Wrestling Again

“Look here”, one of our ambulance officers said to me after I'd been wrestling with a confused patient, “next time, just let them go, don't try and restrain them – if they want to wander off and die it's not your fault”.

I nodded, “OK, I'll be sure to tell the coroner that…”.

—–

The call was sent down to us as “Woman threatening to jump from a window”. As I'm getting past the age of talking people down from tall heights I checked that the police were also being sent to the call.

Unusually we got there before the police, and as the location was distinctly absent of anyone standing in a window, we approached the house.

We were met by an on-call GP and the mother of the patient, the GP explained that our patient was suicidal and kept threatening to take overdoses or jump from a high place, consequently he wanted us to take her into the local hospital for a psychiatric assessment.

What was unusual was that the doctor was still on scene, normally the closest we get to see of them is the rear lights of their car disappearing once they see us arrive – I often wonder if they are scared of us…

Our patient was upset, but agreed to come to the hospital, her mother would also be coming with us. As everything seemed to be calm we cancelled the police from attending.

It was all going fine until our patient suddenly decided that leaping from our moving ambulance into fast night-time traffic would be a good idea.

Needless to say, I disagreed.

So, once more, I found myself wrestling with a patient in the back of the ambulance – she wanted to run away and kill herself, I considered that she didn't have the capacity to refuse psychiatric assessment and so there was a bit of a struggle in the back of the ambulance while my crewmate called for urgent police assistance.

I'm sure that if Liberty or Amnesty International looked at my actions in a court of law I could have been prosecuted for kidnapping, but I sincerely believe that an upset suicidal patient shouldn't be allowed to kill themselves on what seems like spur of the moment decision (even though they may have been thinking about it for a long time).

Importantly I couldn't see any coroner or family member accepting any account of me not trying to stop someone from killing themselves.

I like to think that I'm fairly knowledgeable about Capacity and Consent, and while it might be argued that what I did in keeping her in the ambulance was outside the limits of the law, it was definitely within the limits of human decency.

Besides, there wasn't time to do a formal Capacity assessment when your patient wants to dance in traffic.

The police arrived and were superb in helping me transport her to hospital – they were the police who'd been running to assist us in the first place when we'd cancelled their attendance.

We soon reached the hospital with only a few more struggles, and the duty psychiatrist saw her straight away.

I ended up with sore wrists, that were eased somewhat by an icepack – but I could soon ignore them for the crack on the head that I got from the collision we had on the way to our next job.

I've never been too good at listening to our officers…

—–

Any comments from mental health professionals on how to act when a patient who may or may not have capacity suddenly wants to kill themselves in front of you would be gratefully received. Sometimes, when looking at nursing literature, I think that the accepted thing to do would be to hand the patient a razor blade as a part of 'fulfilling their self-directed life goals'.

It's why I don't read nursing literature anymore.

19 thoughts on “Wrestling Again”

  1. Oh dear… its a good job you don't listen to the officers advice Tom, I'm glad you kept the patient safe but sorry you got hurt in the process. The media would have had a field day with that story – “Safe in their hands? Paramedic allows patient to die” etc good grief and how could you live with yourself having to tell the relatives that the pt exercised her right to choose and is no more when something ccould have prevented it. I bet the officer would not have backed you up with the Coronor either. Do officers have a heart? you must be overwhelmed by their support and sensitivity NOT!Why is it that an incredibly difficult job is made harder and more stressful by the very people that should support and help. Oh well Tom in an ever changing world that's one constant, the officers level of 'support'. Take good care and be careful with your poorly wrists and head, love Lo x

  2. To be fair, the officer was only really showing support for his staff's well-being. We aren't trained to restrain people, only to 'escape and evade', so him telling me to not fight with patients is him telling me to look after myself and not get injured.So I can't really say that he was wrong – just that sometimes you have to work 'outside the box' as it were.

  3. Yeah, it's a tough call sometimes, and we never have much time to make a decision. We do what we feel is right at the time (right for us, right for the patient), and our decision about what is right is often based on that gut instinct that is a combination of our experience and knowledge.It may feel right, but it may not be correct in the eyes of the law, or even of some of our colleagues.

    At the end of the shift we want to go home in one piece. We would like as many of our patients to get to where they need to be in as few pieces as possible, and we do what we can for the 11, 12, or 13 hours we're working to achieve that. How we do that is as variable as each patient we meet.

    Sometimes there is no time for finessing legal niceties. Sometimes you just have to jump on the patient to stop them hurting themselves or anybody else. Other times you stand aside and let them out – preferably after your partner has managed to stop…

  4. Good call. I would rather try to justify why I restrained a patient in this kind of situation than try to justify why I didn't! I work for the ambulance service where a few years ago we had a young girl jump out of the back of an ambulance while on the M5. She sadly died. I know the guys involved (and yes, the attendant tried to restrain her), and they are still reliving the incident.

  5. Imagine the headlines.1) EMT uses violence on patient. (Fails to mention suicidal tendencies.)2) EMT watches as patient is killed. (Falls in front of traffic.)Damned if you do. Damned if you don't.That's what I detest about this country. Whatever you do, there's always some group against it.

  6. Surely you also have to think about the poor MOP who is driving in the car behind you? You aren't necessarily stopping your patient from killing herself, it is more that you are protecting other people from the lifelong trauma of being the unwitting weapon in her suicide bid. (at least, that's how I'd present it in a court of law…)

  7. I agree, more often than not there is someone with a criticism rather than a compliment.Is it just me or is it the people trying to help that come off worse?

  8. Also the fact that she might not have been seriously harmed at all, the car that would have run her over could have been being driven by someone with exceptionally fast reflexes who dodged her andA) crashed into a wall, thereby being killed.

    B) crashed into a pedestrian, killing that person.

    C) crashed into another car, both being killed and killing someone else.

  9. My thoughts align with Bevan and Olixs. I see your actions as a legal means of preventing a crime. If she had jumped out of the vehicle, she would quite likely have caused harm to others. As her intent was to be struck by oncoming cars, that harm could be considered premeditated as she knew that her actions would cause damage and disruption. If it could be argued that she was not in her right mind, and therefore would not be accountable for her actions, you would be off the hook as it could then be shown that she did not have the capacity to refuse psychiatric assessment.

  10. Legally you are entirely in the right if you restrain (though even if you don't, that is your perogative legally and carries no legal or, I should hope, moral, blame).Good call though. So glad there are people like you out there for people like this.

    Incidentally, have recently finished uni and moved from oop narf to take up some besuited legal job in The City and am now living right in the middle of your patch. Having been avidly reading since very near the start, it seems quite odd to be 'there' and to actually relate that little bit more to some of those things you write. Plus, thank you very much for the (blogged) recommendation re Log Cabin. Passing about a week ago and the burgers are indeed that good!

    Ian

  11. Good call, TR – tho i know of many who would say 'let her'.I don't care if the law's on your side to let her do further damage – whether to herself or a n other – living with it yourself is another matter. If she'd escaped then so be it but i think we need to be seen to be trying to help.I doubt she genuinely wished to die. People who wish to die tend to do so without warning.A few months ago my mate and i went to a drunk who, he said, had been clipped by a car. Whatever, his walking was seriously impaired. We gently suggested he go to hospital. the local law occifer was more adamant and he said “Ok”. For Over 30 miles i kept him from 'jumping' from the vehicle.We could've let him out in the middle of nowhere but we conjured images in our heads of him being flattened by the artics. that regularly run that road.Fortunately at no point did he turn on me. He was pretty civil considering.The bigwigs who come up with such 'laws' don't have to come face-to-face with the dilema they pose.

  12. It may be that legally we are allowed to restrain someone who wishes to harm themselves. I assume this would be because we would be acting in the patients best interest. Standing by and just allowing someone to do themselves damage is not what the job is about. However, the problem is, we are not taught restraint techniques. If we were to hurt someone whilst preventing them from self harming, or if we were to hurt ourselves, would we be supported by our own management? You can be sure we wouldn't because somewhere they will have a piece of paper saying they told you not to. The arse covering continues.

  13. I'm an A&E Psychiatric Liaison Nurse. I don't envy LAS who have to make these split-second decisions without the benefit of a triage handover or any background history! I absolutely think you did the right thing and have legal backup under common law.First of all, although they're sometimes reluctant to use them for reasons too long to describe here, the Police could have detained this lady under s136 of the Mental Health Act to remove her to a designated place of safety for assessment (check where your local ones are – they are not always A&Es – on a regular basis we get large groups of officers wrestling cuffed violent patients into A&E whom they intend to uncuff to be “safely” “managed” by me and the Psych junior doctor on call!). Obviously if someone also requires medical treatment the decision to take to A&E is moot (although you can detain under s136 and go to a 136 suite via A&E), and I'll counter my earlier criticism by saying many Police Officers are tremendously helpful in assisting us. Seeing as there was a GP on scene who wanted a MHA I can't see how anyone could have quibbled.

    Anyhow, in this situation you were in the same position as I would be in A&E with an acutely suicidal patient wanting to leave. I would use common law to prevent her from leaving – putting myself between her and the door if necessary – with the justification that she was at imminent risk of harm, there was a likelihood of diminshed capacity due to mental illness and she required further assessment (plus her GP wanted an MHA). I would also document my justification.

    So in summary – would have done exactly what you did do.

  14. Just a quick query here…Mental Capacity Act (2005) states that if the patient does have capacity and makes a decision to (for example) overdose and refuse treatment (knowing the worst possible consequence), then the decision (even if made during a fit of rage) has to be respected…

    Your thoughts please??

  15. Oh forgot to say…bearing in mind our common law responsibilities to e.g. stop someone jumping out the back of the vehicle…but if they ask for you to pull over and get out as you cross a road bridge…As far as our trust is concerned the sheep are grey and woolly…at least you get an officer out!

  16. The Mental Capacity Act is a wonderful thing if you have the time to assess capacity! What happens if you don't have that? Obviously sometimes you're going to have already assessed capacity when the person attempts to leave your vehicle, and if you're able to document that they had capacity, then you have to let them go. More often, I'd imagine, you're talking about the situations where you arrive at chaos and the person will barely speak to you, let alone answer lots of questions.In that situation I would hold them under common law so I can assess capacity – or in your situation until the Police arrive to help you get them somewhere that can be assessed at length. Obviously I do sometimes let people walk out. That's if I've assessed capacity and they have it, or with the frequent flyers I know well. I never take a blind gamble with it though, and I'd always document my decision-making – even something like “Stated immediate plan to end life and appeared very intoxicated with alcohol – appeared to lack capacity so held in A&E under common law so more formal assessment of capacity could be done”

  17. The key thing to remember is that if there are any doubts as to capacity, your responsibility is to “provide treatment” until the patient can be properly assessed.Grey areas can be useful … If it is very obvious someone HAS capacity … Fine. If it is very obvious that someone LACKS capacity … Fine. If there is a grey area and you doubt their capacity or doubt your ability to judge capacity – then your doubts are justification enough.

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