Ambulance staff primarily deal with acute medical and trauma incidents – its what we do best. Yet, by the very nature of “working in the community” we come across people with mental illness. What do we know about mental illness? Bugger all quite frankly. The only time it crops up in training is when we learn about “sectioning” people. Who signs what bit of paper and how long do patients get “locked up”. Why do we have to know this? Because generally, when a person is sectioned, doctors/social workers give us a call to transport the patient. So what about all the other people with mental health problems that we come across, who are being
ignored ‘cared for’ in the community?
There is no area of healthcare more ignored, more under-funded and more misunderstood than the care of the chronically mentally ill. And of the chronically mentally ill, the worst cared for are the schizophrenics. There was a general clear-out of British long-stay mental hospitals about twenty years ago. The “right-on” slogan was “care in the community”. The chronically mentally ill were thus pushed out of the cuckoos’ nests on to the streets.
The government does not even pay for the cardboard boxes.
From the incomparable Dr Crippen’s post on Schizophrenia
Just lately I seem to have come across more patients suffering from schizophrenia; or perhaps I’m just becoming more aware. The link with schizophrenia has been that these patients have all been on quetiapine. I’d never heard of it before but having coming across more patients who have been prescibed it I decided it was time I looked it up in the BNF. Pharmacology is another area that we’re pretty crap at, though I gather that’s changing now with the current paramedic syllubus. Mostly you just learn about medications ‘on the job’ and its taken me some years to notice that patients are taking quetiapine.
Over the last week I’ve attended a number of patients with mental health problems. Perhaps its the full moon (the last one was Thursday 7 Sept). Any ambulance person or A&E nurse or doctor will confirm that you get more ‘nutters‘ (very un-PC I know) when its a full moon (or a new moon for that matter: I used to attend an epileptic patient who always seemed to fit on the night of the new moon). Its where the term ‘lunacy’ comes from (Latin luna=moon).
Thursday night I was called to Jenny, a 24 for year old schizophrenic. She’d passed out on her boyfriend’s kitchen floor. A known alcoholic, she’d apparently gone home and taken an overdose. She’d come back to her boyfriend’s house the ‘worse for wear’, announced she’d downed a load of pills, had a few more drinks and then crashed. He told us she lived alone. She’d had three children. One had died recently and the other two were in care. No contact with parents “she hates her mum”. Her boyfriend, who seemed many years older (call me a cynic but… was he taking advantage of a vurnable young girl?), said “she’s lovely when she’s sober but a bitch when she’s had a few. I send her home when she gets drunk.”
As she was unresponsive and we’d no idea what medication she’d o/d on, the crew took her off to A&E. She had a box of quetiapine at her boyfriend’s. Will she get help at the hospital? They’ll do all the necessary tests, I’m sure, but in the end she’ll probably just be observed until she’s ‘safe’ and then sent home, hopefully with a referral to the psychiatric team. (Maybe A&E readers can advise differently). Perhaps I’m overly sentimental but it seemed such a waste of a young life.
[Schizophrenia] is all too often a relentless disintegration of personality, life and self – SHP
Mike Portnoy ©2001
On Friday I was called round to assess Ben, an extremely engaging 25 year old who’d taken an overdose of Quetiapine. Ben is one of those people you can’t help but like; piercing blue eyes, extremely intelligent and very self effacing. He talked to me about the anguish he felt over the voices in his head. What stuck me so forcibly was his insight into his turmoil. He knew what he was hearing came from inside and that no one else could hear, or even understand, what was going on. This made him feel so confused when he acted out of character, following these inner commands. He particularly agonised over the problems he was causing his mother. He’d taken the overdose, he said, because he was struggling to cope with the inner conflict of being told he was ‘God’ when he knew perfectly well he wasn’t. It was tormenting him terribly that ‘they’ wouldn’t shut up about it no matter how often he refuted ‘their’ suggestions.
Symptomatically he wasn’t doing too badly; sinus tachycardia at 150 bpm and feeling drowsy but no chest pain, breathing difficulties or any other adverse reaction. I decided to complete a 12 lead ECG just to check there was nothing else cardiac related happening. Ben was extremely concerned about being ‘wired up’.
Was I going to shock him?
No, this was a monitoring procedure.
Was I going to try and knock him out with the electrodes?
No, they were only going to record the small electrical activity in his heart. Would he like me to demonstrate on myself first?
So I conducted a quick 3-lead electrocardiogram on myself. He seemed satisfied and said he liked to trust people who told him the truth and very apprehensively agreed to have a 12-lead ECG recorded. He certainly found it difficult to relax but once he discovered that he felt nothing he became very compliant. I’m pleased to say nothing sinister showed up.
I spoke to those nice people at Toxbase who confirmed tachycardia was the primary side-effect for a quetiapine overdose but that this should reduce after 6 hours. I was concerned though, we were nearly 8 hours post ingestion with no sign of any reduction in heart rate; cause enough for a visit to A&E. As so often happens these days there were no ambulances available, the nearest being about 50 miles away. As Ben appeared stable I suggested he and his mum travel with me in the response car seeing as Mum didn’t drive.
We had an uneventful 20 mile trip to A&E. We were fortunate that day that the charge nurse on duty was extremely accommodating and we got Ben settled in a cubicle without any problems. One of the nurses appeared wanting to take a blood sample. This caused Ben great alarm; he confided that a voice was telling him the nurse was going to poison him. Mum and I reassured him that that was not the case and the nurse explained patiently exactly what was going to happen. He then relaxed again and agreed.
Whilst I was sorting out the paperwork, outside in the car, Mum came out to talk to me. She said she felt really helpless as Ben was such hard work. She loved him dearly but sometimes he became out of control. He’d apparently tried to stab her last Christmas.
“Is his GP involved with his care?”
“No, its all left to the ‘out reach’ team and they’re pretty useless. They just come round and ask him how he’s getting on and that’s about it. It doesn’t help that there’s one voice that hates me and Ben always quotes what ‘it’ says when they’re around so they think I’m an evil mother and try not to let me get involved. But he lives on his own and doesn’t really cope that well, so he often comes round for meals and for company. He doesn’t tell the team though otherwise they’d try and stop him. Even when I cook for him he has to stand and watch every step just in case I’m going to poison him.”
She went on to explain that Ben was extremely intelligent. “He picks things up without any effort. Ask him about planets, the life cycle of ants or all sorts of strange things and he can rattle off facts no end. He even taught himself the piano and the guitar without any input from anyone else; but for practical day-to-day living he’s hopeless. Doesn’t matter how many times I explain to him how to boil an egg he still can’t get the hang of it.”
“He’d really like to go to college but the ‘team’ tell him he’s not ready. When will he be ready? They just say he’ll drop out but why not let him try? At least give him a chance to see how he gets on. I really don’t have much faith in the out reach team. They’re not doing anything for him. He used to be seen at [the mental health ward] at the local hospital but they’ve banned him now. Someone asked him to hide a package for them under his pillow. He’s so trusting that he did and when the staff found out they accused him of distributing drugs. Even though other patients and staff identified the real culprit ‘they‘ won’t listen; just made him a scapegoat. Probably a blessing in one sense as there’s more drugs on that ward than out on the street.”
While we were talking one of the nurses came out to fetch mum as Ben had pulled his cannula out. We went in to see him. “They told me to. Said the nurse was going to poison me. I’m really sorry mum. I’m causing so much trouble for everyone.”
I stayed with Ben and his mum for a while; he has that effect on people. He’d be great to have as a friend I’m sure.
Mum asked the nurse how long things might take. It was getting late and it emerged that she’d have to catch the last train home. She had her husband to look after as well: he’d had a stroke. Goodness! If she’d known what lay ahead on her wedding day I wonder if she’d have chosen differently. So what happens if she gets ill?
The NHS is already in crises. Who’s going to care for the carers?
The care of schizophrenics in the UK is a disgrace. – Dr Crippen
Pictures from SilvaLab