Spot The Difference
I am delighted to host another blog from a guest from the medical profession. In fact, today’s author wears two hats for as well as being a doctor @NCGarrard is also a Special Sergeant so has a very good view of all angles of this debate.
What wouldn’t any of is give to have a colleague working with us with that amount of medical training.
For the last few weeks I have been talking about my belief that we need to look beyond trying to define a crisis whilst it is in progress.
Think back to the Panorama programme and the scenes of at least three of the detainees in cells who were either being restrained or who were injuring themselves to the point where they needed to be restrained.
AT THAT POINT does it matter what the cause of this behaviour is?
Whether it be a mental health disturbance, drug or alcohol induced or something else surely this is a situation which requires immediate medical involvement.
In the programme, we saw that the only option available to officers was physical restraint in a cold hard cell.
Neill’s blog illustrates the same situation in a clinical setting.
It doesn’t matter whether you have medical training or not. In fact, if you haven’t got medical training then it’s even better. The vast majority of police officers are not medically trained beyond basic first aid and CPR.
The behaviour described in this blog could happen anywhere.
Please read it carefully, compare the scenes on TV with the options available in a hospital and
Spot the Difference
Stultus quoque, si tacuerit, sapiens reputabitur
After bridging the gap between healthcare and the criminal justice system for a number of years I am more aware than most of the challenges faced by each. Recently these discussions have become increasingly focussed on the challenges faced by the police and mental health services on how best to help those in need of immediate support.
One aspect of these discussions centres on the use of force, sometimes coercive and often to deprive a person of their liberty. This is quickly followed by the question of liberty. Is the “custody or control” of another needed because they are suspected of an offence and an arrest necessary to investigate that offence? Are they suffering from a mental illness that needs treating to prevent the patient or others coming to some foreseeable harm? What if the problem is medical but the patient has no comprehension of their own ill-health because they need treatment? Sometimes the answer is “all of the above” or perhaps “we simply don’t know but we have to do something”.
This case fits in that fourth category, as I simply do not know. Were they guilty of an offence? Drugs may have been a factor but I could never prove it. Was the presentation one in which mental health was a factor? I don’t know. Could I find a medical explanation for their presentation? No, but that doesn’t mean there wasn’t one.
I can also conceive of many different ways he could have ended up in my care. Arrested for possession of a controlled substance and transferred from custody? Detained by police under section 136? In this case someone had dialled 999 and an ambulance had attended. Suffice to say I have changed the details to protect the anonymity of the individual concerned.
It was late at night and I was covering the A&E Resuscitation department. All of my patients were unwell but I was safe in the knowledge they were in the right place receiving appropriate treatment. As I sat writing some notes, I heard the red phone ring and my heart stopped for just a moment. If you have ever watched “24 Hours in A&E” – you’ve heard the red phone. Any police officer reading this who doesn’t know what that feels like, imagine the last time a colleague pressed their panic button and you heard that unmistakable triple beep followed by an open channel of static.
On answering it the operator told me that I had a male patient en-route, GCS 3 (unconscious), post-epileptic fit. Blood pressure – unrecordable, heart rate 110bpm (too fast), sats 85% on oxygen (too low), temperature unrecordable, blood sugar – unrecordable (an instant concern), ETA 5 minutes. Thereafter followed a drill I’ve done dozens if not hundreds of times. “BLUE CALL, ETA FIVE MINUTES” went across the tannoy, my nursing colleagues were briefed, airway equipment prepared, monitors setup for a new patient, and an array of drugs, fluids and kit laid out ready to deal with whatever presented itself.
We were ready just in time for the patient to be wheeled in on an ambulance stretcher, whilst he was trying to jump off. He wasn’t succeeding as the seatbelts were still on, a point that seemed to confuse him into believing he was being held by an invisible force field. As the paramedic handed over I learnt that a member of the public, trained in first aid had seen him collapse. He had an epileptic like seizure and was still unconscious when the ambulance arrived only to suddenly wake up on arrival at hospital. He was cold to the touch and admittedly it was raining outside but more interesting was the way he acted.
Observing for a few seconds I could see he was hyper vigilant, wanting to know about everything around him but unable to describe where he was. He had no wallet or other identity on him and couldn’t remember his name or even how old he was. His speech was fast, rapidly changing from thought to thought, each a different delusion. Some were of his own importance (delusions of grandeur), some were that the government were after him (persecutory) and some focussed around science fiction. He was both confused and manic.
Mania is symptom present in some mental health presentations and some ‘recreational’ drug use. As I listened to the paramedic I became more concerned as he had unmistakable blunt trauma to the head. Now I had four clues – confusion, mania, a seizure and a head injury. As to the order in which they had occurred, I had no way of knowing. Add to that the random smacking of his tongue and I couldn’t even make an educated guess.
When all else fails, go back to your ABC’s – in this case Airway, Breathing, Circulation, Don’t Ever Forget Glucose, Disability and Exposure. Each was assessed and treated in order but despite calming him down there was no way he would stay still long enough for me to do some of the most basic investigations that might save his life, or may turn out to be completely irrelevant. In short I did not know if his life was in danger and if so, how to minimise that risk. All I knew for certain was that he wasn’t safe to leave the hospital, even if that might be his desire.
There was only option and I took it. I asked for help. In this case I bleeped a colleague in intensive care, who came down and gave a second opinion. We had no doubts between us that the only option was RSI or rapid sequence induction. In short, we give him a general anaesthetic, intubate him and start our ABC’s again. Everyone now had a job. Security talked to the patient, the nurses prepared drugs, the anaesthetic technician prepared the equipment we needed, my colleague spoke to his Consultant to agree the ITU admission and I wrote a lot of notes to explain why this course of action was in the patient’s best interests and what further steps would be needed afterwards.
Fortunately the patient co-operated with us for just a few minutes, and he was intubated. Once he was stable, we reassessed him and finding no immediate cause for concern transferred him to our CT-scanner. Perhaps he had a bleed to the brain, meningitis or an encephalopathy? There was nothing of concern on the scan, so we moved him into intensive care to have a lumbar puncture and more tests.
This was not a decision we took lightly. This is one of those rare moments in medicine where we detained someone, not with handcuffs or bars but with drugs. In doing so we deprived him of not only his liberty, but of consciousness. He was now a man without identity, without a voice, and without a personality, albeit temporarily.
That was the last I heard of him. I know he survived to discharge, and I know they never worked out what caused all of his symptoms but he did remember his name when he woke up.
So tell me, next time you see a confused and manic person: Are they under the influence of drugs, suffering from a mental illness or so medically unwell you should bring them into A&E with blue-lights flashing just to make sure they’ll survive.
Dr Neill Garrard is a Middle Grade in Emergency Medicine and a Special Police Sergeant