean up operation. (Whilst thinking about Jaffa Cakes)

Another resident of the care home appeared next to me. She was absolutely tiny! She stood next to me in her nightie, clutching tightly to her zimmer frame. 

"Hello my dear!"

"Hello. You do know he ate an entire pack of Jaffa Cakes, don't you? The whole pack. I'd be sick if I ate a whole pack."

"Has he?! What a pig! Did he share them?!"

"Nope, not one, ate the lot. He deserves to be sick."

With that, she toddled off. Clearly the rumour mill in this care home is rife! A WHOLE box of Jaffa Cakes! IN ONE SITTING! And NO sharing. It's an utter outrage and quite frankly I just don't know how he will recover from this. In fact, I don't know how the care home will recover from this. I'm assuming all the national papers have been notified. I expect the tabloids are frantically working on headlines as we speak. 

Whole pack of Jaffa Cakes. Well I never!