Tuesday, January 07, 2014

This interesting news item is doing the rounds today and attracted my attention when I emerged from my pit at 05.30. One common theme when I assessed people in A & E departments was that of the regular attenders or 'Frequent Fliers' as they were sometimes called.

"Dr Cliff Mann, of the College of Emergency Medicine, said there were a variety of issues which led patients to become frequent visitors, including mental health and problems such as drug and alcohol abuse, which suggested that with better support in the community, particularly from social care, repeat visits could be prevented."

In fact, I can think of one individual who contacted their GP several times a day, called the crisis team daily, called out ambulances or attended A & E, often three - four times per week. I even went so far as to request a meeting of all services to discuss a strategy to manage the situation including considering an 'ASBO' but my boss refused to do this. A selfish and inconsiderate individual who refused to take responsibility for their behaviour that put others at risk. They called out paramedics twice in one day stating they were suffering chest pains. This individuals diagnosis, after constant badgering of and heated discussions with the Consultant Psychiatrist by ourselves and others, was eventually agreed as Personality Disorder. The psychiatrist had stuck to "Depressive Episodes" for years despite no evidence of depression. Hence my rather jaundiced view of psychiatry as a medical science but that will be a future lengthy post. That individual clearly had problems and was unable to deal with these, instead using up the considerable time and input of a variety of services when a robust carefully orchestrated plan would have addressed the issues. Again, there are many concerns about the diagnosis of personality disorder with a frequent complaint being whether such conditions exist... another future post perhaps.

But there are a number of people who do frequently attend A & E because of alcohol, substance abuse and mental health problems. As a crisis team we got to know them and would work with other agencies to address their problems and hopefully prevent the frequent attendances. "

Why would an individual attending A & E be such a problem?" I hear you ask.

I'll give an example...
A young woman who has an alcohol problem and often resorts to self harming behaviour calls the police and she is ferried to an A & E dept. having made superficial scratches to her arm. She is extremely drunk to the point of falling over having consumed three large bottles of super strength cider during the evening and she states she intends to kill herself. A & E attend to her wounds, make her comfortable and she sleeps it off for a few hours. Crisis team is called and we attend at 8 am; assess and agree to provide support regarding her deliberate self harm issues and for an on-going assessment. We also liaise with GP, local alcohol services, her family and local housing services. Daily home visits agreed and she goes home. We home visit early afternoon and no reply but we continue to phone and make attempts to contact her. That night she is assessed at another A & E dept. repeating the above scenario involving police and ambulance. That local crisis team aware of our involvement and once sobered up she returns home - seen by us and agrees to plan of support. Over the next two weeks she attends various A & E departments with similar presentations: drunk, superficial scratches to arms and threats, whilst drunk, to kill herself. Her engagement with services is patchy and she misses appointments arranged for her with housing, social services, GP, etc... Unfortunately, the police and paramedics are caught up in a Catch 22 situation because she has taken to phoning them from public areas and threatens to kill herself, often inveigling passing members of the public so services have to respond. She is detained by police using section 136 and is assessed by AMHP's and designated doctors, sometimes in the police cells as well as in hospital. However, the outcome is that with sobriety she presents as engaging, no evidence of low mood and she denies any intent to harm herself. She blames the alcohol, her social situation and a variety of others including the GP, police, social services, family and friends. Eventually, she stops drinking with the support of a local agency and remains sober with no contact at all with services including local A & E departments. Two years later it all begins again because she is once again drinking alcohol...
The problem for A & E is that ensuring an individuals needs are met, that they are safe and cared for takes them away from others attending A & E. Particularly if the drunk individual is aggressive, vomits, urinates or defecates everywhere, behaves inappropriately towards other patients and staffs. Police officers may have to remain in situ, if staffs are assaulted they are not available to perform their duties. An ambulance required for a heart attack victim or a vehicle accident is tied up, etc... I do believe drunk tanks are required and any person whose drunken behaviour results in the results needing to be cleaned up or the attention of police, paramedics, etc... should be made to pay for their behaviour. ( Cleaning up in the evenings under supervision of other drunks comes to mind plus a large fine to pay for services used - other suggestiond welcomed).

For the six hundred square miles our crisis team covered there were a number of people presenting in similar scenarios. The salient feature was alcohol abuse and I place the emphasis upon the latter word abuse. The nannying prohibitionists will leap upon this and extend it to anyone who drinks more than a glass or two of wine a day but they have an agenda and tend to be puritanical onanists who could do with some laughter in their narrow lives. There are also individuals who present with mental health issues such as anxiety, deliberate self harm, etc... who frequently attend A & E. Again it can be extremely complicated in enabling these individuals to manage their health and social issues but this is where services have to provide good care and support. One could state that I am making judgements,especially regarding those who present with alcohol problems. But again it is a question of resources and responsibility for one's own behaviour. This was often a topic of heated debate within the team and with other agencies. One can stop drinking alcohol, often with enormous difficulty, but it can be stopped and if there are underlying issues then these can be addressed by the individual and with the support of whoever is best able to help. Anxiety is an extremely common mental health issue and often downplayed by many who believe "Snap out of it... pull yourself together" is the appropriate approach. I have nursed individuals whose lives and their personal wellbeing has been destroyed by extreme anxiety. People who are unable to leave the house, to socially engage with others or have killed themselves because of this. Most people are able to imagine and empathise with that individual but when the frequent attender suffers from schizophrenia, or has a diagnosis of personality disorder or is inadequate and can't cope for a variety of relationship / social /  etc... issues. What is worrying is that social care is being cut, the impact is increased dependence upon the NHS and other services and the last thirty years has seen the social contract torn up with piecemeal and patchy social support via neighbours, friends, family, parish, etc... We can argue as to why and how such a state of affairs has arisen but it doesn't detract from the current parlous situation that exists. For the latter, various media, politicos, blogs, etc... will blame right / left wings, the state, lack of religion, capitalism, ad infinitum... Ho hum... interesting times indeed.



Blogger Scoakat said...

That was a great read. We have different health systems here but no less problems. All my respect for doing that job, I don't know if I'd have it in me. But I do understand the early, well-deserved retirement. Cheers!

10:52 pm  
Blogger delcatto said...

Thanks Scoakat.
The article and ongoing debate attracted my attention, hence the lengthy post.

7:21 pm  
Anonymous Blue Witch said...

There's been a lot on the radio about this today. I was thinking of you while listening.

8:45 pm  
Blogger delcatto said...

Cheers BW.
I think this year will see things steadily deteriorate as the politicians & media expend more useless hot air about it all.

9:13 am  

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