We opened the side door to the ambulance and started getting our bags out. Our patient was young and unconscious, probably a diabetic, but you can never be too sure so it was time to take most of our equipment into the hostel.
One of the staff of the hostel led us to the patient – it is perhaps worrying that he knew more about the patient and their medical history than many of the nursing homes we go into. The patient had only arrived earlier that day.
The staff had found him semi-conscious and rambling, they had called us straight away and by the time we arrived the patient was deeply unconscious. He was so cold and sweaty he put me in mind of horses when they work up a lather. Our gloved hands kept slipping off his skin.
First things first – he was 'snoring' which is the sign of an airway about to block, a simple tilt of the head solved that and while my crewmate checked his blood sugar I started him on some oxygen.
The check of his blood sugar showed that it was so low it was outside the measuring range of our equipment. He wasn't too far from dying.
We have two main ways of dealing with an unconscious diabetic with low blood sugar, we can give them an injection into their muscle that frees up some sugar from the patient's liver. This is slow and only works if the patient has sugar stored in their liver. The other way of treating this is to put a needle into their vein and administer 10% dextrose – essentially sugar water straight into the blood stream.
Our problem was that he didn't have 'good' veins. They were invisible and deep.
So we gave him the injection into his muscle while we searched for a vein. If we couldn't get a needle in then we would need to 'scoop and run' which would mean moving someone with poor airway control – never much fun.
We managed to get a needle into him, more through luck than design, and we started pouring in the sugar water.
His blood sugar came back up, but he was still deeply unconscious. This is not good.
We knew that he was on opioid painkillers – perhaps he had overdosed? I went down to the ambulance to get the drug that reverses such overdoses.
It was probably then that I left the ambulance unlocked…
We gave him some of the reversal agent. With an overdose the patient will often sit bolt upright and go into instant withdrawal – this didn't happen but the patient did slowly come round. It seems that he was just taking his time recovering from the low blood sugar.
We sat and chatted for a while, he didn't want to go to hospital.
…But there was something about him that I didn't like the look of. I don't know if it was because his sugar had been so low, it might have been because he had been so slow to respond to the sugar we had forced into his veins, it might have been something else that I was picking up on…
I didn't think that it would be a good idea to leave him at home, he needed to be looked at by people more skilled than I.
So we argued the toss back and forth, I would plead, he would refuse. I would explain why he needed to go to hospital, he refused. I let him know how close to death he had been, he refused. I told him that if his blood sugar dropped again then he would die, he refused.
So I lied to him.
I told him that if he didn't come to hospital under his own free will then I would place him under 'medical arrest' and that if he didn't come with me to the hospital I would get the police to help me remove him. I was holding my breath that he wouldn't call my bluff – luckily he didn't.
This is really naughty.
I'm sure I could 'fudge' a capacity check, say that he was confused and take him in under that, but it would be a stretch and almost certainly untrue. I wasn't going to be able to physically drag him out (and that would be crossing a line I wasn't willing to cross). Instead I had to bend the truth, and I do feel bad about doing it. I don't do it for all patients, but there was something about this man that made me want him in hospital.
We took him into hospital.
Later that night we saw him again – he was barely conscious in the resuscitation room. His blood sugar had plummeted again and he was septic and really rather sick. His temperature had obviously been disguised by his cold sweat as an effect of his low blood sugar.
I glad the hostel staff had found him, I'm glad that our treatment had worked, I'm glad my bluff had worked.
I'm not glad I had to bluff him though but I'd like to think that if he recovers he'd forgive me.
I could get into trouble for writing about this, but I think that it is important that people learn the truth about what we have to deal with, and how we sometimes have to bend the rules in the best interests of our patients. If that makes me a fascist… well then I'm a fascist.