Wanting To Punch A Nurse

Sod that Dr. Crippen – he's only gone and posted on what I'm writing on today.

Now, I have to be careful how I write this as I have sent various official documents to people about this incident. Also, should I need to make a statement I can just print out this post…

We were sent to 'psychiatric patient – feeling violent' and as he was known to carry weaponry we decided to hang back until the police got there – they have much better kit for dissuading people from stabbing them than us.

The police were there first, so we walked into the house – our patient was sitting in a chair looking very distressed, but thankfully not violent.

I spoke to him and he told me that he'd been discharged from the local Mental Health unit the week before. Now he was wanting to go into the street and beat someone up, and then kill himself.

He was crying as he said this – so I let him know that we would look after him and take him somewhere safe.

When asked if he would be kind enough not to beat me up, he couldn't guarantee it, so a police officer would travel with me in the back of the ambulance, with his partner following in the response car.

During transporting the patient he told me that he was seeing things, and that he was hearing voices. On several occasions he became very agitated and it was only the complicated seatbelt that stopped him from leaping around the back of the ambulance.

He then told me that if he were to be taken to the A&E department he'd probably 'kick off' as the department is too crowded and too noisy with people who don't 'understand him'.

I've mentioned in the past how an A&E department is a completely inappropriate place for people with mental health problems – so I could see his point.

As we can't take people straight to the mental health unit I would have to take him to A&E. But then I had a cunning thought of a way around the problem.

We would park outside the A&E department, my crewmate would go into the department and phone the mental health unit to see if they would directly assess the patient.

It came as no surprise when the Mental Health unit told us that they wouldn't accept the patient unless he was under a Section, and that A&E would have to see him.

My patient was still in the ambulance refusing to enter the A&E department and looking more distressed.

I turned to the policeman.

“This place is accessible to the public”, I indicated the open doors to the ambulance, “and anyway, if he leaves the ambulance he won't enter the A&E department”.

The policeman agreed, I think he knew what I was getting at.

“How about we Section 136 him here, then he can get to the place where he needs to go?”, I suggested.

The policeman agreed, he went to his partner, had a quick discussion and started filling in the Section 136 form.

A “Section 136”, allows the police to take someone who is mentally ill and in a public place (and is a danger to themselves or others) to a 'place of safety' for assessment.

So we let the mental health unit know that we would be bringing in a Sectioned patient for assessment and drove the 200m up the road to the unit.

We rang the bell and waited, and waited, and waited…

Finally a person who I assumed to be a psychiatric nurse came to the door. He took one look at the patient and sighed loudly, “Oh. It's him! Take him to A&E”.

I explained that the patient warned me that he would become violent in A&E, but that he wouldn't if he were in the care of the Mental Health unit. I explained that he was seeing and hearing things and that there was no physical injury to himself.

The nurse then accused me of lying about the patient's symptoms, “He never said that”, he told me.

The nurse then turned on the policeman, “I don't believe that you Sectioned him in a public place – I think you did it in his house”. The nurse was accusing the policeman of (a) Breaking the Law, and (B) Lying.

When the policeman pointed this out, and pointed out that he could be seen filling the form in on the unit's own CCTV the nurse backed down a little.

“He's drunk”, the nurse said, “he always is when he comes here”.

Now, admittedly, the patient had drunk two cans of lager during the morning – he'd admitted it to me, but there was no way he was 'drunk'. As one of my mates put it, “Two beers is breakfast for a lot of folks 'round here”.

So now the nurse began accusing the patient of lying about how much he'd drunk, about the symptoms that he was having and of the need to call an ambulance.

By now I was severely tempted to punch this nurse on the nose for the instant, horribly incorrect, assessment he'd made of the police, the patient and me.

As an aside, I'm aware that when someone starts to get me angry I start to pace, and flap my arms about like a stereotypical homosexual from an early eighties sit-com. The flapping is because I want to punch the person annoying me, while knowing that I can't. This is why I was gripping the handrails of the ambulance very tightly.

But somehow – possibly because I asked the nurse his name for the complaint form, the clinical risk form and for the form where I think that a hospital has had an 'untoward incident' – he accepted the patient.

The police officer and I had a quick 'debrief'. Then it was back to station to fill out the forms and have a quick chat with a Station officer over the phone who congratulated me on not punching the nurse.

He also confirmed that I had done the correct thing all the way down the line.

This is nice to know as I have the same tendency towards pig-headedness as the next person.

Anyway, my boss talks to the boss of the mental health unit on a regular basis, so I expect that this incident will be mentioned.

In thirteen years of working for the NHS I've only once known a referal to a mental health team go as expected. Like GPs, I know there must be good ones out there – but it seems that I never get to meet them.

Zarathusa – if you'd like to pitch in I'd like your take on this.

36 thoughts on “Wanting To Punch A Nurse”

  1. Oh my goodness, I don't know what to say. I can't even get angry anymore, I just want to cry. Why are these people even allowed to work in mental health? (or with the public in general) I have no faith that your complaint will see this person sacked – only “moved on” to another place to treat some other poor unfortunate soul in this disgusting manner.This brings back too many bad memories. What makes it worse is that we have no idea how this “nurse” treated the man once you had left.

    Patients sometimes have to put up with this poor attitude every day. You are at least able to complain – the patient won't be taken seriously because he's psychotic and probably paranoid so he obviously imagined the whole conversation. As a “sane” person you wanted to punch the nurse – but after being forced to put up with this kind of treatment day after day, if this bloke lost his rag he would either be restrained and injected with drugs or would be arrested (or both).

    The only answer is for you to give me the name of the nurse so that I can practice cleaver throwing at him.

  2. “”I'm assuming it's not like they get patients like this every day!””Erm, it's the mental health unit; which pretty much guarantees that a significant number of your patients are going to be, to use the vernacular, raving looneys.”

    I meant delivered to them (so to speak), in that way, as opposed to dealing with the people in the unit. Unless sectioning is something that does go on a lot? I haven't a notion 🙂 I didn't explain myself very well though 🙂

  3. Dear sweet holy mother of God, I don't know how you managed it, I'm going mental and I'm only READING it! I hope this gets sorted out, and that nothing like it ever happens again! I'm assuming it's not like they get patients like this every day! It would have cost the nurse a bit of paperwork I'm sure (I haven't a BREEZE what goes on with these things), and time, but that's the whole point! I'm sure you don't want to go to some of the calls that you go to, but you have to do it! Bloody hell!!!!

  4. That nurse sounds like someone who needs to be thinking about another line of work. Something soothing, without any loud noises.

  5. People like that are dragging down the NHS. They could really do with a punch (and another job) Can I do the punching? Please?

  6. “I'm assuming it's not like they get patients like this every day!”Erm, it's the mental health unit; which pretty much guarantees that a significant number of your patients are going to be, to use the vernacular, raving looneys.

    What gets me about this is that you've a patient presenting who is in a precarious state of mind, is trying very hard to mitigate this, and is faced with someone who clearly indicates that they'd prefer it if he ****ed off and died. This is someone who obvious needs compassion, understanding and caring in dealing with them and they're getting the opposite thrown in their face.

    If I'd been Brian I'd have gone “Bloody hell, what's that?” while pointing into the distance, waited for the copper to turn and look and then lamped the nurse good and proper. Said copper could then have said with complete (lawyer-like) honesty “Sarge, I was standing right next to him and I can categorically say I did not see him strike the nurse”.

  7. “I've mentioned in the past how an A&E department is a completely inappropriate place for people with mental health problems”.Some A&E departments – no names no pack drill – are completely inappropriate places for people with health problems, full stop. >-)

  8. Hi TomThanks for your invitation. To be honest, I don't really have much to add to your assessment of the situation – the nurse in question was being a dick and there's no excuse for accusing the police officer to his face of lying – especially in front of the patient and an EMT.

    It sounds like he just wanted an excuse not to have to admit him, but I suspect you probably knew that anyway. You're quite right to report the incident.

  9. I've seen that crappy attitude from some nurses during their shift change (Darn EMTs bringing patients in during that time! Can't we wait? NO.). Either way, there is no excuse for her attempts to refuse a patient.

  10. I bloody well hope this wasn't my hospital.. and I bloody well hope it wasn't the A&E department next door, as they have psychiatric liaison staff there which you should have been told about.THIS is why I do the work I do, as this treatment happens WAY too often. Sometimes I think I am getting somewhere, and then I read something like this that reminds me – even if I change the way 50 of the workforce works, there are always going to be total dicks like this nurse.

  11. Incidentally, since you link to Dr Crippen's lambasting of me for telling him he's wrong about a psychiatric patient he thought should be admitted, I expect somebody will want to know why I agree that your case should have been admitted but disagree with Dr Crippen's.The reason is that your patient was:

    1. a risk to himself

    2. a risk to others

    and

    3, psychotic

    In Dr Crippen's case, the patient was, as far as we can tell, none of those three. Hence I think Dr Crippen is simply wrong.

  12. Zarathustra and Fimb put succinctly. The nurse was a complete twat and happily you restrained yourself. I hold my head in my hands and mutter why? This one twat represents psychiatry and his behaviour should see him on the road to the job centre wuth his P45.

    Out of interest, is there a crisis team or psychiatric liaison staff in that locality?

  13. Can you imagine a person with that attitude lasting five minutes in another job?BOSS: What are you doing, there's a queue of customers at your till!

    NURSE: Those aren't customers.

    BOSS: Yes they are, and that man at the front just ordered a Big Mac, now go and get it for him.

    NURSE: You must be joking. Did he tell you he wanted a Big Mac?

    CO-WORKER: Yes he did, I heard him.

    NURSE: Oh… well, he comes in here every weekend wanting a Big Mac. I've had enough of serving him Big Macs. He needs to go to the KFC down the road.

    CUSTOMER'S WIFE: But he's allergic to chicken.

    NURSE: Am I bovvered?

  14. This situation only shows that so many people think that people with mental illness do it for attention, and they are not truly sick. The fact that someone who is meant to care for these people was so arrogant about this admission, I have to shake my head. So utterly wrong.As a teenager I saw the inside of a few of these wards. With a friend in dire need of help, they were in and out. Some of the staff were wonderful, others were absolutely pants .

    Nearly ten years on, looking back, I'm passionate about things like this. I've seen the good, the bad and the ugly and in all nursing you should only see good.

  15. Brilliant comparison, batsgirl!It sounds like you encountered one of the nurses working for the Trust I am “served” (or not!) by. The ones who insisted I did not need support despite the many other professionals who told them I did…

  16. As I sometimes have to remind myself (when some patient is being…challenging) – mental health illness is just the same as diabetes or cancer. It's not like people *decide* to be mentally ill.

  17. I can see why Crippen was annoyed about the patient not being admitted. But likewise, your comment made a lot of sense, it was like his misunderstanding of what ambulance folks do and why they do it. Just really a lack of insight and a gap between expectation and reality.In the end, I agree with your logic.

    I think he's getting to the stage when he hates anything that isn't him…

    At least that's the way his writing seems to be going.

  18. Just really a lack of insight and a gap between expectation and realityi seem to remember crippen criticising his patients on several occasions for a similar lack of insight. pot, kettle …

  19. Tom, you so succintly put how ambos throughout the country are infuriated by the crap way that people with a history of Mental Illness are dealt with when they are 'in a crisis'. i have given up counting how many times I have tried to get in touch with 'Crisis Teams' or named C.P.N.s (Community Psychiatric Nurses ) only to be told that patients can't be assessed as they have consumed alcohol! FFS they may well have had a can of lager but that doesn't make them drunk or un-assessable. And I'm sorry to say to Delcatto that the behaviour by the nurse that Tom described is not unusual, in fact it is more the norm in my 28 years of ambo work. Though I must admit the idea of having a Crisis team or some psychiatric liason staff in an A+E 24/7 sounds like a good idea.On another point I'm pretty sure that my Trust, just west of Heathrow, recently put out a document, but originally from another agency, maybe the DoH, that clearly stated that A+E Depts were now no longer considered 'places of safety'.

  20. I used to work at a drug treatment facitlity and I don't have to tell you that drug abuse and mental illness go hand in hand. Most of my patients were bonkers, full stop. Add to that, the wonderful charm of opiate addiction and you have quite an interesting bunch.When these people were truly in crisis, they refused to go hospital or to see their GP because of the way they were treated by the nurses.

    I had one female patient (extremely intelligent, former legal assistant to a large law firm) who had the unfortunate habit of skin popping. She had a horrible abcess on her abdomen and needed medical attention right away. She cried and told me how badly they treated her when she went in to the Emergency Department and then asked me what sort of thing would they do to her. I explained how they would most likely lance it, clean it all out, pack it and send her home with some lovely antibiotics.

    Two days later when I saw her at the clinic, she showed me how she had lanced it, irrigated it, packed it with gauze and was taking her brother's antibiotics!!!

  21. I can't disagree with the frustrations and the un-professionalism of the nurse concerned. However, I'm trying to get promoted to a pen pushing job, so I'm practising my rational & diplomatic reasoning here;Firstly, the copper had lawful authority on the matter and could have just let the nurse rant and then said; “Interesting point, now where would you like your patient?” Once the s136 is in place, there's a lawful duty of the MH services to provide.

    Having said that, not sure what grade this nurse was (obviously nothing much above janitor), the referral/admission process should go a lot easier than that. In my neck of the woods we have similar detentions available where even Ambulance drivers can lawfully remove a person for assessment and their care is transferred on delivery to A&E where there is a daytime (8am – 9pm) experienced (charge nurse level) MH nurse to assess, or an on-call psych registrar 24/7. Police & ambulance frequently dump and run – based on experiences similar to how you describe. Who can blame them? Their job is done. (Tho need to get a little more communication going and not expecting A&E staff to deal with violent patients).

    In regards the reluctance to admit; there's probably a whole heap of political drama preceding this event – and the nurse's frustrations at this person requiring re-admission again are probably nothing more than a venting of those; just as you are frustrated at having to do what you do, just to be thwarted by everyone who should assist and support, so probably was s/he. Her manner, as you describe, is unacceptable tho.

    As an overall guess on the picture you paint; I'd say the main issues are in the process and ready availabilities of people for these sort of scenarios – A&E dept is not a good place for a MH patient (neither are many of the MH places either tho) but it's what the system provides.

    It would be worthy to use this scenario as a way to also challenge the system and how it contributed to the problems (ie A&E dept for MH patients) – you may bring about a change of processes – and sometimes people higher up don't realise the issues lower down – because they don't see them.

    I think what the nurse failed to realise that, as long as you're working on this problem, it stops you and your crew from being on the road. When it becomes his/her problem, it stops nothing – tho may create some more problems, but doesn't stop him/her doing their job.

    Personally, I'd have told you (in private) if I wasn't happy about the admission (because sometimes other professionals need to know the politics, even if we don't care for them) – but that it's not your fault, thanks for everything you've done and on you go – I'll deal with it now.

    Anyhow… do I get the job?

    Ps: as a side tip; (not in the manual) being an infrequent visitor to MH units as you might be (compared to your visits to A&E) if you have time/chance I'd suggest you do like your boss and also get to know the MH nursing bosses – preferably those that run the shifts (Charge Nurse or Team Leaders) +/or their immediate boss – it's always easier if you have a contact face/name – and one with some authority, not just an opinion.

  22. “He then told me that if he were to be taken to the A&E department he'd probably 'kick off' as the department is too crowded and too noisy with people who don't 'understand him'.”I'm still trying to get my head round the fact that this person seems to be capable of a more realistic assessment of his needs and problems, than the nurse charged with caring for him.

  23. You get the job!If the nurse had raised concerns with me privately I would have been a *lot* happier than when he argued with all three of us there.

    Good point on the idea of changing the process – the station officer who spoke to me afterwards told me that they were already in the process of trying to change things as to how the unit deals with us ambulance lot. I might try and sit in on things (as an ex-A&E nurse I may be well placed for this).

    Nice comment – cheers!

  24. What really scares me is, people like this nurse are responsible for looking after the most vulnerable our society has to offer.

  25. Hi, same thing happened to me recently, with a patient who was threatening to go into the street with a knife & kill someone, anyone. Police rode with us to A&E, not the right place of course but until we get direct admission to a mental health unit , what else can we do (get an out of hours GP?, get real)? Police accompanied us to A&E, where I asked my mate to go & explain the situation, thinking we might be able to get the bloke into a side room, for everyones' benefit. No chance, out comes the A&E consultant, took one look at the patient, & refused to admit him. He told us that as the police were there, they should detain him on a 136. The officers were split 50:50, one for one (with mental health liaison experienc) against. Their sergeant, back in his nice cosy station argued that as the guy was at a place of safety (in an ambulance, outside A&E), they couldn't section him. Catch 22! By the way, we were now well past the end of our shift. Final compromise was that we spoke to the local mental health unit, who (wonder of wonders) agreed to take this patient if the A&E consultant would confirm over the phone. The only people to emerge with any credit from this whole sorry affair were the people at the MH unit, & it's not often I say that. To be fair to them, it's not really their fault, but the system which stinks: yet another illustration of how shameful provision for mental health is in this rich country. The only way we could have got this patient the treatment he needed via A&E would have been for him to become violent & to have been hurt while being restrained: & I'm being serious.

  26. Sounds like your bog standard, everyday 'psyche' nurse. Met a few, worked with a couple, never impressed. Every single one I came across was highly opinionated and absolutely sure that no matter how irrational their contentions, it was the God's honest truth. They were right, and never let the facts get in the way. What made me concerned was the way they'd make something up without recouse to reality and forcefully insist that it was 24 carat truth.I made the mistake when I was young and foolinsh, of going out for a drink with a few Mental Nurses one night when I was working in a hospital. Never, ever again. They had a very odd sense of cringe making 'fun', and couldn't seem to get their heads round the fact that they weren't at work. The memory of that evening still makes me shudder.

    In fairness I suppose working with the irrational, day in day out, can kind of kick your ability to tell insanity from sanity into touch.

  27. Another point to consider other than 1) a complete failure of service planning by the PCT 2) the jobs worthy 'Nurse' lack of professionalism is simpley the patient identified that 1) he has a problem 2) he knew his actions would endanger A&E and the public 3) by these admissions doesnt he deserve to be helped? I would who has the mental health problems in this scenario? I hope the patient receives care he is due and in leiu of the petty problems that present themselves at A&E everyday.

  28. Fascinating stuff Tom, your observations highlight several complex issues.Perhaps it should be made clear that a Section136 does NOT authorise psychiatric admission – a S136 is simply a device within the mental health act to mandate assessment by a psychiatrist in a place of safety (places of safety can include a police station, A&E department, or psychiatric reception suite where such services exist).

    Once S136 assessment is complete further sections under the MHA would need to be invoked if the patient still refuses admission (either Section4, S2, or S3) – as you know these sections require an Approved Social Worker and Section12 approved doctor, as a minimum, before the patient can be forced into hospital.

    These procedures, while potentially frustrating, provide essential checks and balances when it comes to safe-guarding a patient rights, for example, a decision might be taken to wrestle some poor sod to the ground in order to inject them against their wishes (a thoroughly unpleasant task) – several bodged restraints have resulted in death.

    http://www.guardian.co.uk/society/2007/feb/16/youthjustice.law

    Clearly your psychiatric patient needed admission but many other patients also need admitting – perhaps it's akin to taking a patient with severe LVF, say, directly to the medical ward and asking for a bed ?

    The patient with LVF may well need a bed but only after angioplasty because they are suffering pulmonary oedema after a silent MI.

    The disturbed psychiatric patient described in your anecdote may well have had a forensic history, for example, and may have benefited from admission to secure psychiatric setting (PICU) rather than the ? acute ward he was taken to.

  29. Absolutely re: the S.136 – I'm rather happy with the checks and balances that we have, even if it does mean having to deal with social workers *grin*.I wasn't too sure that my patient *did* need admitting (that's a psych Dr.'s job), I would guess that it was needed. *But* – what was needed was him to be assessed in a place of safety by people experienced in his problems. For this particular patient the A&E department wasn't a place of safety, it would have had him kicking off with all that entails.

    I see it more as taking an MI to the cath lab rather than A&E.

  30. Tom – your views are at one with the Royal College of Psychiatrists and British Association of Accident and Emergency Medicine.These august authorities suggested identical arrangements more than 10 years ago – I believe the PFI hospital just down the road is finally due to open such a purpose built unit, although these beacons of excellence are very few and far between, and the nurse you encountered is unlikely to find employment there, although Zaruthustra or Mr Ian probably would ;o)

    http://www.rcpsych.ac.uk/files/pdfversion/cr61.pdf

  31. Hold on, the patient said himself he was likely to punch someone and “kick off” if taken to A&E, and the psych nurse doesn't think that's true?Simple.

    “That dude out there doesn't think you're crazy enough to be here…”

    Open ambulance doors

    Wait for the thud

    Job done.

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