Big Grey Lie

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.

97 thoughts on “Big Grey Lie”

  1. I can see that there's a sort of logic behind the arguments of those objecting to Tom's actions, if you believe rules and laws are there to be followed strictly to the letter. But rules and laws are just too general and inflexible to be effective if you have that attitude.If you scrutinised every facet of every job ambulances are called to, I'd be willing to bet that in at least 50% of cases there is some small violation of a law or rule or of standard policy. Same goes for police and fire and army and… actually probably pretty much any job going: accountants, lawyers, teachers, factory workers, newspeper deliverers… We all fudge little things and cut small corners and brush things under the carpet… because if we followed every rule and every law strictly and rigidly, the laws and rules would end up causing more difficulties than they solve.

    At least one person here seems to have the idealist attitude that it is possible to follow rules without having to “interpret them” with a bit of common sense. As Tom says, nothing is ever back and white. So feel free to argue that Tom's particular interpretation of the rules was folly, but do so in the realisation that Tom's job (or practically any job) involves making intelligent decisions that are not always strictly in complete compliance with the rulebook .

  2. I think when you are trying to save someones life, although you have rules to stick to, guidelines etc, you still need to be able to think on the spot and do whatever it takes to make sure that patient is treated? This is the 1st time Ive commented on your posts, although Ive been following what you write daily, and just felt I needed to say that. Just finished your book man, it made me laugh and cry, a brilliant read, wish i hadnt got to the end! Good job!!

  3. This is when you really earn your money Tom, don't feel bad. You saved his life.If anyone challenges you, remind them, you saved his life.

    Because, you know, that whole “life” thing is worth saving (not the twats that stole stuff from your ambulance though..)

    Well done.

  4. I think it's fantastic that you did what you did. I think there is far too much emphasis on sticking to procedures when common sense would dictate something very different. In this situation, who's to say he was even capable of rational thought? In a way, it scares me that rules might cause other professionals to act differently in this sort of situation, as all sorts of conditions could make a person think they were OK when they're not.What you saw later on really confirms you did the right thing. If you had left him, he would have died, wouldn't he?

  5. For the record: if I've been unconscious and am burbling, I don't know what's best for me – I'm hazy on things like who and where I am, let alone what my best course of action is. In these circumstances I want you and your colleagues to protect me and use your skills, knowledge and actually-being-awake-ness to make a call on what is best for me. And if the options are (a) leaving me to die, (b) mucking about trying to get me sectioned, (c) physically wrestling me, or (d) telling me something that isn't strictly true that won't have a negative effect on my condition but will have the desired effect of getting me to safety… then I will take (d) every time.

  6. Brave of you to write it down Tom!Experience is a powerful thing & thank God for your patients, you've got it.

    It makes me take a deep breath in when I think about the potential plop you may have been in if you allowed him his original decision of staying at home (despite him signing forms).

    Dunno about your management but ours (believed soon to be yours) would take great delight in pointing the finger at crews and turning their backs after watching you squirm.

    Can I ask Tom, are you not a Para because you're on a roster, which you'd lose if you did the course?

  7. An ex-flatmate of mine was type 1 diabetic, and she told me when I moved into the flat that if she ever became sleepy, aggressive, spaced out, etc etc, to get food into her straight away and to totally disregard anything she told me at the time about being fine and not wanting anything, however lucid or insistent she was. I'm sure when he recovers this lad will feel only too glad that you persisted.

  8. Good job, Tom. People forget that the service is about thinking on your feet and common sense and can get bogged down in political rules. If a bend works positively for a patient then, in my book, there is no case for 'but you lied'.Keep up the good work. And looking forward to no 2 book 🙂

  9. Incredibly so, considering what might happen to you now Tom. Although hopefully common sense will win out and the fact you made the right decision in getting that patient to hospital, a decision clearly vindicated by the fact he also ended up in resus, will mitigate any problem management have with you.Regards

    Nick

    http://nickhough.blogspot.com

  10. I totally agree. Low blood sugar plus opiods = not good at the best of times – which of us hasn't made an occasional lousy decision even when just averagely hungry, or tired, or intoxicated?

  11. I've been reading this blog for about a year now and this is my first (and last) comment. I read this post with great disappointment, over the past year or so I'd built up a great respect for you and your work, but that's gone now. You've crossed a line that no medical person can ever be justified in crossing, you've ignored the clearly stated wishes of a mentally competant patient, and threatened them with violence to get your way ( That's what arrest is after all, the threat of force if you don't do what you're told, that it's legal is beside the point ). I have to say I hope this post does cost you your job because after today, I wouldn't want you attending to me or any of my family.

  12. Doing the slightly “wrong” thing, for the right reasons, is a choice most adults have to make at some time.Doing the wrong thing for the “right” reasons is the comfortable daily option of most politicians, it seems…

    Perhaps there should be a new piece in the manuals and legislation governing EMTs, and suchlike professionals, saying something like:

    to obtain the long-term therapeutically optimal outcome, they may tailor their presentation of factual issues, and non-factual creations, to the “client” in ways they feel are most appropriate and comprehensible to that client's level of understanding at the time of diagnosis and/or treatment?!

    Or similar legalise bulls41t indicating that if someone's bleeding to death but, due to some pills they've just snaffled, will only let Darth Vader in to stop the flow, it's time to stick a black bucket on your head, and breathe deeply…

  13. Dear SteveR – I can't believe you said what you did. Apart from sounding unbelievably sanctimonious how can you possibly mean what you said. Please have your wishes tattooed on your forehead and those of your family and friends, saying that you prefer to be left to die rather than be told a white lie. I'm quite sure you will then be extraordinarily happy when you croak it and can perch on your cloud and polish your halo. You can lie to me or mine any time, Tom, and if you lose your job or get any sort of disciplinary action, I promise I shall write to every newspaper in the area I can think of. And this is the second time of trying to post this reply, perhaps luckily with the first one I forgot my log-in and had to start again.

  14. But given what Tom had told him about why he wanted to take him in, and given that he'd just had a major hypo, how can refusing further treatment really be deemed as the act of someone who was at that point in time 'mentally competent'?

  15. Steve, can I ask you one thing (I don't know Reynolds at all, as a “statement of interest”) – have you ever been in an altered state due to low blood sugar, drink, drugs, anything?And made a bad call that could/would have negatively affected you from that?

    Make your choice as you will, I'd far rather have someone who KNOWS I'm freaking out when I tell them to get the mice outta my head than not.

    Sorry for commenting before the blog owner, but sheessh, BS.

  16. Oh dear! Firstly I can tell you're a person with no decent emergency medical knowledge when you made the comment “mentally competant”. This seriously ill patient was indeed not mentally competant. This person was Septic – a dangerous and unpleasant illness.Septic shock causes a dramatic drop in blood pressure, affecting the supply of oxygen to major organs such as the brain, heart, liver and kidneys.

    Signs of septic shock include confusion, pale-looking skin, cold clammy skin (only in later stages), collapse, very low blood pressure prevents blood being supplied to all parts of the body, and leads to organ failure.

    Tom & his crew mate saved this man and it's down to them that this man can now make a choice to thank them when he is better.

    I hope now you understand the extreme nature of this man's acute illness, you will be of a different opinion as to the actions of Tom & his crewmate.

    I'd have no hesitation for Tom to come to me, my friends and family in our time if need.

  17. I clicked on your blog link, mainly I confess so I could find out what your issues are, but also for a laught.I found, this:

    “We picked up my train ticket for Prague after a half-hour battle of wills with the lady at the counter who couldn't find the same ticket we'd been informed about the day before. Finally, ticket in wallet, we ran for the bus to Karpacz Gorny (Upper Karpacz).”

    Ye gods you middle class tosser, what exactly is your game?

  18. As far as I understand it, it for for the EMT at the scene to decide whether someone is 'mentally competant' or not. Someone exiting from a diabetic episode is often unfit to decide on whether they need further treatment.Tom is a professional who saves lives regularly. He decided the man needed to go to hospital for further treatment. If someone of his experience says you need to go to hospital then you really need to go, despite whatever wishes you may be expressing in your half lucid state.

    Tom did the right thing, he saved the mans life. However you play it that is more important than the wishes of a patient who has just come out of a hypo.

  19. Tom. you are a hero, simple as that. I too have been in a similar semi-conscious state, suffering from septacemia, and muttering about not wanting to go to hospital as it meant leaving my children (who are grown up and were worrying about me being half dead). Luckily the nice London ambulance man was taking none of my nonsense whatsoever, told me I was not being left to die as it meant too much paperwork for him (!), and he was taking me in. That nice London ambulance man saved my life. I am very grateful for that, and extremely glad he didn't listen to my semi conscious warblings.Tom you did the right thing, you know that, we know that. Anyone who says anything else is just a troll and ignore them! Little white lies rarely kill anyone, but in this case they saved a man's life. Another one you can chalk up. Well done 🙂

  20. Heck, when my sugar is low from, say, not eating when I should, I can't think clearly, much less when its like that. I'm glad you were willing to do what you had to, to make sure he was treated. Sometimes instinct and common sense trumps protocol.

  21. OK I had intended that last post to be my final one but I feel I need to reply to some of the feedback, this definatly will be the last time I comment though becuase I won't be returning to this blog.I knew my first comment would be a controversial one, but I am surprised that the only other person anywhere on this forum who seems in the least uncomfortable about lying to people to manipulate them is Reynolds himself “Instead I had to bend the truth, and I do feel bad about doing it.” and “This is really naughty.”

    Regarding Julie's accusation that I'm just a troll, well, pretty much by definition there's no way to answer that accusation, all I can say is that I really do mean what I said.

    almeida, smoochie597, Debs ( I have a fair bit of medical knowledge actually ) and Mr Biscuits, as for if he was competant to decide his own treatment, I'm not relying on my own judgement here. “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.” Reynold's own statement says he was. Doctors have been struck off for ignoring patients wishes and treating them against thier will, and I see no moral or ethical difference between strapping someone to a bed and forcably treating them, and lying to and threatening them to get “consent”. I know that's a rather emotive example, but I believe it apt.

    Debs and Mr Biscuits, you seem to be asserting what's basically “The ends justify the means” which I simply can't accept. I'll freely admit this is an area of debate where there's no clear consensus, but my personal view is that the ends can never justify the means.

    deborah, I was trying not to be sanctimonious, but I'll grant it may have come across that way a bit; I have extremely strong views about a persons right to control thier own body and by extension it's treatment. I would rather hope that a “Don't lie to me” forehead tatoo is unecessary! I really would expect medical people to tell me the truth and allow me to make my own choices. There is clear precident that a person who's mentally competant (see above for justification of that) has the right to make thier own choices about thier care, even if that puts thier life at risk.

  22. SteveR. I have to say I think you are a complete knob.Hoping TR loses his job as a result of trying anything possible to get a seriously ill man into hospital, is quite the nastiest thing I have heard recently. In the ambulance service, crews try everything in their power to convince patients who need hospital treatment to allow us to convey them. If they refuse completely AGAINST ALL ADVICE, we try to get a doctor to visit. Sometimes, that would take far too long, and the patient could conceivably die in the interim. This patient may possibly have had the capacity to refuse, but that does not necessarily mean that he knew what was best for him – as evinced by his subsequent downhill path.

    On a personal basis – people in LAS who know and work with TR (especially those on his complex) invariably speak of him as having a mixture of professionalism, expertise, experience, humanity and humour that certain others would do well to copy. They also say he is a damn good bloke. I tend to respect their opinion far more than yours.

    And finally – as I said – You appear to be a complete knob.

  23. Here, here..Without trying to sound condescending sometimes patients don't always know what's best for them when they are confused.. Well done for going with your “spidey sense” Tom.. I've done it in the past and will do it again..

  24. Fair enough. Thats his 'personal opinion'. It's rather telling that he is the only one here with that particular opinion.The end doesn't justify the means? Of course it does. What good is a daft little civil liberty like the right to refuse treatment if it winds up getting you in a bodybag.

    The man was dying. He had his 'right' violated to preserve his life. I would hope any medical professional would do the same thing.

  25. Like the previous poster, I'm absolutely appalled at your flagrant abuse of both the law and professional ethical standards. Alot of the posters here think you're a “hero”. I'm not one of them.You and others think that the patient wasn't able to make his own decision. This may well be the case. To be competent under the Mental Capacity Act you have:-

    # to understand the information relevant to the decision or

    # to retain that information, or

    # to use or weigh that information as part of the process of making the decision or

    # to communicate the decision

    It may well be that your patient didn't meet one of those criteria (often, in my experience, the ability to use the information given). In that case, yes, take them to hospital.

    What you should never, ever, do is lie to a patient to force your agenda onto them. The Mental Capacity Act makes it very clear that patients are allowed to make decisions which seem unwise, or even ludicrous, to those treating them. If they are truly incompetent, then yes act without their consent, but do not, do not, do NOT lie to them in order to get your own way.

    Your post suggests not a caring or empathetic viewpoint, or even a desire to help your patient, but a desire to show off that you saved a life, with no regard to the consequences.

    Who the hell made you the arbiter of what's right? Your actions suggest a bullying, completely unprofessional attitude, and as I'm sure you probably know you also broke the law. Saving life is good, but it's not the be all and end all that you think it is. You may think you did good, but I assure you that you absolutely did not.

    You deserve to lose your job.

  26. 24601 – another one who obviously knowns nothing about the ambulance service – TR sure as hell would have lost his job (or at the least been disciplined and been in deep shit) had the patient died. He did the best possible for his patient; the patient NEEDED HOSPITAL. Oh by the way – read his post properly: he does NOT say that he is proud of having to mislead the patient, quite the reverse. Oh – and TR COULD have asked us in control to get the police to scene, in order to try to get the patient to agree conveyance for his own good.

  27. I am getting mighty sick of this leftist bullshit attitude. Whilst rights are an important part of modern society they are not as bloody important as all that, especially something as minor as this. Tom knew the man needed hospital, and did his level best to get him there, whatever that might have took.Christ, we get lied to everyday, from all quarters. You can be damned sure very few of those lies are with the intention of saving your life

    If this is what this perticular law means in reality, then it's time it was dropped.

  28. I work in healthcare and know more than you think about these kinds of things.It is never, ever, acceptable to trick a patient into doing anything. If the patient didn't want to go to hospital, and understood the risks, then this was his choice, and it is absolutely wrong to trick him into doing otherwise.

    As a side issue, it's not very likely that someone with a recent history of a hypo is septic, as the stress which septicaemia puts on the body causes a release of steroids which push the blood sugar up.

  29. Who the hell are you, I, or Tom to take these decisions away from patients?I don't give a damn what the patient's reasons were, but if he understood the risks then I would have stood by his decision 100%, and anybody who does otherwise is guilty of professional misconduct and probably broke the law. The rules are there for a good reason.

    Saving a life isn't the only option just because we consider it to be the right one.

  30. In which case you are obviously not au fait with the way the ambulance service are getting the blame for everything that goes wrong with any patient. At least one crew in London to my knowledge has in the past year been stuck on disciplinary charges for NOT CONVEYING a patient who REFUSED CONVEYANCE. Because of the namby-pamby everyone's a victim Claims Direct culture that we now endure, crews are losing their jobs for DOING THEIR JOBS. Moreover, people like you do not help.

  31. Well if that's really going on (which I doubt), then the managers who are doing it are just as guilty.It's a tragedy when somebody dies, but we shouldn't always save them just because we can.

    I absolutely believe (as does the public, the HPC, the NMC, the GMC and the law) that patients have the ultimate right to decide what treatment they receive.

  32. After reading the last few posts, all I can say is I am glad when I was semi conscious that I had a sensible London ambulance man make the decision to take me to hospital and ignore my protests, therefore making sure I lived that night and didn't die and leave three children without a mother – rather than 24601 in charge of my medical care who would have listened to my warblings and left me home alone to die – and then told my children that had been my choice.

  33. If your condition was impairing your decision making abilities then you would have failed the test of competency I described above. At that point I would have taken you to hospital, even if it was against your wishes, if necessary with the use of force (as I'm sure Tom or anybody else would).What is not acceptable is deciding without really assessing that a patient is incompetent, and then proceeding to lie to them in order to trick/scare them into complying in order to obtain dubious “consent”. That's known as bullying.

  34. All Tom did was transport the patient to hospital. Once he was there the patient could then have decided to refuse further treatment – obviously he didn't (or the doctors decided to treat him anyway).So – no harm done.

    Had Tom not encouraged the patient to go to hospital, he wouldn't have been able to decide anything.

  35. It is a known fact that if a diabetic has an infection, 9times out of 10 it will cause them to experience a hypo

  36. 24601: if he understood the risksThat's the nub right there, isn't it? In Tom's professional judgment, the patient did NOT understand the risks, but taking the time-consuming steps necessary to haul him to hospital anyway could have cost the man his life. So Tom bamboozled him because that was the most elegant solution in that case.

    That's the essence of a talented and humane helper: knowing when to help. I know I've read several posts of his where he left patients be at their request, despite his judgment. That, then, seems to be what he does when the patient DOES seem to understand the risks. In other words, you, 24601, and SteveR, wouldn't have your rights trampled as much as you seem to fear.

    Take a deep breath, both of you.

  37. I have earlier stated that a person suffering from Septic shock will present with certain symptoms – and Tom & mate were presented with those symptoms.One of the symptoms was confusion.

    I've read the blog & it states that the gent was confused.

    I understand confusion to be whereby a person's thought process is obscured for one reason or another and therefore cannot be expected to make a clear decision.

    You wrote:

    “If your condition was impairing your decision making abilities then you would have failed the test of competency I described above. At that point I would have taken you to hospital, even if it was against your wishes, if necessary with the use of force”

    You appear to have come to the same conclusion that Tom & his crewmate came to…

  38. I have earlier stated that a person suffering from Septic shock will present with certain symptoms – and Tom & mate were presented with those symptoms.One of the symptoms was confusion.

    I've read the blog & it states that the gent was confused.

    I understand confusion to be whereby a person's thought process is obscured for one reason or another and therefore cannot be expected to make a clear decision.

    You wrote:

    “If your condition was impairing your decision making abilities then you would have failed the test of competency I described above. At that point I would have taken you to hospital, even if it was against your wishes, if necessary with the use of force”

    You appear to have come to the same conclusion that Tom & his crewmate came to…

  39. I understand your concern about care homes but I work in one and the information we are given by the medical profession is very limited to say the least. In fact, it is appalling. We are given a list of medication that the people we care for are on but no details as to why there are on it or as to their medical condition – it is deemed confidential and can only be divulged directly to family members. I also work in at veterinary practice, have a BA and a BSc and am in my final year of working for my MSc. However, I still struggle when speaking to doctors and ambulance staff when it comes to given the information they need from the care plan with which I am provided. One night, I dearly would have loved to have accompanied a frightened elderly lady with Alzheimers and breathing difficulties on her last trip to hospital but could not because that would have left only 1 person on the night shift and that is an impossible (and illegal) situation. As I held that lady's hand for the last time I found myself trying reassure her whilst trying to explain this to the paramedic whilst my heart was torn apart. Some of us do really care. Honestly. Please don't tar us all with the same brush. Some of us do really care – and it hurts when we can't do as much as we want to.

  40. This post made me really happy. It convinces me that (at least some of) the paramedics out there :a) can use creatively what occupies a large part of their skull

    b) care more about their patients welfare than doing everything by the book and making sure that nobody can file a complaint against them. After all, it would have been easier for you to leave him there, you would have nothing to worry about for yourself (since he clearly refused to go to the hospital).

    I hope when the guy wakes up values his life a bit more…

  41. I'd just like to say, Tom, that I hope you, or someone of a like mind, attend to my nearest and dearest in their moment of need. Sometimes the rules have to be stretched and common sense applied.I've not long finished reading your book and thouroughly enjoyed it. Hoping for a sequel,

  42. I came to the same conclusion as to the medical need for hospitalisation.I have no idea whether the patient was competent or not, but if he was it was his right to refuse it.

    If he wasn't, then yes I would have taken to hospital, but not through the use of of trickery and deception.

  43. Tom, as an ambo from west of London I support 110% what you and your crew mate did for this bloke. I have done much the same in the past and will almost certainly do so again in the future. And I think Tom, if you were in the same situation again on your next shift you would do exactly the same.As for SteveR and 24601, I hope you read this even if you don't post again. Try to consider how your parents, children or loved ones might feel when a copper knocks on their door and has to tell them you had died, and that you could have been saved but an ambo left you to peg out because you said you wanted to, even though just like this bloke you were not in full control of your faculties.Perhaps you think that the failed Glasgow Airport suicide bombers should have been given an extra few litres of petrol to pour over themselves and do the job properley, instead of one of them being a drain on the health service that provided him with a living and maybe the cash to by his bomb making gear.

    Take heart from the positive comments Tom, as yours to me did a few months back. Most of the real world is right behind you

  44. Well done Tom, as my mum once told me you sometimes have to be cruel to be kind. It is all very well to comment on it now with hindsight and the full facts on our side, only Tom and his partner were able to make the call to coherce him to hospital or leave him to die. It takes a brave person to go against guidlines these days and i'm just glad there are folk like tom who know when to use some sense rather than the rulebook.Bullying someone into going to hospital, what's next, firefighters forcing trapped folk out of a burning building against their will? It's political correctness gone mad frankly.

  45. I completely agree. Yes, there are some care homes that just don't seem to care about their residents, but I'm sure that they are far outweighed by those that do. I care deeply about each and every resident in my care home, and we're all hit hard when one of them dies, because they're like family.

  46. This is my first comment on Tom's blog. It seems to be a topic on which one needs to comment. Perhaps we should have some sort of poll. Hands up those who would like to have Tom come to their aid when seriously ill, or those who would like someone with different views. I would vote for Tom; I would rather be manipulated into having my life saved than be self-righteously left to die by someone uncaring.Rights should be balanced by responsibilities, and it is Tom's responsibility to save lives. If he considers that someone does not really understand the decision to be made then he should do what he can to save them. This man did not want to die, or he could not have been taken to hospital under any circumstances (he could have called Tom's bluff) he simply was not in a condition to really understand what he should do.

    Well done Tom. I hope there is someone like you if I am making the wrong decision like that.

    I presume that those with opposing views would simply leave a patient in the middle of the road if they expressed the wish to lie there and die after an RTA? No? I thought not.

  47. Steve R: and 24601, appear to love words; and the rights to live and die : 'Tis why lawyers have fun sueing: this case could have made nice head lines for the Tabloids. ” NHS leaves a Diabetic to die alone in Hostel as they would not transport patient to Hostel. Hostel residents watch as patient dies.”I just waiting for the Lawers to the The airport for dragging patient to Hospital because he did not want to go to hospital but die a Martyr, did they not violate his civil rights as out lined above.

  48. Steve R: and 24601, appear to love words; and the rights to live and die : 'Tis why lawyers have fun sueing: this case could have made nice head lines for the Tabloids. ” NHS leaves a Diabetic to die alone in Hostel as they would not transport patient to Host[pit]el. Hostel residents watch as patient dies.”I just be waiting for the Lawyers to sue the the airport and every one involved for dragging patient to the Hospital because he did not want to go to hospital but die a Martyr, did they not violate his civil rights as out lined above.

  49. Can I ask Tom, are you not a Para because you're on a roster, which you'd lose if you did the course?That's a huge part of it, yes.

  50. The main premise for the service's existence is defined by a short and very simple phraseTo Preserve Life And Promote Recovery.

    Tom and his crewie did exactly that.

    Whilst lying may not appear to be right gentle coercing is better than assault which is what removing someone physically, as another poster has suggested, would be. That is a far far bigger no-no in the service than persuasion

    Imagine the scene:

    A terrified patient lies dying in your arms. There is nothing you can genuinely do. Perhaps they are trapped by the wreckage of a car around them. They need some peace and hope. “Am i going to die?” they ask. What are you gonna say?

  51. Steve R and the guy whose name is numbers: don't stress too much. If the guy lives and hates Tom for making him do so, he can always find himself a nice high bridge and throw himself off it, can't he?Or, he could wake up – and feel immensely grateful to the man who allowed him to do so.

    Tom – you did the right thing. You saved his life. Seriously, don't stress. You know you were right, deep down saving people's lives is the reason why you took up this job in the first place. If you'd left him to die, you'd have driven yourself insane constantly berating yourself for doing so.

    I for one would feel completely at ease knowing it was you that was coming to help me if ever I need the LAS.

  52. Actually, 24601 is correct. Infections typically create hyperglycemia and not hypoglycemia. If you really want to learn more about diabetes, you can read an incredibly boring manual on clinical guidelines for diabetes by the American Association of Clinical Endocrinologist (it's a huge manual it takes a bit to download before you can view). Also, speaking as a diabetic I do know that when I have any type of infection, it impacts my sugar control negatively, causing hyperglycemia. It's very well known that infections increase sugars and diabetics.With that said, this patient had septicemia which is not an ordinary infection. There is typically some underlying co-morbidity for the massive infection. Knowing the unpredictability of diabetes, I wouldn't think it out of the realm of possibilities to have hypoglycemia.

  53. I personally think the only person qualified to make a comment on the ethics of what happened is the patient himself. That may not happen, but I'm damned sure that if I was in a similar situation, I would want someone like Tom to coax me to hospital – telling white lies or not.To SteveR and the “numbers guy” – would you be of the same opinion if it was your brother or sister, a parent or a (adult) child? Would you take such a “tough shit, he should have played by the rules to the letter” attitude then?

  54. I'm all in favour of civil liberties, you only have to look back at Soviet Russia to see what happens when medication without consent becomes part of the armoury of the authorities.But unless I missed something, this guy wasn't refusing treatment for strongly held religious or ethical reasons, and wasn't refusiing treatment that, for example, would alter his mood permanently (eg an unwanted prescription of ritalin, or anti-depressants: and unless you include “not being dead” as a mood altering treatment) – he just didn't want to go to hospital.

    I cannot seriously believe there are two people posting here who honestly think this man would be better off dead today, for making a flawed decision in a confused state of mind – that's actually a pretty harsh punishment for being wrong.

    It also reminds me of the extreme views held by people who have in the past ignored massive wrongs because they were “only obeying orders”…. it's so easy to let your personal responsibilities as a decent human being slide when there's a rulebook to hand, isn't it?

  55. TomDon't beat yourself up about this – your gut feeling appears to have been that the patient was not competent to refuse transport, whether or not the paperwork would have supported it (I would suggest that had you taken the time to fill in all the paperwork, it quite probably would have confirmed your initial impression). I also suspect that, had you taken the time to do everything exactly by the book, the patient would have died, making the paperwork somewhat irrelevant.

    So, having come to the conclusion that the patient was not competent to refuse treatment/transport to hospital, rather than a: slavishly follow procedure and call for the relevant assistance (thereby increasing the likelihood of patient dying at the scene) or b: putting him in the bus (and I quote) “if necessary with the use of force”, you chose c: convincing him that, in his own best interests, he should get in the ambulance.

    I define 'his own best interests' here as 'not being dead'…

    OK, telling the porkie was somewhat off the reservation, but IT WAS THE LEAST BAD OPTION AVAILABLE AT THE TIME.

    Hmm – the pills must be working – I got through that without swearing once.

  56. OK, as a nurse, I have imprinted on my brain the following “FIRST DO NO HARM”. Have to say that although I can hear and picture the ethics lecturer I cannot remember who said it. BUT it was said so often during my training that I have NEVER forgotten it.So, in this case – “first do no harm” – leaving this patient in the hostel would have done harm; waiting for the police potential for harm; sectioning – potential for harm. Persuading the patient to go to hospital where he could refuse treatment if he wanted to – potential for harm (to his confidence in the health service). However, of the options presented to Tom, I believe this to have been the least harmful. I don't wholeheartedly agree with lying to a patient, but as a nurse (based these days from home as an occ health adviser) iI know that there are occasions when you have to go against the patients wishes in their best interests. I know from experience that mental capacity forms have their place BUT also have major flaws. Tom is an experienced EMT and before that a nurse, and there are occasions when despite what is presented to you, there is something about the situation that has your instincts yelling. Had the patient called Tom's bluff, Tom would have filled in the paperwork and/or called the police, and from what is written here the patient would have been taken to hospital with a delay which could have caused harm.As an OHA, when providing advice or managing difficult situations, I try to look at the bigger picure, which in my line of work means tribunals – are the actions/words ones that you would be happy to say “i did this, your honour, because” and feel that the situation warrants the action. While I can see where Steve and numbers guy are coming from, and have sympathy with them, they were not there and do not know the entire story (this applies to everyone other than the patient, hostel owner and Tom/crewmate).In summary, I feel that the patient needs to decide whether he was happy with his treatment.BTW, if anyone knows the origin of the quote a reminder would be helpful!

  57. Dear SteveR,Have you ever been in a situation when you've had to make a decision based on gut feeling combined with sound clinical judgement and the benefit of experience?

    I thought not.

    Have you ever lain awake at three am with the events of a day going around in your head and wishing desperately that you'd made a different decision – because if you had the likelihood of someone surviving to see the following day might have been greater?

    I thought not.

    Has it crossed your mind that this patient might have seen Tom's 'lie' for what it was had he been in full command of his faculties?

    Thought not.

    Did it not occur to you that whatever the technical right and wrongs of this situation, Tom did what he did in in the best interests of his patient? He wasn't trumping something up to contravene the 1983 Mental Health Act, or the new Mental Capacity Act – he was looking at a patient who he knew was physically ill.

    Of course it didn't?

    Now go away and play on the My Little Pony website if you want right and wrong in black & white. When you feel mature enough to come and discuss what happens in the real world – don't bother us.

  58. I am extremely needle-phobic. If all the medics with syringes in hand had listened, and 'obeyed' my screams of “no, no , NO”, at worst, I wouldn't be here to type this now and at best, I'd have had a hell of a lot of repeat appointments to try again, wasting mine and, more precious, NHS time. Is 'scared' enough to make me mentally incompetent, or can I now sue them for going against my wishes and injecting me?

  59. Steve R,I know you have said you are not returning, and I have been on nights so haven't had a chance to catch up with the blog, but I would be very interested to hear how you would have dealt with this situation? How would you have got this person the treatment that has ultimately saved his life? Or would you have left him on scene, in which case what would you be saying to the coroner when they ask you why you have left someone on scene, quite clearly (from the evidence given, oh yes they work on that rather than actually being on scene with you, so you see the blog on this occasion can be taken as Tom's statement) not mentally competant?

    I see a few people are glad to see you go, but I for one would like to hear more from you, just those three points would be a start thanks.

  60. Trickery and Deception…So as you have come to exactly the same conclusion the Tom and his crew mate did, how would you have continued? or if you had decided to leave the patient on scene, I ask you what I asked Steve R.

    To be fair you weren't there, nor was I, no-one but Tom and his crew mate. Its difficult to make a judgment call without all the facts in front of you, so maybe I am wrong in asking both of you to answer me, but based on what you have read in the blog, how would you be explaining yourself to the loved ones that have gone to the hearing, and to the coroner that is asking why you left this person to die?

  61. I'm in a bit of a rush as I'm going onto nights.. just wanted to say that all the pompous asses on here, moaning on about how taking this patient to hospital by telling him a little white lie, is that I hope that when the time comes for you to be in a life or death situation and know your rights, you die and then you can lord it down on us from whatever Heaven or Hell you may believe in..I've been asked by many a cancer patient whom I've taken to our local hospice if I've ever taken anyone home from there.. I've told them yes but the truth is no, as it's for mainly terminal patients.. so from now on should I say ” nope.. end of the road for you missus/ mate.. sorry and all that..”

    Does lying to them make me a bad person..? If so, I can live with it.

  62. re hyper or hypo glycemiayes, infection does usually cause hyperglycemia (high blood sugar levels) it also cause hypoglycemia (low blood sugar). i know this for a fact after having treated my mum for a hypo attack whilst waiting for an ambulance to come to take her to hospital – she was admitted with a diagnosis of septacemia as a direct result of a recent operation. diabetes is indeed unpradictable

    as for the other issues. i agree that what TR did was wrong, and that patients have a right to say what happens to their body, but i would have done the same (maybe not the EXACT same method, but…). paramedics and EMT work on the spot and make on the spot decisions (as do the vast majority of other health care proffesionals) and guess what they are human, and dont always get it right; TR was in a no win situation. i hope you don't lose your job

    just an after thought. if the patient was indeed concious when he arrived at hospital, as described, why was his treatment then continued if he was against it???? me thinks that actually TR made the right call about his competency as the other staff seemed to make the same call. just at thought…

  63. i meant to add that of course the only ones qualifed to make a real decision are Tom, his crewmate and the patient (and then maybe the other profesionals involved).also (i will shut up in a min) i have to admire Tom for his honesty in posting this, many people (esp' when feeling guilty) would have ommited the details that are now causing people to bay for his blood.

  64. “Steve R… I would be very interested to hear how you would have dealt with this situation?”I agree. It's too easy to “shoot and run” on a situation like this.

  65. You twat. I cannot believe such an idiotic comment, i wonder if your blood sugar is low when you were writing.Potentially a do-gooder ready to smack down the good parts of society covering up for their own lack of morals and self advocating, left wing arrogant attitudes and would guess claiming a sickness/disabled benefit whilst running a car boot on a Sunday and running a business on Ebay selling your Kids clothes.

  66. Whether the patient was competent or not is to some extent a moot point, as it is never acceptable to deceive a patient in order to obtain compliance.I could argue that this is even more the case in a severely ill, very vulnerable patient.

  67. Debs, 15 years of experience in emergency care and latterly time spent specifically in endocrinology, along with a knowledge of basic physiology, is where I received that information :)Hypoglycaemia isn't totally out of the question, but it's extremely unlikely. A more credible scenario is that the sepsis caused peripheral shutdown which meant that the capillary blood sample obtained was innacurate, and the venous blood glucose would have actually been much higher. Running in dextrose (which in this situation acted more or less as any other IV fluid) and administering oxygen, and getting the patient to wake up a bit and sit up will have got the peripheries perfusing again, at which point the blood sugar reading will have been more accurate.

  68. Surely we want to save people who make mistakes?… which means that the patient and Tom need a break.

    At the end of the day we do our best for people … The world isn't as black and white as the “expert” accusers here make out.

    As a result, what we do doesn't have to RIGHT … It just has to be reasonable.

    Cheers

    Blippie

  69. YEAH! 24601 is right …. Let the bugger DIE!Sheesh!

    Sleep well, Tom, you might not have done RIGHT, but you did well.

    Cheers

    Blippie

  70. As I understand it, Tom hasn't forced any sort of treatment on this poor chap, once his immediate medical needs were catered for. All he's done is to coerce him into the back of an ambulance for a 10 minute ride to hospital. There, there would have been people better qualified (I mean that nicely) to make judgements on his actual treatment, and also on his capacity to consider his right of refusal to said treatment. The fact that he obviously didn't just turn around and walk out, says that he probably wanted treating, and that the only people that could be deemed to have provided that care against his wishes were the staff at the hospital. They treated him, and would no doubt have carefully considered the patients wishes before doing so.If I ever need an ambulance, you're welcome to come and get me Tom. 🙂

  71. Apparently not – all I can get from google is that is is from Galen but I'm sure there was a theory that was behind it….

  72. I think the 'knowledge of basic physiology' comment is slightly sarcastic and needn't have been said.I too have that, but I'd imagine it was your time spent in endocrinology that gives you the edge on me.

    That aside thank you for taking the time to explain – it is appreciated.

  73. I'm likely in the minority, but I think you should be allowed to arrest persons who require but refuse medical treatment.That's sucide isn't it?

    Not allowed under current law.

    Aren't there laws already about interfering with firefighters or medical personell while they are working?

    By the way… this is the second time I've noticed you using your mysterious “that doesn't look right” sense.

    It's probably the subconcious result of years of experience and not “reading of distressed auras”.

  74. Can I try to make a constructive comment on this – aka, I'm not ARGUING, just raising points, which may be wrong? :o)”I think you should be allowed to arrest persons who require but refuse medical treatment.”

    My opinion on your post: NO. No-one should be allowed to prevent someone from ending their life, when they are mentally capable but just don't wish to live anymore.

    If I own my own body, my essential personhood (regardless of religious belief or lack thereof) then I have the right to cease having this existance – I have the right to terminate service.

    You (anyone) do have the right to question why I want to end that life, should I plan so badly that you interrrupt me in the act, and if the reason sounds like depression then go ahead and section me, but please do not question the basic human right to not – be.

    But I equally have the right that, if I've done something stupid that causes service to cease without my express wish (ate a poisonous toad, or more depressingly but far more realistically, just got pissed and fell over) then I deserve not to be euthenised by a medical profession that concentrates on maximising tax income and minimising benefit/welfare outlay.

    Not that I'm opinionated or anything….

  75. Just so there can be no doubt where I stand, 24601 is a sanctmonious jumped up git and needs to spend a night shift with us. To clarify one point however, madmouse made the very valid point that we “work on the spot and have to make on the spot decisions………….as do the vast majority of other healthcare professionals”. This is just not true. A GP can refer on to a hospital……the hospital refers onto a specialist consultant who has at his disposal a vast array of diagnostic tests and machinery to categorically satisfy himself of his diagnosis before embarking on his treatment program.We (with the exception of A&E doctors in resus rooms) are the only healthcare professionals who have to make on the spot decisions, in often impossibly stressful situations, by which we (and often the patient) stand or fall. We have limited diagnostic tools available to us, most of which become largely unreliable when faced with the conditions under which we operate and are rendered virtually useless as soon as we start running to hospital. Were it not for our sixth and seventh sense to read, judge and call situations under intense pressure, we would lose many more patients.

    I suspect either 24601 has never been in this situation, OR, he has applied his self righteousness and gross lack of common sense in a situation before, and left a patient to die. I wonder if his crusade against Tom is part of his lifetime challenge to face and justify his own ineptitude. No surprises therefore that he only wishes to be known by a number.

    Tom, we've all been there and we're all with you mate. Good on you for highlighting how intensely hard and stressful our job is to Jo Public…..and those too scared to be known by anything other than a number.

  76. Well you know what……they're not making it up, and it is going on…..furthermore hate to disappoint everyone out there, but you know what else……we lie to you every single day.For example……(from patient who's got his knob stuck in a bottle)”You must think I'm completely stupid” …….me: “No, not at all, we see things much worse than this”

    (from wee girlie who's had a frightening amount of booze) “You do believe me don't you? I have only had two drinks”. Me: “Of course, don't you worry, now, if you'd kindly vomit in the bag now that'd be great”.

    (from aged abandoned elderly patient with no family to give a damn and whose had no home care because some nameless faceless number (sound familiar 24601?) decided it was ok to let them refuse care, but is now welded to their chair with urine and faeces, and discharge from chemical burns from their excrement) “I'm sorry, I must smell dreadful, this must be terrible for you” Me: “Not at all, don't you worry, its not a problem to us at all, that's what we're here for”.

    Oh, and by the way, I've been to all these patients, (I cried over the last one when I got home, and again the next day when I discovered he'd died), and no, the last one isn't rare or unusual, he was discovered when a neighbour complained about the smell. Thank god for our ability to lie and be insincere convincingly. It's critical to our patient care,

    You're wrong 24601. Give it up.

  77. Of course you did the right thing. How could saving a life ever be the wrong thing to do?I hope you and your brother are OK.

  78. Just finished another night shift, I'm 'fired up' and thought I'd revisit the blog….Wanted to say thanks AmbuSam.

    My 'pride pot' has been filled a little after reading your 2 (so far) comments.

    Thank you

  79. NICE one!”When it all goes to shit I want a medic who puts me, not the rulebook, first”… not as catchy but sheesh, I'd wear it every day (it'd be the “clean underwear” mum told me to wear in case of accidents!)

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