Another Normal Job

Imagine being called to the third pub of the shift, like the other calls the patient is 'collapsed'. You arrive and the person is stinking drunk.

He's able to answer questions, an examination shows nothing serious. You tell him that you'll take him to hospital.

He refuses.

He becomes aggressive, swearing at you, flailing around to push you away.

You can't 'kidnap' him, even if you could there is no way to safely force him into your ambulance.

So you leave him with his friends, or the police arrest him. Then you spend the rest of the night worrying that there was something wrong with him and that you'll end up standing in a coroner's court.

That nightmare has just happened to an ambulance crew.

I have a problem with the sub-headline 'Paramedic refused to treat him'. It looks to me that they tried to treat him but that he refused.

99.99% of these jobs would turn out fine, the patient would sober up in the police cells, or back at home – unfortunately there is always the slight chance that alcohol is masking something more serious.

Obviously the report can't tell us everything that happened that night, and I wasn't there and anything I write about this situation is supposition. However I do have experience with calls very much like this one – a lot of experience.

I can see how the crew made the decisions that they did. I've made similar decisions myself.

Take for instance the report of being unconscious for ten minutes. Daily I come across people who don't know what 'unconscious' means, for some people sitting on the floor means 'unconscious'. For others groaning in pain is 'unconsciousness' and for some being dizzy means that they are 'unconscious'.

If the witnesses to an event have all been drinking and aren't medically trained, then you often take what they say with a pinch of salt.

If you are unconscious for ten minutes there is a good chance of you occluding your airway and dying, someone sitting there chatting to you is unlikely to have been unconscious. I'm not saying it never happens, it's just unlikely.

So I can't blame the crew for taking the history with a pinch of salt.

But in any case, they tried to take the patient to hospital (where he would probably be sat out in the waiting room to sober up where the headline would then be 'Nurses sat patient in waiting room to die'). It was only when the patient because abusive and aggressive that they stopped trying to get him into the ambulance.

So at what level of aggressiveness do you stop trying to force someone into your ambulance? When they tell you to 'fuck off'? When they threaten to hit you? When they take a swing at you? When they push you away? When they connect with a punch? When they connect with a second punch?

At what point do our bosses, and the courts, or the press, want us to ignore being abused?

When can we kidnap people? What powers should we have to force people to submit to treatment and transport? If someone doesn't want to go to hospital and they seem to understand what is happening then we have no power to drag them to hospital.

So it's not as if the crew didn't try to take him to hospital.

The question comes down to asking if the head injury this person suffered is what caused the aggression. Unfortunately we don't have portable CT scanners and the skill to read recent onset cerebral bleeds.

Also injuries of this sort after a fall of this type are very rare – I can't count the number of 'drunk – head injuries' that I've gone to (and yes, I try to take them all to hospital), but I can't remember any that went on to die.

So, it's not incompetence, it's not a lack of care, it's not a “oh, he's just another drunk, lets leave him”. It's a combination of it being illegal to take someone to hospital who doesn't want to go, of not wanting to have a fight in the back of an ambulance, and of the unlikely odds of this being something serious.

So, based on the reporting, I look at what this crew did and I think that I probably wouldn't have done anything different.

Honestly, what would I do? Take him to hospital in police cuffs for apparently only a graze to the head?

What would you do, without the benefit of 20/20 hindsight?

I have sympathy for the patient, his friends and his relatives. I also have sympathy for the ambulance crew, no-one wants their patients to die.

But that is the risk we take whenever we don't take someone to hospital.

32 thoughts on “Another Normal Job”

  1. If the choice of hospital was the James Paget, I'd avoid it like the bloody plague, and if I was stuck there for two whole days, curling up and dying would seem like a reasonable option./thank god I'm away from Norfolk blogLooks to me like your paramedic there arranged appropriate care. She couldn't safely get him into the ambulance for the 'first choice' of taking him straight to A&E, but the patient was seen by a doctor (albeit the police doctor) within a couple of hours, and from there, taken to hospital. That he then died is a sad thing, but old people and people with head injuries do that sometimes.

  2. Tom, I agree with you to a certain extent, but any crew who ignores a history of a patient being unconscious for 10 mins is a fool, esp if the patient is then aggressive. It stinks of a combative head injury. You might not believe it, but you have to take it seriously. An abusive drunk if a drunk person with neurological deficit, until they've been scanned and proven to been a drunk pillock. I feel sorry for the crew, and I also take any media reporting with a pinch of salt, but I think they are about to learn a very valuable, al beit unfortunate lesson.

  3. I'm not sure what country you are writing from, but we don't CT scan all drunks with a head injury in the UK. Nor every aggressive one unless the aggression continues or they drop their GCS.And even if they didn't ignore the unconsciousness (and they may well not have done) there was still the difficulty of dragging someone to hospital who doesn't want to go.

  4. Maybe dictaphones only turned on for recording the tricksy parts?Identification only by the crew's numbers, ambulance number, job number/location, and there'd only be a very slight chance that someone typing up the transcripts for the records would recognise a voice.

  5. Just a quick question: what about a refusal of treatment form? The patient should have been made to sign one; and it is always a possibility to have a witness or witnesses sign it instead.

  6. I'm reminded of the old mantra: “Beware the drunk with a head injury”…Yes, in view of his age and history of unconsciousness, he ought to have had a CT scan “immediately”, but the logistics of arranging such things, especially for patients who are drunk and combative are never straightforward.

    And it's a sad fact, but in all honesty, at 77 years old, I suspect the neurosurgeons would have been unlikely to attempt any heroics anyway.

  7. and herein lies the major problem, we cannot kidnap people from the street. The aggressive person who turns out to be a diabetic having a hypo, there are so many possible end results…..there are countless people I have left behind that I think about for days afterwards, there are also countless people that I am happy to leave, but have that niggling feeling about a little later on in the shift. We cannot get it right 100% of the time unfortunately, thats because we are human, and we are in an age where everyone has rights to refuse, even if we bang on about it for hours that they are making the wrong choice.

    Now I do not condone us being able to take people against their will, but we need support from the media on this, people need to know that we cannot and will not force people into our ambulances against their will. The reporting of this story doesn't seem fair, and just like Tom, no one with the exception of the people who were there can make judgment on what happened. We in this industry come across this type of thing on a daily basis, and whilst I also extend my sympathies to the family, friends and the crew, it is an inevitable outcome, only because we face abuse all the time, what are we to do? There are only so many things we can try before we have no more routes to follow

  8. I agree that drunk head injuries are a complete nightmare to manage. However, the safety of myself and my colleague always come first. As soon as a patient becomes verbally or physically aggressive towards us, I stand back and wait for the Police. They are fully trained and equipped to restrain the patient if necessary. I am not! I think the crew did the right thing. The police had the choice either to take the patient to A&E or get him seen by their doctor (which they did). The Tust that I work for is very supportive in these matters, having a zero tolerance policy for any violent or aggressive behaviour towards its staff.

  9. And who's going to force them to fill in a form.And if they're forced to fill it in, what good it is? They'll just say “they forced me to sign it”.

  10. Witnesses are always an option, though, unless it's a private area like a house or something. Still, I completely support the actions of the ambulance crew. I guess people will always search for someone to blame, even if that person might save your life tomorrow.

  11. I feel very sorry for the crew concerned, Paramedics face volatile, agressive abusive potentially violent patients on a daily basis. This risk is not matched by a high salary, all too often the zero tolerence policy is not enforced its there on paper but not a reality. I feel it is so wrong for the crew to be blamed, that patient chose to drink to the point of being incoherant and refused to go in the ambulance and posed enough of a threat for the police to be involved and yet still the finger of blame is pointed at the crew. It is so unfair to blame the crew why oh why should NHS employees have to deal with alcohol induced violence – the crew had no powers to 'kidnap' him and acted correctly to protect there safety. If you are going to drink then i think you should be prepared to deal with the consequences and not expect overworked Paramedics to jeopordise their safety to treat you.Am glad your back Tom, have missed you muchly. Go steady with your foot, take good care, Lois

  12. I wonder if it will eventually be possible for EMTs to routinely wear tiny portable video cameras such as the ones some police wear clipped to their collars/helmets etc?This would mean that in events like this there would be recorded evidence of exactly what happened -and of the person refusing treatment. (Easier than trying to get them to sign a disclaimer).

    It might also cut down the number of assaults on EMTs -or at least mean easier prosecutions for those responsible.

  13. Any ideas what is happening to the crew?While the thought of any disciplinary action is stupid, I srill wouldn't surprise me.

  14. I agree with marco,my safety and that of my crewmate are always paramount in my mind the time honoured phrase”Fuck Off” would have been enough for me to have withdrawn and called the old bill(my service has a very good working relationship with our old bill) and i wouldn`t have given a toss if he had a 6ft geyser of blood spewing forth from his head and if you think i`m a tosser then you havn`t been assaulted by a 70yr old man (out celebrating his grandsons coming of age birthday and fell on the way home )passer by rang 999 i arrive enquire about his health he takes an instant dislike to me cos “you is whitey” but hey what can a 70yr old drunk man on the floor do to me ???….how wrong could i be!!! i bends over “let me have a look old fella make sure your ok” my collegeague moves i look to see at what just then i`m seeing stars from a blow to the back of the head….lucky me it could have been my jaw which most certainly would have been broken….that was many moons ago and since then that time honoured phrase has been enough for me to walk away still intact

  15. I forgot to add i hate pubs as well with your “unconscious”pt sat up smoking a cig/drinkng a pint/chatting on mobile/joking with mates and the 300 doctors in attendance……………..can you tell i`ve had a bad night????? : (

  16. Wouldn't patient confidentiality be an issue though?At one extreme, you'd have people who'd OD'd or even just drank too much, and wouldn't admit to it on a camera that could be used as evidence, on the other hand you have data loss of potentially sensitive patient info, or images of body parts most people wouldn't wish to see being broadcast & shared (not by the ambu crews, but data is hardly leakproof and the NHS isn't immune to loss of files).

    I feel for the crew on this, I think the old guys's age was the biggest factor and I think there should be some facility for perhaps recording a patient refusing treatment, but otherwise, no.

  17. Surely the safety of the paramedic crew should come first? Personally I think that unless there is a real and recognised danger of the patient coming to serious harm if they aren't removed to hospital then the crew should be allowed to leave at the first sign of violence. It is deemed unacceaptable for patients to show violence towards A&E nurses, why should paramedics not get the same regard? Why can't the ambulance service set up a small team of specialist paramedics who are specially trained to deal with violent patients who are at risk and who have specialist ambulances that allow the patient to be safely contained or restrained? They could be called out after an assessment by a regular paramedic. Just an idea.

  18. A standard 'disclaimer' has virtually no legal validity (in hospital or anywhere else) since a name scribbled on a piece of paper does not tell you anything about 'capacity'.A court would need to know if a patient was able to retain the information about the treatment being offered (transfer to hospital in an ambulance for a medical examination).

    And if that person was able to weigh up the pros/cons – risks/benefits of what was being proposed, in order to arrive at a meaningful decision.

    Needless to say 'capacity' is impossible to demonstrate in a drunk with a head injury – how does anyone unpick the effects of the sauce vs the possible effects of raised intracraniel pressure (from a subdural, say).

    Of course alcoholics are known to be more at risk of repeated head injury and coagulopthy, increasing their risk of adverse outcomes, such as a brain injury requiring neurosurgical intervention.

    Doctors are authorised to treat patients, against their wishes sometimes, if the patient lacks capacity and treatment refusal is likely to endanger their life – as far as I know, no doctor has ever been disciplined for it (through the courts or GMC) since the doctor is simply acting in the 'best interest' of the patient.

    I'm slightly suprised that ambulance crews seem slightly less certain of their legal position, nor does there seem to be a standard operating procedure in cases where a patient may be combatative due to the effects of an expanding intracranial lesion (exacerbated by alcohol, of course).

  19. remember tho if the person is being aggressive is it from the head injury or just because they are a fighting drunk?Being a paramedic is a job like a nurse, you cannot expect them to open themselves to assault charges for restraining a patient because they suspect something. Unfortunately all they can do is what was done in this case and get the police involved.

  20. Right, I know, Zarathustra, but that's why you can have a witness sign. I was just wondering. I too support the actions of the crew.

  21. it a shame when something lke this happens, for the family, and also the crew involved for slightly different reasons; unfortunately as usual the press have jumped on the band wagon and decided to have a go at the ambulance service again… I don't know what it's like in Norfolk but up here (NW) the police will do their utmost to get the patient into the ambulance rather than their van simply because it's easier for them (and less paperwork – their words not mine)… Why doesn't the media focus on the level of abuse that we face daily rather than the “ambulance crew refuses to treat pt”?Having done this job for over 10 years and been assaulted a number of times I have to admit I would have done the same as the crew – as I suspect 99% of experienced road staff would have done…

    There's always the option of asking the police to transport the pt up to cas in their van, however if the pt beame violent in the a & e they woul drefuse to treat him; so then the headline would read “A + E dept refused to treat pt”

  22. it a shame when something lke this happens, for the family, and also the crew involved for slightly different reasons; unfortunately as usual the press have jumped on the band wagon and decided to have a go at the ambulance service again… I don't know what it's like in Norfolk but up here (NW) the police will do their utmost to get the patient into the ambulance rather than their van simply because it's easier for them (and less paperwork – their words not mine)… Why doesn't the media focus on the level of abuse that we face daily rather than the “ambulance crew refuses to treat pt”?Having done this job for over 10 years and been assaulted a number of times I have to admit I would have done the same as the crew – as I suspect 99% of experienced road staff would have done…

    There's always the option of asking the police to transport the pt up to cas in their van, however if the pt beame violent in the a & e they would refuse to treat him; so then the headline would read “A + E dept refused to treat pt”

  23. “Needless to say 'capacity' is impossible to demonstrate in a drunk with a head injury – how does anyone unpick the effects of the sauce vs the possible effects of raised intracraniel pressure (from a subdural, say). “Sorry but that isn't true, a patient in such a condition is very unlikely to have capacity, but the test is simple and just as pertinant to a drunk as a diabetic. The fact of the matter is that regardless of the cause of the incapacity (drink or head injury) the patient still does not have capacity.

    I feel for the crew, but I would point out that they have only been critisied by the patient's friends not the coroner. Odd thing is we all think nothing of wrestling with a diabetic who's gone hypo but do a runner at the first sign of verbals from a drunk, the real truth is that we all judge our patients on the cause of their incapacity not on their presenting medical condition.

    DSO

  24. Down here in London we are certain of the legal position – I would suspect it is the same in other parts of the country as well.We have a nice little flowchart that identifies people who have the capacity to refuse – and if they have the capacity to refuse, even if their leg is hanging off they can refuse treatment and lay down and die.

    This is why, when I leave someone at home I'll document 'Capacity +ve', then, should I be called in by the coroners office I can quote the flowchart at them.

    If someone doesn't have capacity, then I'll document *fully* why they don't have capacity.

    If someone is combative due to a head injury then they don't have the capacity to refuse treatment, in which case they get bundled into the ambulance (and I no doubt get inured for my trouble – so it goes). There is no SOP because every case is different.

    However the legal difficulty is that the patient may well have had capacity, it was longer than two hours before he was seen in hospital and I suspect that if he had collapsed before then he would have had an ambulance called straight away.

    The only solution is that we are allowed to kidnap people who are 'altered' due to alcohol and then they get some serial CT scans to make sure that everything is alright.

  25. …Which is why I think that this person may have had capacity.(As a mate of mine may have put it, 'six pints? That's breakfast around here').

    DSO – I think that the difference in treatment between a diabetic who is hypo and a drunk is threefold.

    1) They've done it themselves. (Harsh maybe, but true – personal responsibility has to come into it somewhere, otherwise why would people get arrested and charged with doing naughty things while they are drunk, but not while being hypo?)

    2) A diabetic hypo is a medical emergency, being pissed and violent isn't.

    3) A diabetic hypo won't cure themselves, a drunk will (normally) get better in time.

    It's a risk/benefit assessment we do – what would we do with an aggressive drunk should we wrestle them to the ground? Hold them there until they sober up?

    At the end of the day, and I think you'll agree with me here DSO, your main concern is the safety of yourself, and then the safety of your patient. Unfortunately sometimes you'll get tripped up, but if you can justify your decision making then you *should* be in the clear.

  26. Sashenka, I was JUST about to ask the same question – one such form exists doesn't it… surely…?That would then help cover the crew on a “them-versus-us” case scenario…

    I don't envy this crew though. It's a nightmare come true.

  27. Have to back up the crew here. I wouldnt have done anything differently. They had a patient with a head injury refusing treatment and transport. They could of had a witness sign the refusal, reported to control and been on there merry way, but they chose to take the better path by involving the police, who could legitimitely force the patient to have treatment, albeit with a D and I or a Breach under his belt. Sympathies to the family of the gentlemen who unfortunately died. But I firmly believe the crew has acted to the best of there powers.

  28. Have to back up the crew here. I wouldnt have done anything differently. They had a patient with a head injury refusing treatment and transport. They could of had a witness sign the refusal, reported to control and been on there merry way, but they chose to take the better path by involving the police, who could legitimitely force the patient to have treatment, albeit with a D and I or a Breach under his belt. Sympathies to the family of the gentlemen who unfortunately died. But I firmly believe the crew has acted to the best of there powers.

  29. what are the chances of training one paramedic in each crew in basic defense to a level where they have the right to restrain people. I no they still couldn't take them to hospital but surely,if it doesn't make them more aggressive, it would give them a chance to be assessed in a safER way?

  30. It's perhaps worth pointing out also that the article (BBC website) is reporting what the witnesses told the inquest – the reporter does not appear to be directly critising the ambulance workers. Of course, i fully accept that if they don't give equal prominance to the evidence given by the ambulance/police as to why the man wasn't taken to hospital then a false impression is given but this does appear to be fairy 'straight' reporting of waht the witness said, not necessarily endorsing or agreeing with it.Just occasionally they are NOT out to get you!

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