No Evidence

It's cold and dark, and for the next few days I'm working nightshifts, this will either result in a 'sense of humour failure'* on my part or I'll suddenly find myself sobbing in the corner of the room. Place your bets on what it'll be…

With it getting cold it becomes 'Homeless season' for the ambulance service. People who are normally happy** sleeping rough, drinking the day away on a park bench and having a nap wherever they can suddenly realise that it gets a bit chilly and that their normal lifestyle is a bit… uncomfortable.

So, as a service, or at least in my part of the world, we find ourselves being called to more homeless folk than is normal, at the risk of sounding politically incorrect let me just define 'homeless' for the purposes of this article as those people who are long-term homeless, normally due to alcoholism (caused in some part by the lack of 'wet' hostels for them) or the mentally ill (caused in some part by Thatcher). I'm not referring to the homeless who seek to improve their condition, but instead the outliers who either refuse help or who cannot keep the rules that are expected of them.

An example of how things change with the weather – in the last cold snap I was queuing up to hand over my homeless patient, also queuing up were another three ambulances with patients similar to mine. One was incontinent while waiting and another had been incontinent in the ambulance. Actually incontinent is perhaps the wrong word, one of the men whipped out his 'member' and urinated up the wall of the department.

Welcome to the world of healthcare.

But, you know, the homeless are people as well and they deserve as much care and consideration as anyone else, even if their sole contribution to society seems to be limited to turning cider into urine.

My patient, for example, told me that he had been vomiting blood – something that can be the sign of something serious, especially in the alcoholic patient. I listened to his history in the back of the ambulance, took his vitals and started my paperwork. I looked him up and down and wrote 'Patient complaining of vomited blood, no evidence seen'.

I stopped and looked at what I'd just written.

There wasn't any sign of blood or vomit on the man's clothing so what I had written was factually true. What stopped me was wondering if I would have written such a thing if I'd picked this patient up from a clean house? If he hadn't been an alcoholic?

I'd treated him with respect, I'd done all the same things that I would have done for anyone else complaining of the same thing, but still I'd written those words on my report form.

I may as well have written 'patient says he vomited blood but I don't believe him'.

So we took him to hospital. When we got there I started handing over to the nurse, as soon as I mentioned the vomiting of blood she turned round and asked me, “Was there any evidence of this?”.

This isn't a 'harsh' nurse, she's pretty good actually – caring and considerate and definitely hardworking, yet she'd also asked me the same thing that I'd written down on my paperwork without thinking.

The patient went out to the waiting room.

I wonder if he would have been put out into the waiting room if he hadn't been homeless.

It's not a criticism of the nurse, trolleys are in short supply in the A&E department and the handover nurse has to make decisions between who gets to stay in the main department to be seen soon and those who can go out in the waiting room. While the various professional organisations that look after nursing and ambulance people would have us treat every word that comes forth from the patient's mouth as complete truth, there comes a time when you start to watch for people trying to 'trick' you for whatever reason they have.

It might be the junkie looking for narcotics, it might be the person playing up their illness in an effort to get seen sooner or it might be the person who lies about not being able to get an appointment at the GP as the reason for dialling 999.

One of the 'classics' is the patient who tries to convince you that their pain score is 'ten out of ten', and as the NMC*** say, 'pain is what the patient says it is', which is hard to believe when the source of their pain is a tiny shaving cut…

While I can normally tell a lie, I'm more than happy to give the benefit of the doubt to a patient, regardless of their background. I'd rather give analgesia to a junkie than withhold relief from someone in genuine pain.

Which is why I wondered why I wrote 'no evidence seen' on my report form.

*Sense of humour failure is a term that some people use to indicate losing their temper. I may well be using it in a similar way…

**'Happy' is perhaps the wrong word here.

***Who live in happy fairy land it would seem and when I was a nurse seemed to publish a lot of twaddle about any old rubbish. They may have got better. I doubt it though. They'd be very unhappy about me calling everyone either 'Luv' or 'Mate' for instance.

13 thoughts on “No Evidence”

  1. Vomiting blood is not as straight forward as it sounds.It can be confused with haemoptysis.

    Or there may be a few small streaks of blood after a mallory weiss tear (related to episodes of vomiting that have a caused a tear to the oesophagus).

    Sometimes the term coffee-grounds is used i.e. blood that has been in the stomach for a while.

    Obviously fresh blood in significant volumes is a variceal bleed until proven otherwise – such patients are rather like Mount Vesuvius and can exsanguinate in minutes after a torrential GI bleed.

    Irrespective of whether you saw blood or not a patient with tachycardia and hypotension should be monitored in resus until a full medical assessment is performed.

  2. At the risk of sounding like Roger Whitaker, you had feelings, nothing more than feelings. Which is enough. I'm sure that after dealing with people for this long, especially with your repeat customers, that you probably have a good intuitive feel for just how ill the patient is. But good luck writing that up in triplicate for the Royal Department of Covering Their Own Arse.

  3. “Vomiting blood” can mean so many things to a civilian- It could mean “Vomiting a large amount of blood from the stomach”; It could also mean “Vomiting with traces of blood from throat or mouth bleeding”, or “Vomiting a dark red liquid”.Proper treatment requires that you determine which “Vomiting blood” the patient has. The only way to do that is to see the evidence. Thus, what evidence you see IS medically important.

    Also, for whatever reason, some patients will lie. Again, the medically correct thing to do is to use all available information, and not assume that a person untrained in medicine (the patient) can always use the correct terminology or make a correct diagnosis. (Even the police have had trouble distinguishing “Comatose” from “Violently resisting arrest”)

    Would it be impractical, or dangerous (to you or your job) to ask “Is it just that you want to spend the night in A+E?”

    In that case, your report would read either “Patient complaining of vomited blood, no evidence seen. Patient stated just wanted to spend night in A+E for observations” or “Patient complaining of vomited blood, no evidence seen. Patient stated did not want to spend night in A+E unless medically indicated”

    The real solution, however, is to give the transient population a place to spend the night, and a place for adequate food. Combine it with a low-security prison- that way, when they misbehave, you can lock them up for a few days without any cider, eating the same food. See how quick they learn to behave.

  4. That isn't exactly true. If that is the worst pain they have ever felt in their life, then it is a 10/10. And some people have extremely high thresholds of pain, and can control their pain for quite sometime, before a 6 or 7 suddenly jumps to a 10 and catches them off-guard, for example. Just because they can tell you it is severe, does not mean it isn't.Here's a recent example that I treated: I had a patient with an obvious distal tib/fib fracture, along with an ankle dislocation (in fact, his foot is 90 degrees in the wrong direction). Good sensation, good pedal pulse, can wiggle his toes (although it obviously hurts). He is obviously in pain, but very able to talk with you. For him, that injury is a 10/10 on the pain scale. He's never felt anything that bad. He obviously isn't faking it. I splinted him in position of comfort, placed him on a long board (not for c-spine protocols, but ease in moving him without too much more pain) and got him off the race course he was on via a quick response vehicle.

    Pain control in this patient is warranted, and very useful for both transportation in some semblance of comfort, as well as helpful in dealing with the muscle spasms that do push this well-controlled patient over the edge once in a while. Part of the reason behind this patient's control is the natural endorphins floating through his system due to being in a mountain bike race. It won't last long. The paramedics did this guy a HUGE favor in starting a line, and pushing morphine before we moved him from my vehicle (I work providing standby BLS medical at events – we don't leave the event so we transfer care to another service), even though he wasn't screaming.

  5. “Combine it with a low-security prison- that way, when they misbehave, you can lock them up for a few days without any cider, eating the same food. See how quick they learn to behave.”Maybe before we start locking people up, we should look at whether we can help them? Without making immediate hardcore sobriety part of the deal? Who knows what hell people have gone through, that end up like that – to criminalise and punish them yet again just seems at best, counterproductive, and at worst callous and inhumane.

    Sure, they “waste resources” – but so do people with skiing injuries, people in RTAs caused by their own carelessness, people who eat the wrong things, miss a few scans, etc etc…

    To drink abusively (or at all) is a choice, but sometimes people are so messed up, it seems (like suicide for other people) to be the only meaningful choice left to them.

    Until we can provide care for these people that offers them a viable alternative, and a non-religious (ie not 12 step based) way out of alcohol/drug abuse (such as Rational Recovery, which is NEVER mentioned in the media or healthcare centres) WHEN they're ready, then we have as much (or rather as little) right to sneer at them as we do people with any other illness or injury, in which choices that seemed reasonable at the time played a part.

    And since that's everyone who needs healthcare except those born with some kind of disability, none of us has the right to get on our high horses about it.

  6. Yes a feeling in the guts based on extensive personal experience.Its probable that a few people had one re baby p but unfortunately there was no tick box coverig that.

  7. You are right. The vast majority of pain relief we give is to make movement easier. Moving people is, after all, our main role. The reason I said that is the fact that someone giving a pain score of 10 is one of those signs which starts alarm bells ringing (along with specifically asking for morphine). I must admit, I don't ask patients to think of 10 as the worse pain they have ever felt but as the worse pain they could imagine…if they still say 10 then they are in serious pain…or have no sense of imagination.

  8. Or, if they have a really GRUESOME imagination like me, they'll never hit a ten even when they need help! My back can make me in so much pain I can barely breathe, let alone discuss statistics, but compared to some things I can think of, that can and sadly have been done to the human body over the years… let's just say I hope and pray I never hit a ten.

  9. Every so often I hear (or in this case read) about patients who fake their pain in order to obtain narcotics.My questions:

    1. Provided they are junkies, shouldn't it be easy to spot them from 2 miles away anyway (i.e. marks from needles, skin type, general looks)

    2. Is it always the same type of person (i.e. a coloured, dodgy looking patient pretending to suffer from sickle cell) or do you get other people as well? Maybe people who look completely decent/normal but who've let it become a habit to get their “high” from nice and clean ambo “morphine” instead of a chocolate bar?

    3. What can you actually do if you think you are dealing with someone faking their pain? (As we all know “pain is what a patient says it is”)

    Is using placebos allowed at all?

  10. I think my comments (as above) are cursed.I've posted a few and never got a response 🙁 Never 🙁

    I think they're invisible, really, and only I can see them 🙂

  11. Actually, I think writing “no evidence” may have been the best way to express that feeling/intuition in the report in a CYA kind of manner.It's not lying. His complaint is included. It's not stating an opinion. It might be implying an opinion, but it's not explicit.

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