Mental Capacity

Warning:  This is a very long blog entry

The Mental Capacity Act of 2005 states that “a person lacks capacity in relation to a matter if at the material time he is unable to make a decision for himself in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain.”

Seeing as we have a ‘duty of care’ for the well being of patients this means that if a person is injured or sick and lacks the mental capacity to make the “right” decision for their well being – we may have to step in and use force to help and/or remove them.

In this job we often come across patients who lack capacity.  If their lack of capacity is obvious then the decision to remove and help the patient is easy enough – but still not nice.  An example of this might be a 90 year old lady with a urinary tract infection which has given her a raging temperature and made her delirious.  When asking her what day it is she might reply by saying, “I am a tomato” and then attempt to stick a fish in her ear.  This lack of capacity is clear cut and simple to deal with.

The big problems arise when we are presented with patients where;

a)  Its difficult to determine whether they have mental capacity or not and
b)  They don’t want to do anything that you or anyone else would deem in the best interests for their health

This is arguably one of the worse ethical positions for any Paramenace or Technician to be in.  It can become very ugly and not nice and ultimately its exhausting for all involved . . .

__________________      __________________      __________________

I peered over the railing down at my crew mate.  She was leaning against the wall by the front door of a granny flat listening to the voice coming from within.  She glanced up and laughed at my appearance.  My hair was dishevelled and scratches covered my arms and face along with mud and sludge.  I spat out a couple of leaves and caught my breath.

“No luck that way”  I motioned to the back garden.

We’d been here for ages and had still not gained entry to the flat.  This was fast becoming a difficult position to be in.  An hour and half earlier and it was a different situation . . .

The call had come down as “Collapse Behind Close Doors”.  Albeit a neighbour was able to talk with the patient it was apparent they could not get their self up to open the front door.  This meant – ‘granny down’!  After talking with the neighbour we obtained the history – a seventy two year old lady with rheumatoid arthritis and osteoporosis had fallen over and couldn’t get herself back up.  She lived on her own and appeared to be locked in.  No one else had any keys to her home!

By all accounts this appeared to be a simple job.  We’d establish what injuries the patient had, get her permission to force an entry, help her up, check her over and either take her to hospital or leave her be – with a nice cup of tea and some toast.  Bish bash bosh, job done – cue sunset and tune of “In the City” by The Eagles, for us to walk off into.

I knocked on the door and could hear the frail voice, clearly in distress, on the floor.

“What’s your name my dear?”  I shouted.
“Cassandra* . . . oh dear” Came back the little Jamaican voice.
“What’s happened Cassandra?”
“Nothing.  I’m fine.  Please go away”

Ah.  Problem.

“What do you mean nothing Cassandra.  Are you hurt?”
“No I’m not.  Now please just leave me alone”  She sounded upset.
“Your neighbour is concerned for you Cassandra.  He says you’ve been on the floor since yesterday evening.  Can you get up?”  I strained to listen for her response.
“What nonsense is that . . . I’m fine.  He has no right to do that . . . oh dear”
“Can you get up at all Cassandra?  Just so we can check you’re ok?”
“Yes I can”

There was a long pause of nothing happening.

“Are you trying to get up at all Cassandra?”
“No.  Leave me alone.  I’m fine.  Go away!”

And so the conversation continued.  We could clearly hear the patient was on the floor and it was plain to us that she was in some form of painful distress.  Yet she didn’t want our help.  The neighbours confirmed she was a tiny frail woman with knotted hands stick like legs.

After much questioning we decided that her mental capacity was questionable, as lots of her answers to our questions were not consistent.  The description of her also suggested that she could not get up off the floor, whether she wanted to or not.  However, she was adamant she did not want our help and was becoming more and more upset by our presence outside.  But because of her predicament we had to assume she was in potential danger – albeit, not imminent – and therefore we made the difficult decision of forcing an entry.

My crew mate stayed by the front door to talk with the patient whilst I went round the back with the police to see what we could do.

Her back yard was like the heart of the Peruvian jungle – immensely over grown and not looked after.  Barbed wire lined the top of her flimsy wooden fence and thick rose bush thorns interlaced them.  Albeit the fence was only face height, it was so fragile and rickety it appeared that any attempt to scale it would result in its collapse and subsequent entanglement and consumption of the person struggling to do so.

With the help of a step ladder, a Leatherman multi-tool and a crow bar we succeeded in scaling the fence and fighting our way through the undergrowth to the back door beating off spiders, snails, slugs, thorns, pots, broken bottles, sludge, dog and cat poo, mice, badgers, snakes, elephants and the occasional ancient hidden Japanese General refusing to believe that the war was over.  Here, the police managed to pry open a window to the back kitchen.  Looking in it didn’t appear to be much different than the back yard.  The small room was stacked floor to ceiling with dog and cat food tins – some open, some not.  Stacked around them were all manner of objects that seemed to have no purpose other than filling the spaces not taken up by the dog and cat food!

After moving enough clutter to allow entry I climbed through the window.  Remembering a time in my life when I was supple and agile enough to do so, I attempted to jump down through the mess.  Landing flat on my face, my pride was hurt further with several piles of tins collapsing on top of me.  Jumping up as if nothing had happened I brushed myself down and picked my way to the kitchen door.  Through a small window in the door I could see our patient at the far end of the house sitting awkwardly on the floor.  Brilliant, I thought, we’re in.  Keeping my eyes on Cassandra I pulled the handle.

It was locked.  Oh for gods sake – really?!  After all this!!!?  A quick scan of my surroundings suggested it was pointless trying to force this door as it opened toward me and there wasn’t enough room to try.

I looked back at the police officer who’s head was poking through the window watching my progress.  He let out a sigh.

So, back at the front of the house, I peered over the rail down at my crew mate.

“No luck that way”  I spat out the leaves,  “we’ll have to go in through the front door”

The police gained entry quickly and without causing too much damage and then stepped back to let us through.  The patient was sat crumpled up against an inner door.  She was practically naked and was literally a bundle of arthritic bones wrapped in skin – emaciated and clearly dehydrated.  The house had long been left to deteriorate and there was barely enough room to move anywhere and the smell of pet food, both fresh and rotting, filled the stale air.

We immediately set about checking Cassandra over and it quickly became apparent that her obs were border line normal.  But looking at her you could tell she was in immense pain and there was no chance she was getting up off the floor on her own.  She was also still upset and wanted us to leave.  I therefore started to determine whether she had capacity to make these decisions.

“What day is it Cassandra”
“Tuesday”  She answered this correctly and as quick as lightening.  After I’d worked out what day it was I moved on.
“What month is it?”
“January!”
“What year?”
“2012!!!”

She was on the ball and I was being beaten at my own game.

“What’s the capital of Syria?”  I winced.
“What a stupid question!  Go away and leave me alone!  I have capacity.  I used to be a nurse you know.  This is not fair – please, PLEASE go away!”

She was right.  She did have capacity.  And what’s more, she knew about capacity which suggested that she had probably been a nurse also. To finish with I had to make sure she understood the implications of us leaving her where she was.

“Cassandra, I need you to listen carefully.  If we leave you here do you know what will happen?”
“I’m not interested!  Go away!”
“Cassandra!  If we leave you here you may well die.  Do you understand that?”
“Of course I know that!  I’m seventy two years old – look at me!  Do you think I care about that anymore!?  Now please – leave!”

Now we really were in a predicament.  And to be honest, this was breaking both our hearts.  Cassandra had clear mental capacity to make her own decisions and was choosing to sit there and (eventually) die.  By law, we could do nothing to stop this and had to respect her resolution.

At that moment a long haired Chihuahua-resembling-ratty-dog-thing bounced into the hall and proceeded in pasting the entire contents of its mouth over our hands and bodies.  It looked skeletal and gaunt – but then again, all Chihuahua type dogs look like that to me.  I shooed it away.

We decided to phone our “Clinical Support Desk” (a.k.a. Google Desk) and ask their opinion.  It was in vein as they confirmed what we already knew, but were trying to deny – which was that we had no jurisdiction over her decision.  We had to leave her.

I knelt down in front of our patient and took her hand, “Ok Cassandra, we’re sorry.  We’re going t . . . ”

At that moment I felt a strange wet sensation down by my crotch.  Looking down, the ratty-dog-thing was frantically licking my private parts.  I grabbed it and “assisted” it to one side.

” . . . we’re going to leave you.  But can we at least help you up and make you c . . .”  The ratty-dog-thing was back licking my crotch.  I stood up, ” . . . comfortable?”

“Yes.  Please Cassandra . . .” My crew mate now stepped forward, “please, let us get you up from here.  You’re in so much pain – its upsetting us as well”

As my crew mate continued to persuade our patient, I concentrated on defending my honour from the sexual advances of the ratty-dog-thing until eventually I heard Cassandra utter the golden words, “OK then, please”.

To get her up, onto our carry chair and moved back a few paces took a further half an hour and lots of screaming in pain.  Eventually we stopped further down the hall way and crouched down to talk with our patient.  Well, my crew mate crouched – I stood and continued to kick at the sexually overzealous ratty-dog-thing.

After another thirty minutes of persuasion – we’d nailed it.  Cassandra had agreed to come with us.  This was fantastic news!  Not only because she would receive much needed medical treatment but also that she’d made the decision herself.  For the first time since we’d made contact with Cassandra she appeared content.

Now all we had to do was get her out.  There was no way we were getting a line in our patient so we gave her drinkable Morphine instead.  And, after making her as secure as possible on our chair – and with the ratty-dog-thing in tow jumping at my knackers – we made our way out of the house and onto the ambulance.

A police crew had remained on scene all this time and as we transferred Cassandra to our trolley bed we spied the officers running around the street trying to chase down the ratty-dog-thing.  Cassandra smiled – I suspect for the first time in a long while.

“Will they look after my dog?”  Her voice was now quiet and sweet and with a full Jamaican accent.  Seeing Cassandra smile we both turned away and started to scratch at the sudden ‘itch’ around our eyes and cheeks.

One of the officers poked their head round the door, “Don’t worry Cassandra, we’ve arranged for the RSPCA to look after your dog until you return home – ok?”  She smiled again, and this time laid back, closed her eyes and relaxed.

With the help of the Morphine she eventually dozed off and we imagined it was the first proper sleep she’d had in weeks, possibly months.  On arrival to Hospital we explained the story to the nurses who, after listening intently, went to work and made Cassandra as comfortable as they could.

We had been on scene for six hours and it ended up being our off-job.  As jobs go, it was difficult and interesting enough to warrant “earning your pay”.  But if Cassandra had continued to refuse help, we would have had no choice but to leave her there.  It would have broken our hearts and gone against everything we believed in.  And ultimately she would have died, there on the floor.  This, like many other bad jobs, would be put down to experience and have to be chalked up as just another bad day – as is sometimes the case.

But thankfully it wasn’t – and I think we can chalk this one up as a good day after all.  I hope.

Binder

*Not her real name of course.
NB – I apologise that this was a long one.  Its difficult to get across all the emotions that happen in such a long job and I’m sure I could have shortened this with the right editing.  But you know what?  In the end I couldn’t be arsed – sorry.

 

 

You’re Dead?

We’d been standing in front of the patient for about ten minutes trying to ascertain why it was he had called us.  We still didn’t know and it was starting to become a little frustrating.

He was a short Eastern European man who appeared to live on his own in an unkempt and chronically neglected flat.  He had one arm in plaster with wires connected to his fingers and the entire flat reeked of cheap lager and industrial strength vodka.

The call had come down as a “45 year old man with a hurt arm – “.  After radioing in we were informed the patient had a history of belligerence and violence toward crews and were therefore told to hold back for the police.

After we’d hooked up with a police we approached the patient’s flat – police first of course – and knocked on his door.  The little man opened up and upon seeing the police standing in front of him he reeled backwards spitting his disdain.

Patient:          “What!  You not come here!  Go away!!”
Police:           “Hello sir, we’ve come to check that you’re alright – ”
Patient:          “Fuck off!  I not have terrorist papers!  Go away!  They come in, not you!”
Police:           “Now sir, we just need to see that everything is fine – can we come in?”
Patient:          “No!  They come in, not you.  No terrorist papers.  Fuck off!”

My crew mate and I stood on the stairs at a safe distance watching.  We glanced at each other and shrugged our shoulders.  After a short time, the police were able to calm the patient enough to allow us all to enter.

So – here we were trying to work out what it was he wanted.  We’d exhausted almost all avenues and were starting to become exasperated.

Crew mate:     “So, do you have any pain?  Anywhere?  Your arm?  Anything?”
Patient:           “No”
Crew mate:     “Well, what is it?  Why have you called us?”
Patient:           “I’m dead”
Crew mate:     “I’m sorry?”
Patient:           “I’m dead”
Crew mate:     “You’re dead?”
Patient:           “I’m dead”
Crew mate:     “Do you think you’re dying?”
Patient:            “No.  GP say I’m dead”
Crew mate:     “Did he say you’re dying?”
Patient:           “No. I’m dead”
Crew mate:     “You’re dead”
Patient:           “Yes.  Dead”
Crew mate:     “. . . . . . . !!!?”
Patient:           “. . . . . . . . .”
Binder:            “So . . . you’re not alive.  Is that it?”
Patient:           “Yes.  GP say I’m dead”
Crew mate:     “. . . . . . . !!!?”
Binder:            “. . . . . . . !!!?”
Patient:           “. . . . . . . . .”

Again, my crew mate and I exchanged glances and ever so gently shrugged our shoulders.  The patient looked up at us both expectantly.  Sighing, I stepped up to the patient and took his wrist checking his pulse.

Binder:             “You’re not dead.  You’re alive.  You have a pulse, see.  This means you’re heart is beating.  This means you’re alive.  OK?”
Patient:            “I’m alive??!!”
Binder:             “Yes”
Patient:            “Not dead??!!”
Binder:             “Not dead.  Alive.  Its a miracle.  Happy days!”
Patient:            “Thank you!  Thank you!!  I’m alive!”

The patient looked genuinely over the moon with our diagnosis.

Binder:             “Would you like anything else?  To go to hospital perhaps?”
Patient:            “No. No.  Thank you.  Nothing else.  Goodbye.”

We picked up our bags and left quickly, almost running down the stairs to the ambulance.  Once back at our truck the police passed as chuckling.

Police:             “You guys are goddam heroes!  How do you cope?  We could never do your job”  They mocked.
Binder:            “You’re goddam right we’re heroes!  But you know what?  We’re just doing our job man – we’re just taking it one day at a time”  We mocked back.

Binder

 

“Location Match”. This means the address we’re going to has a history.  Usually to do with violence but sometimes based around a general clinical history.  It also means that in most cases we need to hold back and wait for the Police to attend – for our safety.  This process of protecting us works for the most part – but on very few occasions we get the ‘Loc Match’ details after we have made contact with the patient!

Pain Scoring

When dealing with patients who are in pain, we are told we need to obtain a “pain score” from them.  This is so we can monitor the progress of their pain throughout our treatment. We use a simple method by scoring the pain out of ten.  Ten being the highest and most painful and one meaning no pain.  Simple.

Or so you’d think.  But sadly its not really that simple.  Pain scoring is very subjective and relative to that one person’s definition of pain.  We therefore, as clinicians, have to use a little ‘creative common sense’ when dealing with some people’s definition of pain.

Here are three good examples of why this is so.

Patient 1
An elderly lady from somewhere in India sits in front of me complaining of global-everything pain.  She leans forward and strains to listen.

Binder:          So, on a scale of one to ten, ten being the worse pain imaginable and one being nothing, what number would you give?

As if on cue the lady throws her arms to her head and she starts wailing.

Lady:               Too much pain!
(arms wave and holds head)
(Lady stops to listen)
Binder:           No, I need a number between . . .
Lady:               Too much pain!
(arms wave and holds head)
(Lady stops to listen)
Binder:           Yes, fine, but can you just give me a number . . .
Lady:               Too much pain!
(arms wave and holds head)
(Lady stops to listen)
Binder:           No, a number.  Between . . .
Lady:               Too much pain!
(arms wave and holds head)
(Lady stops to listen)
Binder:           Any number . . .
Lady:               Too much pain!
(arms wave and holds head)
(Lady stops to listen)
Binder:           Right.  I’ll um . . . make it a three then shall I?

Patient 2
A thirty year old male sits before me complaining of chest pain after being in a police cell for a few hours.  He looks ahead nonchalantly.  Two police officers are standing beside him.

Binder:          So, on a scale of one to ten, ten being the worse pain imaginable and one being . . .
Patient:           Ten
(patient looks nonchalant)
Binder:            Ten?
Patient:           Ten
(patient looks nonchalant)
Binder:            Really?
Patient:           Yep
(patient looks nonchalant)
Binder:            Honestly?
Patient:           Yep
(patient looks nonchalant)
Binder:            So this pain couldn’t get any worse
Patient:            Nope
(patient looks nonchalant)
Binder:            . . . . !
Patient:           . . . . .
(patient looks nonchalant)
Binder:            Even if I dropped a large piano on your head this is still a . . .
Patient:           Ten.  Yes.
(patient yawns)
Binder:            . . . . . . . wow.

As I look at the patient I write a three.

Patient 3
I kneel in front of a tiny eighty eight year old lady who’s been lying in an awkward position at the bottom of her stairs for nearly four hours.  One of her legs is shorter than the other by half a foot and her pelvis looks clearly deformed.  Her wrist is bent in the wrong direction and a large gash on her forehead has left her hair and face matted with blood.

After all the obvious primary checks I stumble my next words.

Binder:          So, on a scale of one to ten, ten being the worse pain imaginable and one being nothing, what number would you give?
Old Lady:        Well, it does smart a little.  So, I’d probably give it a four or a five.  But I don’t want to make a fuss.
(patient tries to smile)

My jaw drops and tears well up.  I stare at the patient dumb founded and as one hand scribbles “100” in the scoring box my other reaches for the morphine in my pocket.

Binder

A Grand Entrance

We were racing down the road on blue lights and finally saw our patient waving at us from the other side of the road.  We swung the ambulance across the traffic and screeched to a halt beside him.

He was standing by a telephone box clutching at his chest and was attempting to look in immense pain.  I wound down the window.

Binder:             You can take your hands off your chest now Alan.  And please stop making that ghastly face, there’s a good fellow.

Our patient did as he was told and his face reverted back to a frozen expression of placid morosity.

This was Alan* – a regular caller.  Alan is an average looking middle aged man whose facial expressions would remain simple and plain for every mood of the day.  He would make his way to various locations, chosen non-strategically around London and call for an ambulance complaining of chest pain.  He’d shuffle rather than walk and his head always seemed to face forward.  This meant he’d only used his eyes to look in different directions and as such this made Alan a strange enigma – as you were never quite sure if anything he was doing was a complete act or not.

After all our checks pointed toward inevitable clinical normality – for Alan – we set off to Hospital.

On arrival I went on ahead to boot open the doors to the A&E Triage area.  Stepping in majestically I spoke with a loud and deep voice.

Binder:              And now, I present to you . . . the one, the only, the most legendary . . .

Pausing, I checked behind me and saw that Alan was still shuffling toward the outer doors.  Looking back I could see I’d gained the attention of the entire department.

Triage Nurse:   Who?
Binder:              I’ll let you guess
Triage Nurse:   Alan?

Grinning, I stepped aside to allow for Alan’s grand entrance.  He shuffled past staring ahead.  Upon seeing Alan the entire department cheered and applauded.  Apart from a couple of drunken patients waiting to be seen – who looked bemused.

Triage Nurse:   Alan!  Good to see you again – chest pain is it?  Come this way . . .

He took hold of his arm and gently led him away.

Binder

*not his real name

New Years

I was off the Christmas period spending five wonderful days getting “geographically embarrassed” (lost) in North Wales.  This meant I was able to escape the wondrous delights of working the festive period.

I wasn’t able to escape working the new year period though.  However, I was lucky enough to be working earlies.  So, as I finished work on New Years eve it was plain to see the city was already gearing up for a huge drugs and alcohol fuelled marathon explosion of drunken debauchery . . . and albeit I was glad not to be working nights, my thoughts went out to those who were.

I also worked New Years day, starting early enough to be dealing with the dregs of the night before.  As my shift started the night turn were just leaving to go home.  Amongst their continuous jobs of dodging multi-directional vomit from the bounty of London’s finest whilst their equally intoxicated colleagues swore blindly that their drinks “had been spiked” was a ‘real’ job.  They told me they’d attended a shooting whereby a hapless individual had been shot three times in the chest.  A  was performed by HEMS with the aid of the crew, in an attempt to perform immediate surgery on the patient’s damaged heart.  But it was to no avail and sadly the patient was pronounced dead at hospital.

Our shift wasn’t even a fraction of their excitement. For the first few hours we scoured the City streets working through the back-log of “Collapse – No Response” patients and dealing with them with the tried and tested KPF technique – (Kick Patient’s Foot).

With each miracle resurrection performed another life was saved!  Eventually we moved onto the lower category calls that had been waiting all night for an ambulance.  They included the lesser important patients like elderly folk who’d fallen to the floor and had been stuck there for half the night.  Or the woman who’d suffered a miscarriage several hours earlier.

Over all I believe I got off lucky.  There were certainly lots of interesting things happening around London that night.  And, as always, there has to be some crew that deals with it.  Thankfully, this time round, it wasn’t me.

Binder

A thoracotomy is an incision into the chest wall to gain access to the vital organs therein.  Best performed under clean hospital conditions but sometimes done “on the road” in emergencies.  This is the perfect time for a doctor to “lose” their watch.