A Mind at Sea

Introduction

In practice, we see a lot of mental health patients, both in and outside of lockdown. Most of them have affective disorders such as anxiety or depression, problems that impact mood, dropping it so low that they overdose or self-harm. This is normally relatively straightforward for us to deal with in A&E - we take a history, medically clear the patient and discharge them to our on site liaison psychiatry team.

However, this is a very narrow spectrum of what can present. And sometimes, what presents can be both difficult and disturbing in its implications for the poor patient.

The Case

A young lady with no fixed abode comes to us having been living from hotel to hotel for an unspecified time.

She arrives in the early hours of the morning with active suicidal intent. Having changed her mind about walking into the sea that night, she called a cab and came through to A&E, where I find her sleeping.

She's wanted to hang herself for months because she says her family is trying to kill her and she sees no way out of her troubled situation; she tries to suppress this and feel safe by engaging in risky sexual behaviours, and finally by trying to come to hospital to talk to someone. She has a folder of information regarding her background (depression/borderline personality disorder/PTSD following a history of parental abuse) as well as other psychiatric documentation in her bag, along with a cute koala fluffy which she has put a mask on. She is not known to our mental health team. It seems she has come from London.

Her mental state is flighty. She randomly forgets then recalls things, has strange jumps where she digresses from the topic at hand, very fixed beliefs (the least serious of which was ‘you can’t be Sri Lankan, they’re all dark, you’re lying!’), impulsivity in thought and action, no formal thought disorder (no hallucinations audio or visual, no insertion or broadcasting), no insight into the randomness of these thought patterns). She often says she wants to leave, yet also wants to stay and talk to someone when she is ready. I class her as someone who is at high risk of absconding and self harm - since if she does leave at any point, chances are something bad will happen. I can’t discharge her.

The First Problem

Our Mental Health Team is all women, especially overnight. There are no consultants on call to actually come in.

Unfortunately, because her mother abused her when she was younger, this lady really really hates seeing or being near other women. She screams at the sight of one or starts shouting if we even suggested she would have to talk to one. When I am with her or the male paramedic is with her, she is calm and you can see her decision-making process is - while perhaps a bit odd to us - not one which means she lacks capacity. She can make decisions, however impulsive, based on the information she hears and weighs up.

The Second Problem

In an A&E staffed with female nurses, it was a matter of time before she saw someone and kicked off.

At the sight of a nurse, she starts screaming, biting and spitting and threatening to hang herself with the ECG cables. At first, she looks angry and is trying to intimidate, but you can tell it’s all borne out of fear and desperation.

Unfortunately, letting this behaviour play out in a busy A&E department beholden to 4 hour targets during a pandemic when there are other frail, frightened, delirious patients wandering around is not possible. We have to call security, corral her like a small animal with a wall of bodies when she tries to move to a different area, isolate her behind a barrier. This is where lack of insight comes in. Mental Health are unwilling to see her until a rational conversation can be had, plus they are full to capacity with previously admitted patients. In this moment, for about an hour or so, she is totally our responsibility.

With her aggression not receding, we are forced to deprive her of liberty (you sign a form reasoning why she cannot weigh up information and why this matters to her serious treatment). Because she is so volatile and a risk to herself and others, we are forced to pin her to her bed and partially sedate her under common law with lorazepam. By now the nurses have called the police as she had tried to assault the nursing staff. However, with the sedation in place, the police can't come to arrest her as there is no active threat of assault and because she is in 'a place of safety'. Mental health are still full, and since she can’t talk, we can’t wheel her down there. We need to think of other options.

What next?

At this point, we know we are going to section this lady under the Mental Health Act. What this means you can determine from the below table:

Credit to Ministry of Ethics for this excellent resource under time pressure

At this point, we know that this lady needs help. For her own safety, she needs admission and formal psychiatric review under a consultant to determine the whys and where to gos for her. She needs sectioning.

Sadly, that process takes absolutely ages to accomplish in practice due to the reams of paperwork that need filling. It was also impossible overnight. Mental Health informed us that even if we called the emergency team to come in and review her under the Mental Health Act - as there were (bizarrely enough) no AMHPs on site and no trained practitioners at the level of Section 12 (i.e. a consultant psychiatrist) to properly document everything.

If she was consistently aggressive and unwilling to see female practitioners, they tell us our only option would be to let her walk out of the department (she did try, though she came back), call the police and have her sectioned under Section 136 (a police section for people in the community outside of a formal healthcare setting, to either take you to a safe space to be assessed under the Mental Health Act or to keep you in a safe space to be assessed). The plan whether she cooperated or not would have been to take her to our off-site psychiatric unit. Obviously, for her own sake, we want her to cooperate.

The Result

Even though the patient calms down and maintains consciousness, her future remains very much up in the air. As such, our extremely assertive flow coordinator (at the 3.5 hour mark) makes Mental Health come up and review her in A&E. I have already had multiple conversations with the patient, having sat down and tried to convince her that because she was clearly so concerned about her life situation, she needed to talk to someone whether they be female or not. These had all failed, but on the 5th time of asking, I tell her that if she were to leave as she kept saying, much worse would befall her than speaking to a lady who could help her.

She acquiesces. I am as surprised as anyone.

When Mental Health come up, she is shy at first, but with myself and other male staff present, she slowly but surely opens up about her backstory and her recent suicide attempt. I’m not sure what happens after this, but I’m fairly sure she is sectioned given how drastic things become. I can only hope for her safety, and that she is at last benefitting from in-depth psychiatric care.

Takeaways

This for me showed the dark side of best interests medicine, taking a patient’s life out of their own hands and depriving them of their freedom. It was necessary, but coldly so. We cannot afford to give patients the luxury of time in A&E, the pressure especially in lockdown is just too great. If they were on a ward, then maybe, but not A&E, not now.

I could see the patient was clearly very frightened and upset. She had been traumatised by so many people in her life that her amygdala was literally on speed-dial, firing wildly at the slightest stimulus in a desperate attempt to keep her alive. I doubt she fully understood the consequences of her behaviour, either on herself or others, but then can you blame her? We were not living her life; she was coming into our world. Of course there would be a disparity.

The most galling thing for me was that the system is clearly so denuded that acute psychiatric emergencies such as this can’t be quickly dealt with. What if we couldn’t restrain her because she was so small? What if she ran and injured another patient or herself? Why is the liaison mental health department confined to such a small room that only 3 patients can be there at once when in lockdown, so many people are suffering? Why would nobody come down for an emergency overnight like any other specialty would?

These are things that we would teach our colleagues trying to learn from this, but these aren’t things we want to teach by any means.

Perhaps I’ve gotten things wrong over the course of this blog post, but put bluntly these were the case’s facts. I very rarely get upset about things, and I’m not in any sense upset following this episode either - what happens happens, and what can happen is infinite in its possibility - but when I think about it, I still shake my head with disappointment. Things could be so much better with better resources and planning. Moreover, to prevent this ever happening in the first place, social awareness of less corrigible disorders like personality disorders or psychosis where treatment adherence is poorer, plus an awareness of what it’s like to be sectioned, is a must.

These are pipe dreams for now. Only the latter, through the hard work of charities like Mind and grassroots groups run by my friends like @theyanacommunity, shows much sign of improvement. Like I said at the end of the case, I can only hope.

After all, when you’re lost in a sea of disappointment, hope can often be your greatest anchor.