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