Friday, 28 February 2014

Opinions Required

Ok people, I require your help! I did a job a few weeks back that I want to write about. First though, I want some options from you lot! 

"44 year old male, chest pain, suicidal, verbally aggressive, police requested"

That was the information that I had. I chose not to wait for police because I was feeling particularly bolshy on this particular day!

The patients brother met us outside the flat and gave us a run down on his past medical history. The highlights included paranoid schizophrenia, delusions, hallucinations, psychotic outbursts and OCD. Today he is extremely agitated. Despite all of the above, we enter the property without the police. 

I swung open the bedroom door. The patient was standing in the middle of the room. He stares at me. He slowly starts walking towards me.

"Get out of my fucking flat or I'll throw you out of the fucking window, I mean it. Fuck off."

He says this whilst raising his fists.

*          *          *          *          *

So! What I want to know is, what would you do? What should I have done? What are your thoughts on the situation I find myself in? I welcome the views of everyone! Ambulance staff, police, mental health working, nurses or anyone who wants to share what they'd do! Please comment!! 

Thanks, Ella x

54 comments:

  1. Withdraw.

    Primary survey is very clear on this, it starts with a D - if you cannot deal with that Danger then withdraw until such time as it's safe.

    You wouldn't enter the live lane of a motorway, you wouldn't enter a burning building and you wouldn't fight people so why put up with that?

    Background - paramedic with former police career.

    ReplyDelete
    Replies
    1. Thank you! I hope you read the final post when I've collated the information! :)

      Delete
    2. What's the danger here? You haven't specified. A person isn't a live lane of a motorway. A person isn't a burning building. Just for good measure I should probably add that a person isn't an unexploded bomb! A person is a person. Having a diagnosis of paranoid schizophrenia doesn't change that or make someone dangerous.

      It's a shame that the mistaken belief that people with mental health problems are unpredictable and potentially violent is so widely held - particularly by those who should be trained to know better because they may be called out to help in a crisis.

      Try to see a person who may be in crisis and who may need your help rather than danger.

      Delete
    3. Someone advancing towards me in an aggressive manner, showing clear signs of violence IS a danger. I'm not going to hang about to find out if they're 'just' threats or whether he means it.

      Just because you can't see that doesn't mean I can't.

      Delete
    4. Sectioneduk I'd love to know what your background is in regards to dealing with Mental Health patients??

      Delete
  2. As an SP, I'd hide behind my mentor...

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    Replies
    1. What would you be hiding from? Do you buy into the misconception that people with mental health problems are unpredictable and potentially violent? If so, I'd urge you to read up on the subject, so you're better prepared to help people who may need you in future.

      I'll leave you with this fact: around 1% of the UK population is diagnosed with paranoid schizophrenia. In fact that percentage is pretty stable around the world. Imagine if everyone with that diagnosis was unpredictable and potentially violent: it would be a bloodbath. Is it? No. Why? Because it's a big fat lie that people with mental health problems are violent or dangerous.

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    2. In fairness, in this brief glimpse at a scenario there was violence threatened and fists raised. I think that is what the hiding was referring to. And unfortunately, it is probably the small percentage of violent patients that we are exposed to most. Regardless, this is irrelevant. This isn't the blog post, I'm just gathering opinions for another one where I am sure you will agree with me. As you can see, regardless of his mental health history I entered and secondly you don't know what I did next, so don't make presumptions!

      Delete
    3. Firstly, I was replying to Ian Studd's comment.

      Second, you asked for comments and have responded constructively to others. I'd hope you'd do the same with mine.

      Delete
  3. Leave him be until the police arrive

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    1. What are you expecting the police to do that the paramedic can't?

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    2. Sectioneduk police can restrain the person if needed paramedics cannot all we expect is being able to do the job without danger to ourselves it's not too much to ask is it not?

      Delete
  4. I would of got out of his flat pronto and waited for the police

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  5. I would of got out of his flat pronto and wait for the police.

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  6. You only have two choices, withdraw and be safe or take charge, physically if necessary. The latter course should only be undertaken when you are properly trained,equipped or it is your only resort. In view of this my advice to a paramedic would be withdraw, contain if possible and wait for the police. (former Police Inspector)

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  7. Crew safety first, patient second. Withdraw and wait for police assistance. You have to respect his wishes

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  8. I try to talk him, calmly. If to no avail then leave and wait for police. My brother suffered the same condition, so much nicer if we solved or calmed the issue before police arrived. If his brother hadn't been there then it would be different as you'd be alone and don't know the guy personally.

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  9. Crew safety first, then the patient. Withdraw to a safe distance and wait for police. Respect his wishes

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  10. Ella,
    Hard call- in the wonderful Disneyland world of training I have no doubt the answer is withdraw and wait the police.- even in the real world a perfectly reasonable thing to do.
    However- potentially his aggression is due to one of his many conditions and he remains a patient potentially having a crisis.

    The police are trained to hit people with metal poles, use handcuffs or tasers.- whilst if he is being violent they would happily assist I'm not sure they should have primacy.

    In an ideal world access to a rapid mental health crisis team (don't laugh at the word rapid) should be available to help you as a professional clinician in dealing with the pt.

    I personally would have given it a few minutes to try and talk said gentleman down ever mindful of how quickly people can close space down. When or if this was unsuccessful leave. The law doesn't allow us to stay there (unless applying the mental capacity act or to prevent a breach of the peace).
    Once left refer to the mental health crisis team and only remain or stay on scene and wait for police if pt presents an immediate danger to himself or others.

    Thanks
    Josh
    (Police background)

    ReplyDelete
    Replies
    1. Does s17 PACE not also apply to the public. If a paramedic believes a person is in danger (be it, in this case, from himself) they have the power of entry.

      Delete
  11. Ella,
    Hard call- in the wonderful Disneyland world of training I have no doubt the answer is withdraw and wait the police.- even in the real world a perfectly reasonable thing to do.
    However- potentially his aggression is due to one of his many conditions and he remains a patient potentially having a crisis.

    The police are trained to hit people with metal poles, use handcuffs or tasers.- whilst if he is being violent they would happily assist I'm not sure they should have primacy.

    In an ideal world access to a rapid mental health crisis team (don't laugh at the word rapid) should be available to help you as a professional clinician in dealing with the pt.

    I personally would have given it a few minutes to try and talk said gentleman down ever mindful of how quickly people can close space down. When or if this was unsuccessful leave. The law doesn't allow us to stay there (unless applying the mental capacity act or to prevent a breach of the peace).
    Once left refer to the mental health crisis team and only remain or stay on scene and wait for police if pt presents an immediate danger to himself or others.

    Thanks
    Josh
    (Police background)

    ReplyDelete
  12. Recently retired after 30 yrs as paramedic. I believe that this is still mentioned during training or rattled into the heads of gungho newbies by experienced colleagues. We are not police or army, we do not enter dangerous situations without proper support and backup. You were told about his mental health problems and severe agitation before you reached the property, your neck hairs should have been standing out at that. You still entered the bedroom. He became threatening and abusive. I don't know about your experience but very first sign of trouble i.e. being told to f@#$ off I would have been back out of property and in ambulance before you could blink. Remember it's not just you involved there is your partner also being put in danger, your family if you are injured or killed and the fact that if you are injured then think of the problems that causes for your service. They're a motor down, some poor officer has to come out of the safe office, they have to talk to press and your family all things officers hate. So simple advice don't go in unless you've got clear exit or better still wait for backup!

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  13. Withdraw, without a doubt. Police have sticks and stuff. We do not.

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  14. As an SP, i'd follow my mentors lead, and she would probably back out of the flat to wait for police back up

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  15. I would not have entered in the first place, people with that Hx can be VERY unpredictable. Is he standing & talking? That's primary CABC taken care of. It then becomes a matter of what's the best you can do for this chap given the circumstances. Talking him down is an option as well as taser/capture spray at the other end of the scale. Background: Advanced Para Ex Army, 6ft1in 18 Stone, no push over.....but hates being stabbed & killed.

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  16. Assuming it is his flat, not the brother's or shared with the brother, then he's clearly not happy for you to be on his premises, you have little option but the leave or your tortuously render yourself liable to civil trespass as you have no lawful grounds to remain.

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    1. He lives there on his own, but his brother is the owner and gave us permission to be there. His brother lives there rent free. His brother is the named carer.

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    2. A slightly unsual tenancy, but it sounds like an agreed arrangement where your patient is the single, sole occupier of the premises - so unless the owner and carer, his brother, has established an agreed basis to enter at will whenever he wants, you may be left with the fact that this patient has sole control of the property apart from entry with reasonable notice to inspect / maintain the flat. Sounds like he's in charge, unless you reach the point of thinking there is a crime, a breach of the peace or a lack of capacity that allows you to overide his wishes. Might still need to know more.

      Delete
    3. Aaahhh you're getting warm Mr Brown! The joys of capacity!

      Delete
  17. Just on instinct (I have no medical training) is to be calm, explain calmy you are leaving the room but will return and they have this time to calm themselves, and back out of there.

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  18. I'm loving the comments about sticks, weapons and sprays. We seem to have a man in his own house who has just repelled the entry of someone he has every right to dismiss - AND if that person does NOT leave, he may use lawful, reasonable force to MAKE them leave his house. You may have a view about the manner of his communication, but the starting point is that an Englishman's home is his castle and if Ella or anybody else wants to go in there, they need a lawful basis that may not necessarily exist, without knowing more!

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    1. Bingo!

      FYI, I 'think' I had legal entitlement to be in there, though he was within his right to tell me to foxtrot oscar!

      Delete
  19. Yes Josh I'm trained to hit people with metal poles use taser or gas but the first thing I do is talk to people!! Despite the fact he needs medical attention if he is offering that level of violence to a paramedic then Police should have primacy.
    Ella ideally try to talk to him but you need to think of your own safety, at the point where you've entered his flat he may be seeing you as an intruder rather than someone there to help him. I would expect you to withdraw and wait for Police support. L

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    1. Police primacy to do what, though? He's in his own house, expressing himself in particular terms whilst apparently unwell. Starting on the basis of his presumed capacity, on what basis do we enter his house to take primary control?

      Delete
  20. Anon,
    I was simply trying to point out as police officers we are not mental health professionals. Of course we will always talk to people and are always more than happy to support and safeguard our ambulance colleagues however really if that patient is having a mental health crisis it should be the mental health professionals we support.

    Often the police and ambulance are used in situations where if intervention had occurred early by other agencies the crisis cold have been averted.

    ReplyDelete
  21. Ahhhhh
    Capacity....that one little word that opens a huge can of worms........
    I would have waited.....which would have given more time to sound the brother out.
    Ps.....im a 30 yr dinosaur aswell....lol

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  22. I wonder why it is that the information provided by the brother or your summary of the man's mental health history seems to say the same thing several times. Is it a misunderstanding of mental health problems? Or perhaps a literary device to ramp up the responses?

    "The patients [sic] brother met us outside the flat and gave us a run down on his past medical history. The highlights included, paranoid schizophrenia, delusions, hallucinations, psychotic outbursts and OCD."

    A diagnosis of paranoid schizophrenia is made on the basis that the patient has experienced certain symptoms, including delusions and hallucinations. Why say "paranoid schizophrenia, delusions and hallucinations"? It's just repetitious.

    You then go on to refer to "psychotic outbursts", whatever they are. That's certainly not a medical definition. As you know, psychosis is a description for symptoms such as ... delusions and hallucinations. So, you're saying the same thing again. Why the repetition?

    Finally, you refer to OCD which, so far as I know, isn't associated with risks to others. It's therefore really interesting that, almost without exception, your fellow paramedics and police officers who responded did so on the basis of the danger to safety that the patient presented. Where is the danger?

    Almost without exception, they have reacted as if the man is dangerous, unpredictable and potentially violent. Sadly, that is an all too common mis-perception of people with mental health problems. The plain fact is that people with mental health problems are far more likely to be victims of crime than perpetrators. Mental health problems make people vulnerable, not violent.

    It is a sad reflection of the levels of understanding that the public - and professionals who really should be better trained - have about mental health problems that this patient has been faced with this response.

    What should you have done? Do a capacity assessment and, if the patient has capacity, leave. Everyone has the right to make decisions about their own health and wellbeing, even when they have been diagnosed with a mental health problem.

    Someone with a diagnosis of mental health problems is not a child who doesn't know his own mind. Nor is he a dangerous and unpredictable animal. He may well need your help but, if he has mental capacity, he is entitled to refuse it.

    Responses such as those to this blog post reveal quite how far we still need to go in undoing damaging myths around mental health problems.

    ReplyDelete
  23. I wonder why it is that the information provided by the brother or your summary of the man's mental health history seems to say the same thing several times. Is it a misunderstanding of mental health problems? Or perhaps a literary device to ramp up the responses?

    "The patients [sic] brother met us outside the flat and gave us a run down on his past medical history. The highlights included, paranoid schizophrenia, delusions, hallucinations, psychotic outbursts and OCD."

    A diagnosis of paranoid schizophrenia is made on the basis that the patient has experienced certain symptoms, including delusions and hallucinations. Why say "paranoid schizophrenia, delusions and hallucinations"? It's just repetitious.

    You then go on to refer to "psychotic outbursts", whatever they are. That's certainly not a medical definition. As you know, psychosis is a description for symptoms such as ... delusions and hallucinations. So, you're saying the same thing again. Why the repetition?

    Finally, you refer to OCD which, so far as I know, isn't associated with risks to others. It's therefore really interesting that, almost without exception, your fellow paramedics and police officers who responded did so on the basis of the danger to safety that the patient presented. Where is the danger?

    Almost without exception, they have reacted as if the man is dangerous, unpredictable and potentially violent. Sadly, that is an all too common mis-perception of people with mental health problems. The plain fact is that people with mental health problems are far more likely to be victims of crime than perpetrators. Mental health problems make people vulnerable, not violent.

    It is a sad reflection of the levels of understanding that the public - and professionals who really should be better trained - have about mental health problems that this patient has been faced with this response.

    What should you have done? Do a capacity assessment and, if the patient has capacity, leave. Everyone has the right to make decisions about their own health and wellbeing, even when they have been diagnosed with a mental health problem.

    Someone with a diagnosis of mental health problems is not a child who doesn't know his own mind. Nor is he a dangerous and unpredictable animal. He may well need your help but, if he has mental capacity, he is entitled to refuse it.

    Responses such as those to this blog post reveal quite how far we still need to go in undoing damaging myths around mental health problems.

    ReplyDelete
    Replies
    1. To be fair, you are accusing people of jumping to conclusions without the story, yet you are doing the same. I merely wrote what the brother told me, and yes, I want to boost responses, because the responses with be relevant to my final blog on the matter. I think you'll agree with my final post and the conclusions I draw. This was an experiment, hence the follow up post a few hours later.

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    2. To be fair, you asked for comments and I have made a balanced, factual and thoughtful comment based on:

      - the words you wrote above
      - the comments I read above
      - my personal experience

      Despite the fact that I have a mental health diagnosis, I am perfectly capable of reading what you wrote and what others wrote and forming a reasoned conclusion based on that.

      I guess when you say "I love comments!" that doesn't apply to people like me who are directly affected by public perceptions of mental health problems and the actions of emergency staff.

      Delete
    3. I didn't dislike your comments. Without spoiling my final post, it is about how mental health is wrongly perceived and mis trusted unnecessarily. I'm showing that changing small bits of information opinions change. The final post will ignore his medical history and treat him both legally, respecting his rights and capacity to refuse. I wasn't having a go at you, I'm just asking you to wait for the final post. I was just asking for comments on what people would do faced with the situation described! :)

      Delete
    4. Sectioned UK you said, "Almost without exception, they have reacted as if the man is dangerous, unpredictable and potentially violent. Sadly, that is an all too common mis-perception of people with mental health problems. The plain fact is that people with mental health problems are far more likely to be victims of crime than perpetrators. Mental health problems make people vulnerable, not violent"

      In my opinion you are jumping to conclusions about peoples negatives views on this male - take away the mental health element - the dilusions, pyschosis etc -

      If you have the scenario purely a paramedic has attended location after being called and you approach a unknown male who is saying ""Get out of my fucking flat or I'll throw you out of the fucking window, I mean it. Fuck off."

      You will envitably "f**k off, and wait for Police to attend.

      So going back to your comment Sectioned UK, "Almost without exception, they have reacted as if the man is dangerous, unpredictable and potentially violent"

      They have reacted accordingly to how the man has behaved, without even considering his mental health background.

      Delete
  24. Need more Iformation. Who called the police and said he was suicidal etc. The brother could have given more information. You said you felt bolshy?In what respect?
    Anyway based on what i have i would asked brother if he can calm him down if he makes it worse or is not able then i would have tried to calm the male from a safe distance after making sure police were on way and preferably an eta for them and if the male did not respond to calming measures at a safe distance for you and i would have waited for police if you felt there was a possibility the male did not have capacity or was in urgent need of medical help. You need to be safe

    from police officer

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  25. It's a difficult one. You are presented by an agitated male making verbal threats against you and making physical actions that to a reasonable person would support his verbal comments. My first instinct - as 6'2 male trained with pava and button, as well as wearing body armour would be to stand my ground and try to talk to him. However I would support any one for backing off. From the medical point of view he is conscious and breathing. Has no obvious life threatening injuries and is alert and able to verbalise his moods and intention. You are lawfully on premises.
    It's your call... Communication is going to be the way forward. Sometimes a bit of bluff calling works. Other times a show of strength is needed but only to allow dialogue to start.
    Only you can justify going in. You had a knowledgeable person with you. I think it was the right call. I would say that due to the potentially altered mind state and perspective leaving him in the flat would give him opportunity to self harm or barricade the room. I have seen both happen. Stay safe and use the most powerful tool we have - the voice. This would give you a view as to his capacity. That gives options. Then once you have back up you can make an informed judgement and make appropriate actions.

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  26. Read comments especially from sectionuk, suspect possible mental health problem/ psyciatric nurse background. Sorry to say but years of dealing with the really sharp end as paramedic on the streets, there's nobody who gives a stuff about the resultant mental health problems that affect Ambulance front line staff. Many paramedics end up burning out, easily seen by lack of interest, slight vacant looks, withdrawing from social groups, substance abuse normally tobacco, alcohol and coffee. There isn't somebody standing up for them in your replies It would seem that being told to f@£? off and threatend by a known mental healh patient should be accepted by paramedics. Just as I had suspected for years we are not worth worrying about and can be likened to cannon fodder what happens to us doesn't rate a mention. Oh by the way other signs of MH problems is that we tend to have rants when we think someoneis taking the p@#s when replying to comments

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  27. I would leave and await police who are trained to deal with violence should it occur. There is no point putting yourself in danger. In my experience mental health patients tend to be quite honest about their feelings and intentions. I have experienced a similar situation except my patient was armed with a large knife and coming toward me. I left very quickly, pausing briefly to hurl the response bag at him to impede his progress toward my crew mate and me.

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  28. Call the amhp. S135 warrant needed.

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  29. Personally, whilst possibly a selfish opinion, I feel I don't get paid enough to take a punch. By all means try and talk the pt. around, but I'd probably try and do it, whilst I make a slow retreat, so as not to agrovate further.

    You also have to bear in mind that whilst you might be comfortable tackling the situation, whoever your crewmate is may not be.

    Tough one.

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  30. Sectioneduk seems hell bent on focusing on the Patient's possible mental health condition, and accusing everyone here of jumping to conclusions for it, but has completely missed that fact that this situation has less to do with his mental health, and everything to do with the fact that the patient made an outright verbal threat of harm!
    I don't care if you're a sweet little grandma; if you threaten someone, then you are a potential danger and the ambulance officer has every right to protect themselves.
    I would have apologized for being where I am not wanted, while leaving pretty bloody quickly.When I was a safe distance away from the risk of being thrown "out of the fucking window", THEN I would readdress the situation to see where we go from there.

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  31. Violence threatened = withdraw.

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  32. Violence threatened = withdraw.

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  33. It's really an informative and well described post. I appreciate your topic for blogging. Thanks for sharing such a useful post.

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  34. Possibly more of a question.. But would you not rely on your gut instinct & what you can see in front of you?
    I get what you are saying but nothing replaces the gut instinct of an experienced person on the scene.
    I do feel if you feel you are at real risk you should withdraw.
    Big difference between someone verbally aggressive & actively agressive

    I do however feel your post has neatly discredited every armchair critic :)

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