Friday, 24 April 2009

Why is there never a bed when you really, really need one?

I’d barely had time to get into work and make myself a coffee when I received a request for a MHA assessment. The GP was at the patient’s house, the patient was agitated, verbally aggressive, deluded and psychotic, an ambulance crew and the police were in attendance, and the GP needed an AMHP as soon as possible. I rang him straight away. He sounded nearly as agitated as the patient, a woman in her 50’s who had recently had her bowel and colon removed following cancer. He had gone round expecting a medical problem, only to find she was apparently acutely mentally ill. In addition to a stoma bag, she had a range of physical health problems, the most concerning of which was insulin dependent diabetes, since she was refusing to check her blood glucose levels and had not taken any insulin for a day.

Her name rang a bell. I looked in my records and realised that I had detained her under Sec.2 nineteen years previously. I realised that I actually remembered that assessment. She had then presented in an extremely bizarre fashion. On interview she was drinking glass after glass of water, could not keep still, was unable to engage in any sort of conversation, and would periodically walk out of the room into her back garden and scream “FUCK OFF!!” at the top of her voice, before coming back in and sitting down again as if nothing had happened.

Her records showed that she had subsequently had involvement with community mental health services for health anxiety, rather than psychosis, and had received more than one course of cognitive behavioural therapy.

Whatever her history, she was presenting as an acute emergency. I tried the local psychiatrist to see if she could attend, but she was unable to. In the circumstances, I decided I should go out and assess the situation without obtaining a psychiatrist, since the nearest available Sec.12 approved psychiatrist was about 30 miles away, and there really didn’t seem time to ring round to find one.

Within a few minutes of receiving the call I was at Mavis’s house – it was easy to find, as there were an ambulance and two police cars parked outside. As I approached the open front door, I could hear her shouting and swearing, and it became clear that she was presenting in a similar way to how she had all those years ago. Her vocabulary consisted mainly of the word “fuck”, and no-one seemed to have any control. I introduced myself and asked her if she remembered me. She actually appeared to recall my involvement with her in the past, but still told me to fuck off, as there was nothing wrong with her except that she had Aids.

Taking the partner to one side, I found out that she had had major surgery because of cancer a few months ago. His mother had died two weeks ago, and Mavis had attended an outpatient appointment just a few days ago in connection with something that had shown up on X-Ray on her lung. Although there was in fact nothing to worry about, it appeared this was the tipping point which had apparently precipitated a reactivation of her health anxiety and a stress-induced psychosis. She believed she had Aids, despite having several times had negative blood tests, and was displaying delusions relating to sex. She refused to consider medication, including her insulin and usual prescribed medication, would not agree to seeing a psychiatrist, and the carer was quite clearly at the end of his tether. I therefore decided the best course of action was to detain her under an emergency Sec.4 with a single medical recommendation from the GP, on the basis that obtaining a second medical recommendation would involve undesirable delay. He was very pleased to oblige, and gratefully scuttled off to his more normal patients.

With an ambulance crew and the police present, what could possibly go wrong? She would be in the local psychiatric unit within half an hour.

I rang Bluebell ward, our local admission ward.

“Hello, I’m an AMHP and I have just detained Mavis under Sec.4 and need a bed.”

“Will that be a female bed?”

“Mavis is a female, yes.”

“We don’t have a female bed.”

“Well how about Snowdrop ward?”

“I’ll ask them... (pause)… They haven’t got a bed either.”

“How about a leave bed?”

“There’s no-one on leave.”

“I happen to know Janice is on leave at the moment.”

“Janice is back for the ward round.”

“Can you find out from the ward round if they’ll be discharging anyone?”

OK… (Another pause)… No they’re not.”

“Look, I need a bed urgently.” I explained why. “Can I speak to the bed manager?”

“She’s in the 136 suite and can’t be contacted at present.”

“What about the charge nurse?”

“I’m just a bank nurse. Do you want to speak to someone else?”

“Yes, how about the charge nurse?”

“I don’t know where he is.”

“I have someone on a Sec.4 who needs a bed urgently. You will have to find one.”

“Do we have to find a bed?”

“Yes, you do.”

“I’ll try and find somebody and ring you back.”

A paramedic came up to me. “Can we get this patient off to hospital now?”

I screamed inside.

“There doesn’t seem to be a bed. I’m trying to get one. God knows where it’ll be. The last time there wasn’t a bed the nearest bed was 70 miles away.”

After half an hour of waiting outside the patient’s house, with the carer, and the patient, becoming more and more agitated and distressed, I decided to ring someone at the Crisis Team, whose offices happened to be next door to the ward.

I explained the situation.

“I’ll go into the ward round and see if I can sort something out.”

Ten minutes later my phone rang. “There’s a bed on Snowdrop Ward.”

And finally off we went.

No comments:

Post a Comment