"50 year old female, GP visited, states patient wants to kill herself by starvation, states patient's partner is assisting her suicide attempt. To be taken to the nearest A & E"
Well this job was pretty self explanatory. A GP (one that'll soon be in charge of the NHS) went round for a rare home visit, he couldn't get her to agree to hospital, so booked an ambulance. He did that in the full knowledge that if she refused hospital, with the information he had given us, we were now responsible for her! He knew she would refuse but it's easier to pass the buck. C'est la vie!
It was a baking hot summer's day, we had spend the morning broken down, sitting out outside the sweltering ambulance eating ice cream! It was a small victory! The second our vehicle was fixed, this job was sent to us. We headed to the address and went in to the building. The patient was lying in bed, only her head visible, the reason she wanted to kill herself was because she was fed up with her Obsessive Compulsive Disorder. She couldn't leave the bed without a 1 hour ritual which made going to the toilet the hardest and, I imagine, the most frustrating of tasks! So, the suggestion of hospital was not one she remotely considered. She refused all observations, any treatment and any transport. She just wanted to be left at home to die. I have seen a lot of patients with OCD but her's was severe. While I sat there talking, I observed the struggle she faced to do the simplest of tasks. She opened a brand new pack of 10 cigarettes wearing latex gloves. She removed a cigarette, cut the tip off with the scissors she removed from a sandwich bag and lit it with a match. She was then unable to smoke the remaining 9 as the pack was already open. Expensive habit!
Our problem was the age old one of capacity. In legal terms its a 'grey area'. The first question on our capacity assessment tool is 'Is the patient free from any external pressure?' Unfortunately we had already been told by the GP that she wasn't. The partner is of the opinion that starvation is a pain free way to die and as our patient was bed bound, by not feeding her, technically he is assisting the suicide attempt, thus preventing her from being free from the aforementioned external pressure! Sigh! We talked and talked about hospital and how we could make it easier for her. We agreed to 'sterilise' the ambulance by covering a seat in plastic bags, we fetched a 'sterile' infection control suit for her to wear and after a few hours we were making progress. She was out of the covers and had the suit on her legs. Then the partner returned:
"She doesn't want to go to hospital"
With that, all our good work was ruined. Within seconds she was back in bed, head poking out above the covers. We requested the police and one of our officers, as by this point we had been on scene for 3 hours and there was no end in sight. While waiting for the grown-ups to arrive some family and friends of the patient arrived 'to say their goodbyes'. Please note, she was not about to die, nowhere even close, but the fact she wanted to die meant I was not happy leaving her, especially in the 'care' of her partner. Once the police arrived we had a lengthy discussion about what to do. A sectioning seemed the likely option. Being in her own home meant we were limited to what section we could use. We went back inside to discuss said sectioning and stumbled upon all 9 people who were now in the house singing 'Kum ba Yah' complete with guitars and drum. It transpired that the big tree outside the property was being felled by the council the following day, so they are all meeting up to sing it a song and have a group photo with it. Yes, a group photo, with a tree! Hippies!
Trying to arrange a sectioning on a Sunday afternoon took hours. Eventually it got to the point where all we needed was her GP, the one who phoned us! We had the police, we a had an AMHP, we had an OOH GP, all we needed was hers. Bare in mind we had now been on scene for over 7 hours. My shift finished 3 hours ago, we hadn't had a toilet break, we were more than a tad annoyed by now and then the following conversation occurred:
Ring ring...
"Hello"
"Hello there, my name is Ella Shaw from the Ambulance Service. Is this Dr Smith?"
"Yes, how can I help"
"Well, we are with Miss Jones, who you requested go to hospital earlier"
"Ah, OK, yes I remember"
"Well, we are trying to arrange a sectioning. We have the police, an OOH GP and AMHP on scene, we just need your signature so we can take her in as you requested."
"I'm sorry, but i've got plans this evening, afraid I can't help you."
What?! Have you?! Dont we all?! What a complete waste of time, we had spent most of the shift there, as had 2 policeman and all because the GP couldn't be bothered to do his job in the first place. The outcome was that the patient stayed at home, our officer in my opinion copped out and gave her capacity to refuse. He asked the police to take the partner out of the property and re-assessed her capacity. He came to the conclusion the external influence was now gone. It wasn't, it was standing outside 20 feet away. We were left bewildered and utterly frustrated. The doctor on scene didn't believe she was in immediate danger so a section 135 would be arranged the following day. At least she would get treatment but that didn't help alleviate my foul mood.
This job did highlighted the issue of OCD. It was the first time I had seen it in such a debilitating way. When people think of OCD this think of excess hand washing, obsessed with tidiness, flicking a light switch on 'X' number of times before entering a room but it is much more varied and severe than people may be aware. It is an anxiety disorder characterised by intrusive thoughts that produce unease, apprehension and fear. The symptoms can vary from excessive washing and extreme hoarding to alienating nervous rituals. It is a mental health disorder that is far more common place than people may be aware and is now the fourth most common disorder to be diagnosed. It is now diagnosed nearly as often as asthma and diabetes. Very rarely is OCD a stand-alone problem. It is often accompanied by depression, generalised anxiety disorder, anorexia, Asperger syndrome and frequent panic attacks amongst others and like all the above, it requires treatment. Our patient had gone without treatment for many years and the consequences were evident in the way she was now suffering. Like with most mental health disorders early recognition and early treatment is the best way to produce a positive outcome. No one wants to enforce a sectioning and no one wants to drag someone out of their own home for treatment but it is a necessary evil. To prevent this, services and referrals need to be more readily available and easily accessibly. I'm sure i've said that before! Why bother though, it's only OCD eh?! Hmmmm!