I Am Not Having Doubts About How I Treat Patients

On Monday I posted about what was apparently ‘bullying’ behaviour on my part in order to get a patient the best care that I could give.  As I was writing this post I realised that I’ve done it again.

I used to swim.  I used to swim alot and so it was a nice surprise to be called back to one of the swimming pools that I used to spend so much time in.  Unfortunately it was for a drowning.

Rather obviously we raced around to the pool.  A member of staff kindly ran us to the first aid room where we would find our patient.  During this run, carrying pretty much the entire contents of our ambulance with us, I was going through my mind about everything I knew about drowning – I was expecting a lot of work on this job.

We entered the first aid room, and the patient, a young lad, was wrapped in a space blanket, sitting up chatting with his friends.  My crewmate and I both breathed a sigh of relief.

We spoke to the patient, his friends and the two lifeguards who’d pulled him out of the water.  The patient had been unconscious on the bottom of the pool for around 30 seconds, after the lifeguards had pulled him out the patient had started breathing on his own.  A short period of time after looking ‘shocked’, and ‘shaking’ the patient had made an apparent full recovery.

“I don’t want to go to hospital”, he told me, “I’m alright”.

My crewmate and I looked at each other.

I turned back to the patient, “You haven’t got a choice mate – you are going to hospital”.

As I looked at the patient the thing that was foremost in my mind (and the mind of my crewmate) was ‘Secondary Drowning’.  In secondary drowning there can be damage to the lungs caused by the inhalation of a fluid.  The patient will then die a couple of hours after being pulled from the water.

He was going to hospital.  I just had to persuade him.  So I tried all the nice ways, the ways that won’t worry the patient, the ways that maintain respect and autonomy and all those other hippy words that are apparently so important even if the patient is bleeding to death in front of you.

None of it worked.

Time for the big guns.

“Ok mate”, I said, “the reason why we are taking you to hospital is because of a thing called secondary drowning – you are alright now, but it can cause you to drop dead in a couple of hours, and there would be nothing we could do about it.  So you are coming to the hospital with us – you have no choice in the matter”.

He agreed to come to hospital with us.  He was a pleasant young man, and he was given the all clear a bit later that day.

My point is – despite the cries of the ‘respect brigade’ (and I don’t mean any of you dear readers – all the comments in the previous post were good points), sometimes you have to become a patriarchal bully in the best interests of the patient.  Sometime it’s the only way to get the patient the care that you know they need.  I don’t like bullying people, but sometimes it’s the only way to protect both the patient – and my job.

So, sod it, sometimes I’m a bully.

20 thoughts on “I Am Not Having Doubts About How I Treat Patients”

  1. Surely there was no need to 'bully', not in this case. Personally, I would have explained in the first place about secondary drowning, never mind all this 'you ARE going to hospital' stuff. Same result, just quicker and more respectful.

  2. That's not bullying it's giving people the inforrmation they need to make a decision.I think it's a fairly safe bet that he didn't know about secondary drowning (I certainly didn't) felt fine and wasn't aware of the risks.

  3. No way can any of what you said be termed 'bullying'. Persuasion, yes.Secondly, to my mind anyway, if an ambulance has already been called for a person, they cannot by definition make the choice of whether to go in the ambulance or not. That decision has to be made by the ambulance. The time to choose whether or not to go in an ambulance has already passed because it occurs at the same time as 999 is dialled…

  4. A bully like you saved my son's life one day when he was holding forth about not wanting to worry his mom by having to go to the ER!Keep up the good work, that type of bully deserves thanks!

  5. Since when is giving someone the truth called bullying? If anything, the whole world needs more of that kind of bullying.

  6. Oh, come on – be fair! You allowed him to make an informed decision, albeit in something of a forceful manner. I agree that one should be frank from the outset, hopefully negating the need to scare the shit out of a patient when they don't do what you want. I'm sure you tried your best – I personally really hate the way we, as health professionals, are supposed to pussy-foot around and not tell people about the scary stuff (like never being allowed to say “cancer” to a patient until you've got a tissue diagnosis, even when you're 95% sure and they just want to know what you're investigating for and already think they've got cancer). That's not a pop at you – I agree about all the hippy stuff. I think showing respect should mean being honest. Patients tend to get a lot more scared if they sense you're tiptoeing round something.If, armed with the information you gave him, he had still refused, and was competent to make the decision, you would have had no choice but to leave him. You wouldn't have been able to say “either you come with me or I call the coppers.” It just so happens that when there's some kind of psychiatric-type behaviour, you can pull the legal trump card to get them to do what you want, which, as you know, is something I raised issue with.

  7. I'm a freeediver. Never heard of secondary drowning.What we call 'fainting spells' can happen while training for freediving. The guy could have been doing that unsupervised, which is a big no no.

    But when we train or compete we're not that tense about fainting spells. We don't like it, try to avoid them… They happen when people get further than their limits, and as training is about coming closer to your limits, well…

    After them if people come back 'normally' (I know it doesn't seem normal at all to you, but if it takes less than 10 secs), people don't go to hospital. They are chastised by a coach or referee and suffer a little shame. First thing you learn while training for static apnea is how to know when your buddy is overdoing it and what to do then.

    I've never had a fainting spell or what we call samba (violent shaking, which is the first sign that you've gone too far) but I don't know if people inhale water in that case. I'll certainly ask my coach about secondary drowning next time.

    Of course, not knowing who the guy was and what he was doing, you were very right to take him to hospital, but I'd agree the explanation why he had to got was maybe a little late…

  8. R, I'm pleased you did this.It reminds me of Casualty (tv show) in the old days. If this had happened in a scene they'd all be trying to be gentle because it's a kid and then some forceful parent would come in as well and verbally abuse the ambulance staff for saying the kid had to go to hospital or something, and then the staff would just walk away shrugging, then the kid would keel over two scenes later.

    And you just think “why could they just stop being nicey nicity for one moment and just tell the patient and whoever's with them that the ambulance folk know best, they are trained, and stop being so awkward and wasting their time and just get in the damn ambulance.

    So Josh or whoever would get a bollocking for letting the kid go home, and he'd be all heartbroken but would probably get to exchange a look with the grief stricken parent at the end, whose eyes would be filled with regret and tears…

    Er sorry got carried away. But this is why I like 'House MD' (have you ever watched that?) he does away with all the softly softly if it means helping the patient. And he's way sexier than Charlie from Casualty.

    I know you're not a doc, but maybe aim for the temperament of a cross between Charlie and House.


  9. Reminds me of when I was hospitalised last year – in A&E I was told “you ARE being admitted because…”, not “we would like to keep you in because…and is that ok with you?”.

  10. Secondary Drowning is a portion of the National Pool Lifeguard Qualification.The information in the Wikipedia is slightly out of date following recommendations by the World Congress on Drowning (2002) which were adopted by ILCOR (2005).

    For further information see a summary here: http://manchesterlifesaving.org.uk/content/view/95/43/

    The effects of Secondary Drowning can occur upto 72 hours after the drowning incident.

    I have deep concerns that the child was on the bottom of the pool for 30 seconds. The human body is fairly bouyant, and doesn't like sinking unless the lungs and stomach are filled with water. But more importantly, if the Lifeguards were doing their job effectively, that's about 20 seconds too long! That's not including the time it took for his body to sink.


  11. I would have done the same, I have been forceful in encouraging patients to go to hospital or agree to treatment. I can still remember a night out where found a teenage girl who had overdosed on a large number of Asprin and Vodka. Told her I wouldnt call an ambulance etc etc as soon as she was u/c called Ambulance, she survived.Sometimes acting in the patients best interest is not doing what they WANT it is doing what they NEED.

  12. Agreed, there is a difference between being stupid (not taking the advice of medical professionals in a case like this) or being mentally ill (in which case the law can help me).So was the girl in the previous post 'mentally ill' or 'stupid'?

    'Stupid' means I can leave them behind, 'mentally ill' means that it's more dangerous to do so, and I have the law as an option.

    Am I trained enough to determine if someone who is mentally ill is (a) competent, and/or (b) safe to leave at home? I'd quite happily say 'no', which is why a Section has such safeguards as you already know.

    In the case of the drowning there was no way of getting him Sectioned, so I had to use other coercive techniques, like putting the fear of death into him in order to get him the care that he needed.

  13. I'm no expert on freediving (except to shake my head and think 'nutters' – but then again I think that about a lot of things…) but I doubt that this fella was training in static apnea.No-one had any idea why he was unconscious at the bottom of the pool, which is the other reason why he needed to go to hospital, something that you point out.

    Have you heard of immersion syndrome, where you faint, and can die coming out of a long stay in water? That's another strange one – Makes me think those people who man lifeboats really must know their stuff.

  14. House is just evil – and we love him for that…But yes – I remember once upon a time watching casualty, and thinking “for god's sake man, pull yourself together and drag them to hospital”.

    You know what – I'm a taxi driver with blue lights, for all my training the best place for a sick person is in hospital so that they can get something other than the half-arsed assessment I can do on them.

    That's why I want everyone to travel to hospital.

    (It's also why I'm against the idea of ECPs – but thats a tale for another day).

    When I was on a nursing course, far back in the mists of time, we got to talking about doing what was right for the patient – I suggested that as the people who knew best, we had a duty in coercing people into getting the best treatment.

    I was told that I had the morals or a Serbian war criminal.

    By the lecturer.

    (Who was, I point out, still breastfeeding her five year old child…)

  15. Immersion Syndrome, also known as Post Immersion Collapse. Particularly common phenomenan during aquatic rescues during the World Wars. The casualty would be in the sea and fine apparantly fine (perhaps a tad chilly!) and by the time they had been winched up into the helo/boat, they had lost consciousness and usually lost effective circulation as well.It's caused by hydrostatic pressure – literally the weight of the sea around you squeezing the fluid from your body (kind of like the special G-Force trousers that jet pilots wear). Whilst you are in the sea you are fine, however, as soon as you leave the water, your blood pressure plumments and you loose consciousness. The best way to avoid this is by taking the casualty out of the water horizontally (or as horizontal as possible).

    Frank Golden and Michael Tipton (both world-leading Naval Researchers) have done a tremendous amount of research on this subject, and has written a fascinating book which discusses it (and more) in detail – Essentials of Sea Survival.

    A more minor example is seen in people who train for long periods in the swimming pool. After an hour or more of swimming, you will be bursting for the toilet – literally your body fluids being squeezed out of you!

    Not that I am a lifeboat crew member (my eyesight is too poor), but the RNLI boys and girls are the best in the world!

  16. To be honest I would say that 99% of competent people will agree to go to hospital if you tell it to them straight. I don't coerce or bully or force people to go to hospital, but I will tell them straight:You need to go to hospital if you have a frontal headache with visual disturbances because you could have pre-eclampsia which if left untreated can lead to the death of you and your baby. That is why I want you to go in; if it's nothing, it's ok, but if it's not nothing, it's proper serious.

    This goes for other 'do I have to?' complaints like bleeding in pregnancy, baby not moving for 24 hours, blah, blah… You were concerned enough to ring me, so take my advice when I talk to you!

  17. I completely agree with what you did in this case, but I'm very much anti-bullying. I take the view that the patient should be given the facts, and then allowed to take the choice. Recently a member of my family was in hospital and just being there was very damaging to them in a number of ways. So I insisted with a doctor that we take them home to recover. The doctor wasn't happy, and their first response was to pretend that we couldn't take them home. I pointed out that there were other factors beyond the one they were considering, and that those were more important. In the end we agreed that they should do some tests so we knew where we stood, and that we'd get a discharge.But there was no respect – the doctor took the view of “I know best” when in fact they didn't, because they didn't see the bigger picture. We were proven right when back home recovery was very quick.

    In your case, it was simple, there was just one thing to worry about, but in more complex cases I think it would be helpful for doctors in particular to listen more closely to patients and relatives and be a little more humble. They don't always get to see the whole picture

  18. I am going into the health field now and I know that ignorance is bliss. When you learn about all of the what ifs, and maybe so it is very scary and concerning. I think you did an amazing job in persuading and in some cases you don't have time to go through the process of explaining in everyday terms and being polite. Our job as a health care professional is to take care of our patients. If they get mad because we seem rude so be it if we are saving their life. Thats my thought on the matter. Keep up the good work.

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