Saturday, March 02, 2013

a pair of glasses


It’s still early. Even though the sun hasn’t warmed things up overmuch, after all the recent rain it’s great to have a day so blue and crisp and defined. Even the commuter traffic, nudging along its familiar routes, seems easier in itself. A postman waves some letters over his head to us as we pass, more a victory salute than a good morning.

We walk up the path to the front door.

Sarah is sitting half-way down the stairs, the watchful centre of a three-point pattern of concern – her sister Kate, standing just above her on the stairs; her brother-in-law Maurice, standing with his arms folded by the coats at the bottom, and Ethan, the first paramedic on scene, hugging his clipboard in the hallway. On the landing above them all is Daniel, Sarah’s fourteen year old son, sitting with his legs crossed, biting his nails.
‘Who are you?’ says Sarah as Maurice shows us in.
‘Hi Sarah. I’m Spence, this is Rae. We’re in the ambulance, just like our colleague Ethan, here.’
‘Show me your identity cards.’
‘Well – I er… I don’t actually have mine on me today, Sarah. I know I should, but it’s just one of those things.’
‘I don’t believe you.’
Rae and Ethan pat themselves down, too, as embarrassed as me not to have a card.
‘But as you can see, we’re wearing our uniforms,’ I carry on. ‘And our ambulance is parked outside.
‘Where?’
‘You can see it just through the window.’
‘What do you want?’
Ethan steps forward and talks to her gently through the stair rails.
‘Do you remember we had that long chat, Sarah? About how - unwell - you were feeling? How you wanted to hurt yourself, and other people? And we went through all the options, and decided in the end maybe the best thing would be to go up the hospital and see a doctor.’
‘What doctor?’
‘One of the doctors at the hospital.’
‘Which one? What’s his name?’
‘I don’t know, Sarah. I haven’t been up there yet. I don’t know who’s on.’
‘You can’t be in the ambulance if you don’t know who the doctor is.’

Sarah is pale and drawn out, trembling on the threshold of something. Her mouth is so dry her words click and crackle. She talks in a superficially rational way, but her arguments turn round and round in aimless loops that promise understanding but keep slipping back and never seem to catch. Everyone takes a turn over the next half an hour or so to stand at the bottom of the stairs and persuade Sarah to come with us, speaking as neutrally and supportively as they can – but in each case, Sarah simply reflects the concern back as flatly as her glasses reflect the light from the front door.

‘Will you let us do some observations, Sarah? Your temperature, blood pressure?’
‘Why?’
‘Because there might be a physical reason why you’re feeling like this.’
‘Feeling like what?’
‘Low and suicidal.’
‘How do you know what I’m feeling?’
‘I don’t – but that’s what you told Ethan, and that’s what your family have said.’
‘What family?’
‘Kate and Maurice. Daniel. Everyone’s worried because you don’t seem yourself.’
‘Are they? I see. Why do they think that?’
‘Because you’re acting out of character.’
‘And why am I acting out of character?’
‘That’s what we’d like to find out, Sarah. That’s why we’d like you to see a doctor. At the hospital.’
‘What doctor?’

We try to arrange for a doctor to come out and see Sarah at home, but suddenly there’s a marked change to the mood of all this.
‘I want you out of my house,’ she says. ‘Get out. Get out of my house.’
‘Sarah – we really can’t leave until we’ve sorted out some help for you. You’re not well.’
‘I’ll call the police.’
‘Why don’t you come down into the lounge, Sarah? We could all have a cup of tea and talk some more about this. How about it?’
‘No! I want you to leave!’
Daniel catches my eye and emphatically shakes his head from side to side. Then he puts his face in his hands and starts to cry.
‘Come on Sarah. Let’s go into the lounge.’
Suddenly she stands up, pushes past her brother-in-law and runs outside. She stands by the recycling bins, leaning forwards with her hands pressed onto her knees and shouts: ‘Help! Help!’ as loudly as she can. Rae and I go outside to stand with her. We try to persuade her to come back in, but every ten seconds or so, when she’s recovered enough breath, she shouts for help again.
I glance back at Ethan; he waves his radio in the air.
‘Sarah? The police are on their way. If you’re behaving like this when they get here, you’ll be taken to the hospital by force. So why not come onto the ambulance with us now? It’ll be so much nicer, and it’ll spare your family all that unpleasantness. Daniel’s pretty upset, you know.’
‘Help!’
Neighbours stare from their windows. People walking by snatch brief, appalled glances in our direction and then hurry past.
Between each scream, Sarah straightens up to look at me. There’s a peculiarly fractured, one dimensional aspect to her expression, a large pair of glasses with two grey eyes, painted flat.

And then, after a few minutes, she turns, holds her dressing-gown around her legs and goes back inside, as if she’d only stepped outside to bring in the milk.

She heads upstairs. Kate has gone up there to comfort Daniel whilst we were out in the street. She sits with her arms round him, and they huddle up closer as Sarah marches to the top of the stairs and sits down on the top step. I stand a couple down from her, within reach if she suddenly lunges forwards.
‘Daniel? You can come to the hospital with me,’ she says.
‘Sarah – please. Don’t do this,’ says Kate, stroking Daniel’s head, and then kissing the top of it. But then Daniel straightens up.
‘Mum? You’re not well. You need help.’
‘I need help, do I? And why do I need help, Daniel?’
‘Because – because you’re not well.’
‘I see. And why am I not well, do you think?’
‘I don’t know. It’s all in your head.’
‘All in my head, is it? You know what they’ll do to me, don’t you? They’ll poison me again – yes? Remember? They’ll pump me full of poison and that’ll do it, do you think?
‘I don’t know Mum. Yes. Maybe.’
‘Well you can come with me, then.’
‘I don’t want to. I just want to go to school.’
‘Why? Who’s at school?’
‘All my friends.’
‘What friends?’
‘I don’t know. Jack. And Graham.’
‘They don’t exist. You’re not going to school. You’re staying here with me.’
‘Mum! Please!’
I try to gently manoeuvre myself between them.
‘Why don’t we go downstairs, have a cup of tea and wait for the police, Sarah? Let’s leave Kate to help Daniel get ready for school.’
Kate takes the cue and stands up with Daniel.
‘No. He’s staying here.’
‘But your behaviour is upsetting him, Sarah.’
‘No. You’re upsetting him. I want you out of my house.’
‘I can’t do that, Sarah. I have to stay here and make sure everyone’s okay.’
‘Get out of my house.’
‘I’m sorry but I’m afraid I can’t.’
‘Get out of my house.’
‘No.’
‘I’ll call the police.’
‘They’ll be here in a minute, Sarah. Daniel – why don’t you go into your bedroom with Auntie Kate for a moment? It’ll be a bit calmer there, and you can – get ready for school.’
They hurry into the bedroom, but Sarah lunges across the hallway to make a grab for the door. She tries to shut herself into the bedroom with Daniel and Kate – but I put myself in the way, jamming the door open with my foot.
‘Get out!’ she says. ‘Get out!’
‘I can’t do it, Sarah. Sorry.’
I look around briefly to see if there’s anything she could use as a weapon. But the only thing within her reach is a collection of Warhammer figurines on the dresser top: trolls, orcs, witches. Some of have fallen over.
Kate has gone to protect Daniel beneath the window. I stand facing Sarah. She has one hand on the door, but although her breathing is hard, her eyes are as flat as before.
I try to make conversation with Daniel about his school, what he likes, what he doesn’t. The whole time I speak, Sarah studies me, waiting to jump.

The police arrive.

After a brief discussion with Ethan and Rae, two officers come up the stairs. The first one comes to take my place in the doorway of the bedroom. I move off just to the side.
‘Hello Sarah,’ he says. ‘My name’s Sergeant Green and this is PC Marchant. What’s been happening today?’
‘Let me see your identity card,’ she says.
‘Certainly.’ He pulls out a battered leather flip-wallet, opens it up and shows it to her. Sarah makes as if to snatch it out of his hands, but he moves it out of the way.
‘Now, now,’ he says. ‘Don’t get all grabby. You asked to see my identity card and there – I’ve shown you. Okay?’ He tucks it back in his stab vest.
‘Who did you say you were again?’ Sarah asks him.
‘Sergeant Green, Sarah. That’s PC Marchant. We’re police officers.’
‘I don’t believe you. I want the police here.’
‘We are the police. Okay?’
‘Show me proof.’
‘Sarah – I’ve shown you my identity card. You can see I’m in a police uniform. I think I’ve done everything I reasonably can to reassure you that I am in fact a police officer. So let’s move on and talk about why we’re here.’
‘You tell me.’
‘No – I’d like to hear your version of things, Sarah.’
‘If you were a real policeman you’d know why.’
‘Sarah – we understand there are concerns you might be unwell.’
‘Who told you that?’
‘The paramedics. And your family.’
‘Get out of my house.’
‘Who’ve you got in the room with you?’
‘No-one.’
‘That’s Kate, Sarah’s sister, and Daniel, her son,’ I say.
Sarah studies me again.
‘Daniel?’ says Sergeant Green. ‘Shouldn’t you be in school?’
‘He’s not going,’ says Sarah.
‘Why not?’
‘He’s staying here with me.’
‘I think he needs to go to school, don’t you?’
Daniel nods and stands up.
‘It’s a legal requirement, Sarah,’ says the Sergeant.
‘No.’
There’s a pause. Daniel suddenly says:
‘I have to go to the loo, Mum. I’m desperate.’
It’s such a natural and simple thing to ask, a son asking his mother for the toilet. She wavers for a moment, drops her arm. The bathroom is next door to the bedroom; the Sergeant nods for Daniel to come through, and holds the door open for him. Sarah suddenly realises that Daniel will be out of her control once he’s inside, but it’s too late. Daniel closes the door and throws the lock.
‘Come on, Sarah. Let’s go downstairs to the ambulance and have a chat there,’ says Sergeant Green. ‘It’ll be so much easier.’
She slides down the wall and sits in the doorway.
‘No,’ she says. ‘No.’
Kate steps over her to leave the bedroom.
‘I’ll wait for you downstairs, Daniel,’ she calls through the door, then passes us in tears down the stairs.

We review the situation with Sarah in the hallway. It’s clear that whatever the reason for Sarah’s acute onset psychosis, psychological or physiological, she lacks capacity and can’t safely be left at home. The only way to get her to hospital for the urgent treatment she needs is to forcibly remove her. We explain all this to Sarah in an effort to get her to walk out peacefully, but her illness prevents her from seeing sense.

Another police officer arrives in a van.

‘Come on, Sarah. It’s time to get you down to the ambulance.’
‘No! No!’
‘Come on.’
As the three of them go to help her to her feet she attacks them, flailing her arms and fists at their faces, baring her teeth. The officers are ready though and bring her under control, turning her arms first into locks against the wrist and elbow joints, then skilfully manipulating them behind her and cuffing them together at the wrist, whilst the whole time she screams and writhes and clacks her teeth together and does everything she can to escape. When she’s safely restrained on the floor, we all catch our breath. Sergeant Green tries to persuade Sarah to walk out, but when they relax their hold she launches herself up again, kicking her legs out, trying to wrest herself away and throw herself down the stairs. The police officers haul her back again, turn her on her front and bind her legs together at the knees and ankles with Velcro straps.
‘We’ll have to do a carry-out, feet first,’ says Sergeant Green. ‘If we take care of Sarah’s arms and legs, do you think you could control her head?’
On a count of three we lift Sarah into the air, me with my hands either side of her face, stopping her from banging her head into anything. She tries to bite my hands but can’t reach. Even though it’s a tight squeeze we make it down the stairs.
Kate runs back up to comfort Daniel as soon as she can fit past.
Incredibly, Sarah’s glasses are still on, hanging from her nose, about to fall. As we go through the front door I change my grip, freeing a hand just long enough to take the glasses and put them on top of the recycling bin to our right. I imagine our progress caught in the lenses as we pass: a strange group, lurching haphazardly out into the street towards a yellow truck, a blurry row of houses beyond.

15 comments:

Golden Psych said...

Just a quick question...how could the police forcibly remove her from her house? A 136 refers to a public place so I just wondered what grounds they forced her to go to hospital?

Cheers.

Spence Kennedy said...

Hi GP

She wasn't 136'd - or even arrested. She simply had to get treatment as there were strong grounds for thinking that her psychosis did have a physical cause. She certainly didn't have capacity, so we were bound to act in her best interest. The police used force to help us achieve that. Once she was at hospital, they left.

One of the most unsettling jobs I've been on. But even though it was painful, I'm confident we did the right thing. Not only did it give the medics a chance to address the problems Sarah was facing, it also gave the family space for any social service involvement that might be needed.

It's a sensitive subject, with all sorts of grey areas. But everyone acted in good faith.

Thanks v much for the comment, GP.

Golden Psych said...

I'm sure you were acting in good faith, it must be hard in those kind of situations where a patient refuses to go to hospital.

I just didn't realise that if no crime had been committed and if the patient was in their own home that the police could remove a patient.

Did you ever find out if there was a physical cause to the psychosis?

I can imagine sometimes it's frustating not knowing what was wrong with a patient. Or is it something you get used to?

Compostwoman said...

Gods. How horrible. For her, her family and for all of you involved in trying to help her.

I hope it had a good outcome. But am not holding my breath...

Spence Kennedy said...

GP - This is the first time in my experience it's happened like that. A very unusual circumstance, thank goodness. The fact that the patient clearly lacked capacity was the key, though. She simply wasn't in a position to make the right decision for herself (and she was also a danger to others).

Later on at the hospital, sepsis was confirmed as a factor, with some other stuff, too that I won't go into as it might make the case more identifiable. There was already some psych history for this patient, so the sepsis possibly caused an exacerbation of that.

Never getting a definitive outcome - or at least only rarely - is pretty much par for the course, unfortunately!

CW - Getting Sarah to hospital (even under such distressing circumstances) meant that she had a chance at recovery, so that was good. Just so long as the medics get on top of the organic side of her illness, I think Sarah has every chance of making a recovery - esp. given the loving family she so obviously has.

:)

JuliesMum said...

Woah, I was in tears by the end of this one. How horrible for Daniel, locked in the loo and hearing her being restrained next door. The way you described it, it did sound like he, and everyone else, was kind of used to things being a bit scary like that. Tough job for everyone.

Spence Kennedy said...

It must have been absolutely devastating for him, JM. At least he was spared seeing his mother bundled up like that (even though hearing it happen was probably just as bad).

I was so impressed with the way he handled himself, though. Despite the extremity of the situation, he was still able to speak up and try to reason with his mum, to try to encourage her to get help. I think he showed enormous maturity and self-possession to have managed as much as he did. Amazing, really.

Cheers for the comment, JM.

Anonymous said...

By coincidence there are a series of blog posts than link to this issue over at another blog I occasionally visit today.

Rather than put a link in if you search for "MentalHealthCop" in should be up the top.

It's called 'The Paramedic Series', might be of help to some readers or they might like to contribute to the discussion.

Spence if you think it worth while it might make a blog post of it's own?


[Belated apologies to Kirby for getting his gender wrong, that'll teach me not to view comments without switching to widescreen.]

Spence Kennedy said...

Thanks for the heads up about MHC, Anon. I'll check it out. As far as doing a specific blog post, though, I tend only to describe actual jobs, and then talk about any of the issues raised in the comments bit. But it's an interesting - and difficult - area.

Thanks again for the comment. Much appreciated.

Invictus said...

Oh my... my heart hurts for Sarah... and how frustrating to have her be *almost* logical, but not quite! She reminds me of a child, constantly asking "why", trying to interpret the world around her in a way that makes sense.

It's too bad she had to be taken out that way, but hopefully she can get some of the issues causing her problems straightened out. I hope for her sake, and the sake of her son, that she can make a return to functional. I have never had a parent with a mental illness, but I have friends who do, and it's horrifying.

Good job, Spence, both with the writing and with the real life scenario. That must have been a tough one.

Spence Kennedy said...

Thanks Invictus

The whole thing was absolutely tragic - and definitely one of the hardest scenarios I've had to deal with. Nobody wanted it to develop like that, but in the end it was simply a question of getting her to the hospital no matter what.

I hope her son Daniel gets plenty of support with this. He was incredibly brave and mature about the whole thing, but a terrible experience for him, and one that's bound to have long-term effects.

jacksofbuxton said...

My goodness Spence,I think a hearty well played to all involved with Sarah.Such a sad state to end up in.How on earth did she slip through the net?Is this a more common occurrence since the government cuts took place or was Sarah just one of those that got away?

Spence Kennedy said...

The police did a sterling job on this occasion, I have to say - unpleasant though the whole thing was. They were patient, restrained and thoughtful, making every step as clear as they possibly could.

I've simplified the whole job, of course. Essentially, Sarah had had a similar episode in the past (but not as severe). She'd had a great deal of stress lately, plus there was a strong suspicion that she was physically unwell, too. A perfect storm, for the whole family.

Cutbacks in the NHS are playing out now in lots of areas. Bed shortages leading to long delays at A&E, a lack of psych provision... you name it. A tough time generally.

Cheers for the comment, Jacks. Hope you're well. :)

uphilldowndale said...

Goodness Spence. What a difficult job that was. Tragic.

Spence Kennedy said...

It was particularly difficult, UHDD. Glad they're quite rare!