Monday, September 24, 2012

vera, first to last

If the first job of the night points the way to the rest of the shift, I may as well go home now.
I call Control.
‘I was just wondering how many ambulances Vera has had today.’
Control doesn’t have the information to hand. Which is surprising. Vera is so prolific, you’d think they’d have a big portrait on the wall, where the eyes flash when she calls and a big electronic counter flips round.
We don’t run red to the job, because in all conscience we do not want to put any other road users at risk unnecessarily. We probably miss the Category A time, which in auditing terms makes whatever happens next a failure, but then of course everything about this job is a failure. One frail old woman, the resource profile of a major incident, money wasted, nothing done.
Even if a multi-discipline meeting between health, social services and the housing trust cost a couple of thousand to organise – even if they held it in the plushest hotel with the finest coffee and biscuits, free gold pens and a table magician – if they finished the day with a handshake and a workable solution it would still represent a saving of hundreds of thousands.
But if there’s one thing Vera is good for it’s to demonstrate the fatal lack of continuity in the system, the lack of resolve between the various agencies. Despite being a prodigiously expensive irritant to everyone from the carer to the local GP, Vera still gets endlessly wheeled around and around, insulting and assaulting and goading and absorbing and causing havoc as she goes. Defiantly untouchable.

Vera is sitting in her chair watching TV: Fiona Bruce investigating the life and works of J M W Turner.
‘I’m in pain! I’m in pain!’ says Vera, over and over, but her eyes remain as hooded and watchful as they always do, her hands placed lightly on the arms of the chair. Vera has three distinct voices – the first and most used is a piping-falsetto for pain and distress; the second is a lower, huskier tone for threats, insults and instruction, the third is the least often heard - a wheedling kind of whisper, for saying how sorry she is. She seems to use each voice instinctively, blindly sensing the advantage in the air. She is like some malign porcelain doll, playing through her voices on a loop until she gets what she wants.
She looks sideways at me and says in Voice Two: ‘Don’t you mess my sofa up.’
The carer is trembling, red in the face, putting her coat on.
‘The other ambulance crew only left about half an hour ago. They’d talked to the out of hours doctor and she’d arranged for a visit later on. But then Vera picked the phone up again. What can you do?’
‘Unplug it?’
The carer smiles as best she can and then shrugs. ‘She threw a can of coke at me, you know.’ she says. ‘Anyway. It’s all logged. Do you need me for anything else? Only I’m behind on my calls.’
She leaves, with a grim, backwards nod to us from the hallway as she closes the door.
We turn our attention to Vera.
‘I’m in pain! Help me! You’re not doing anything!’
‘Where are you in pain, Vera?’
She flutters a hand over her middle.
‘My chest. Around my heart. My legs. Help me!’
Rae picks up the last ambulance sheet to read what actions they took.
Fiona Bruce is in Margate. Apparently Turner had a mistress there. She holds up an old photo, and points to a house marked with an X.

‘Turn that off,’ says Vera. ‘It’s my TV. Turn it off. This is my house. Get off my sofa.’
As she talks she reaches to the table at her side and another can of coke.
‘Don’t you be throwing that, now,’ says Rae, lowering the ambulance sheet. ‘I’m serious, Vera. If you throw your coke at us we’ll have the police here to arrest you for assault.’
Vera withdraws her hand.
Voice Three: ‘I wouldn’t do that. You’re such kind people. I wouldn’t hurt you.’
‘Didn’t stop you throwing it at that poor carer, though, did it?’
‘I’m in pain! I’m in pain!’
She carries on crying out whilst we decide what to do. The most common way of dealing with Vera is simply to load her up and take her in. It’s the most emotionally aerodynamic method. Everyone has attempted to go down other routes, but it gets more and more tortuous and anyway the outcome is always the same – another call from Vera, another attendance. The dull, default position is that if emails, phone calls and reports are ineffective, maybe constant appearances at A&E will inspire some other more definitive action. But it’s the beginning of the shift, we’re fresh and optimistic and still up for an attempt at the right thing to do.
Rae calls the out of hours service. The doctor tells us not to take Vera into hospital. Someone will be with her in an hour or so. I call Control to log the discussion and our visit, but the Dispatcher routes us through the Duty Despatch Manager, who refers us to the Duty Com for a discussion about the implications of the call. The worry is that Vera may actually collapse with an MI or something, and as the last clinician contact, we’d be liable. After all, Vera is complaining of chest pain. It might be real this time. Her ECG does show some anomalies, the kind of thing you might expect to see in an elderly woman, but still, not perfect.
‘Emphasise the concerns you have about her mental capacity,’ he says. ‘We’ll log everything and see if we can sort it out in the morning.’

Fiona Bruce is standing on the sea wall at Margate, holding up a laminated copy of one of Turner’s paintings, trying to identify the landmarks.

I glance across to Vera. She has the phone in her hand. Whilst I’ve been chatting on the mobile to Control and Rae has been writing up her sheet, Vera has dialled 999 again.
‘Yes, I know, we are still here,’ I say to the Duty Com. ‘I think she’s going for a record – how many crews she can fit into her sitting room at the same time.’
We take her in.


Behind the nurse station at A&E majors, the bed board is as busy as the Tote on Derby Day . Our arrival with Vera is greeted with a dismay bordering on hysteria. It transpires Vera currently has an ASBO served on her for racially abusing staff, the result being that only white Anglo-Saxon nurses can attend to her. As a political move more than anything, we’re bumped round to minors where there are fewer BME staff working tonight.
The nurse running the desk there is dabbing a tissue at her eyes and nose.
‘Shall I give you a moment, Stacy?’
She looks up and smiles sadly.
‘Nope. No. I’ll be okay. Phew. Now. How can I help?’
‘I can’t tell you how sorry I am to bring this patient to you.’
‘Who? What do you mean?’ she says, straightening a little.
‘Jesus Christ!’
For a second she flames as brightly as a roman candle. But the white heat of her anger almost seems to cauterize the sorrow that was overwhelming her a second ago. She takes a deep breath; her fire burns blue and cold. She reaches up and gently brushes a strand of hair away from her forehead.
She calls out to a young HCA called Steve, one of only a few staff in the department who are able to deal with Vera.
‘Guess who’s in again,’ she says. Steve slowly puts down the sheets he was carrying, and walks over.

In the A&E reception I get some stats: one hundred and seventy five A&E attendances this year alone, which necessarily means at least double that in ambulance call-outs, five of those tonight. We drive back to base to complete the paperwork – an untoward incident form, a vulnerable adult form, supporting emails and faxes – any angle we can think of to raise Vera’s profile and get something done. Three hours start to finish. We have a cup of tea, realign ourselves with the night, and carry on.


Half an hour before the end of the shift, we get our final job.
Exhausted, we make our way back into the cab. Read the MDT.

Rae drives.
There’s no conversation, none at all when we turn up at her flat. We are clinical operatives, delivery people. We put her in our chair, load her onto the ambulance. She toggles through all of her voices, desperately looking for an angle, a point of leverage, but we are cold to her.

The department has pretty much emptied when we go in through the automatic doors.
A black cleaner working his broom in tired loops.
A Filipino nurse.

Vera watches them both.


Alexia said...

I've read all of your posts since I first discovered your blog, Spence. Some of them have made me laugh, some have brought tears. Many have depressed me. I think that this one is possibly the most sad, depressing and helpless one of all.

Kia kaha.

Spence Kennedy said...

Hi Alexia

Well - there are so many sad and depressing aspects to this particular story, it's hard to know where to begin!

At the centre of it all: Vera, a lonely, confused and at heart quite embittered individual, I think, who has fallen into this awful pattern of behaviour and doesn't seem able to break out of it. I know it doesn't bring her any pleasure. I just wish there was some way of helping her out of the loop. But at the moment, she's been tested for mental capacity - and passed - so there's no quick and easy solution.

She's surrounded by caring and well-meaning people. Although it's also true to say that many have turned against her over the months (and years), worn down by frustration and plain tiredness.

She's getting worse. Her racist behaviour is just another facet of her tendency to look for ways to cause trouble and wind people up - but having said that, of course, it's completely unacceptable and deeply unpleasant to witness. Ultimately I think she'll fail the competency test and be transferred to an EMI unit or similar. Which might actually improve her chances of happiness. It would certainly be more cost effective.

It's probably not a good article to write fresh off a series of nights! Your light burns a little lower until you make the adjustment.

I promise I'll make the next one more upbeat, Alexia! Thanks for reading all this time (and commenting).

Hope you're well.

SK :)

Baglady said...

Fantastic writing as ever Spence. I work on the frontline of accounting (m'noh yes) so it's always good to read something of the real world, as frustrating and painful as that might be.

R said...

Gee whiz. Why on earth has the aforementioned multi-disciplinary team meeting not happened?!

It seems unbelievable that she could be given an ASBO, but not have this incredibly challenging behaviour pattern addressed.

In general, I deplore day centre type services - they're overused, tend not to meet individual needs well and erode choice and independence - but Vera needs not ever to be left on her own, or find herself with nobody to talk to... and some sort of day service could help a fair bit, there.

Charmaine said...

A champion of manipulation...

jacksofbuxton said...

There is,of course,the chance that eventually Vera will see the wolf.In the meantime however I'm going to revert to my default suggestion.

Rubber gloves,Davey Lamp,hose,clamps,monkey wrench,orbital sander.

"Now this may smart a little Vera...."

Spence Kennedy said...

Thanks Baglady!
I can imagine Accounting being a good job, though. My sister in law's an accountant. She used to work for a big firm, but then went self-employed, helping local businesses in her area &c. It'd be great to have a skill like that. I can drive, balance a broom handle on my chin and that's about it.

Becca - Absolutely NO idea why this meeting hasn't happened! The whole scenario is completely unbelievable - which is another reason why Vera's particularly difficult to handle. I agree about Day Centre activity. I'm sure it's been put her way (but I'd bet the Day Centre barred her from attending for obvious reasons).

Jacks - When Steve the HCA was helping us transfer Vera to a trolley, I asked him if The Sopranos really existed, and if they did, would he have their number. It transpired that Steve is actually a huge Sopranos fan (like me). He's even been to New Jersey and been on a Sopranos tour (which would be interesting if a little nerve-wracking - esp. a visit to Satriales Pork Store).

Thanks for the comments... :)

petrolhead said...

What an impossible situation. As much as I deplore the waste of money, services, time etc. Vera has caused, I can't help but feel sorry for her. She must be so lonely, if all she cam think.of is to phone 999 constantly. I do hope something can be done.

I have been reading your blog, Spence, just not found the right words to comment!


Spence Kennedy said...

Hi Petrolhead

I feel sorry for Vera, too (when I'm not actually in the same room...) I think Vera's been let down by the system, just as we all have. I have to say that for a system that's supposed to cover all eventualities, it's strangely inflexible.

I have no idea why she behaves like this - but then, I'm not sure she does, either. It's just a terrible pattern of behaviour she's fallen into that superficially gets attention. Ultimately, I don't think she's happy - and it's a copper-bottomed fact that no-one providing her care and support are happy, either. Someone, somewhere needs to grasp the problem and find a solution. An ambulance crew? Well, we've tried! But when nothing gets done, all that's left is to make yourself into a resilient and self-protective little ball and bounce, bounce, bounce.

Thanks so much for reading the blog all this time, PH. I appreciate it. And I don't mind if you don't comment. It's good to know you're out there...! :0)

Steve'nLubbock said...

Here in Lubbock, TX, USA, we have the same problems. I'm just a resident in an apartment complex for 'older' folks, but there's always one or two who get lonely and call for EMS, when they could go out into the common area and visit. But then they wouldn't be the center of attention, would they? So sad.

tpals said...

I couldn't comment when I first read this - too frustrating! And I don't even have to deal with her.

I hope writing about it helps you cope. :)

Spence Kennedy said...

Hi Steve
I'm sure loneliness is a factor. But then Vera does get carers four times a day, plus a friend who visits pretty much every day, so that's quite a lot of attention already. Her calling for the ambulance seems to fly in the face of all reason; I'm not sure she could explain why she does it. It's a bad habit, and she needs breaking out of it. How, I don't know - beyond our scope of influence, anyway. All we can do is keep reporting our concerns / turning up / taking her in. Hrrmph.

Hey Tpals
Writing about it does help - I can feel a little more objective about the whole thing. There was that other time I wrote about Vera where I just threw myself down on her sofa and said something like: this can't go on!. Utter despair. Esp. in the early hours when you're fund of patience is decidedly overdrawn. Who knows what will happen? (But it's quite plain what a lot of people hope will happen...) Not a nice situation, when her final years could be happy and productive.

Thanks for the comments.

InsomniacMedic said...

There must be a Vera for every ambulance service in the world.

Heartbreaking, infuriating, mind-numbing, threatening, frustrating, all at once.

And then some...

Great writing as always.

Spence Kennedy said...

One of the most infuriating aspects of the case is the feeling that if someone really focused their attention on her, really looked into the reasons why she's behaving like this, a solution could be found. I think it makes good, practical & financial sense to target Vera and people like her - and I'm completely confused why it isn't happening!

Cheers Insomniac. Hope things are good with you & yours.

Wordfiend said...

She really reminds me of someone with a personality disorder, possibly Borderline or Dependent, which usually improve with age, but in her case hasn't. The desperate or compulsive need for attention, possible fear of abandonment, manipulation, threats, and mercurial mood shifts. Absolute hell to deal with.

Spence Kennedy said...

That's an interesting reading of Vera's situation, Wynn. It sounds spot on - esp. that bit about being hell to deal with!

Unknown said...

Hi spence, we have a Vera in the care home, boy can she test the patients of a saint!!! I have a lot of time and patience for ppl, especially with dementia, but her..... but you have to be professional and I do feel sorry for her as she's such a nice kind hearted lady of 96. She does, however, take her meds, talk to the staff and behave impeccably when she has visitors!! Apparently she has capacity but maybe borderline dementia according to the experts.... hmmmmm we know different. And she's the same with the buzzer as your Vera is with 999....

Spence Kennedy said...

Mental capacity is an interesting area, to say the least! Half the time you're left wondering if their behaviour is evidence of a lack of capacity, or simply anti-social behaviour! If Vera had been in a home, at least it would've given 999 a respite. Vera was such a huge drain on resources. I did feel sorry for her - when I wasn't dealing with her - but she was definitely one of the most difficult patients I ever dealt with (and that's saying something!)