This was initially submitted as a comment by Joanna in response to my previous post. However I felt what she said was so important that she's kindly given me permission to post it as a guest post in its own right.
A very high percentage of presenting issues to A&E could be defined as ‘self-inflicted’ through lifestyle, addiction, or choice of activity. The there are people who use A&E as an alternative to GP’s or common sense. Yet how come I’ve seen the Friday night drunks hurling abuse at the nursing staff addressed as ‘sir’ whilst me only speaking when spoken to never daring to enquire about the waiting time is not treated with the same courtesy? How come people needing alcohol induced liver transplants requiring a donor, surgery and lifelong treatments are not endlessly lectured about the cost of this which I’m damn sure has to rival 30 mins suturing? Even plastics repairs would not even dent the cost of smoking induced COPD treatment and palliative care over 20 years. Then of course people chose to do dangerous sports but no one complains about the resulting orthopaedic or neurological surgery and care required to put their bodies together.
Self-harm is not a ‘choice’ for me in that I derive any pleasure from it [at least with smoking/drugs/alcohol there is some positive pay off].
Although being fat is a much maligned self-inflicted state at least there are is bariatric surgery and the associated support services such as dieticians. I couldn’t see an NHS dietician with for osteopenia and vitamin D deficiency which I have not induced.
I believe everyone should be treated equally, irrespective of whether we perceive actions to be stupid, lazy or totally out of a person’s control. I believe everyone should have equal access and that any rationing of services should be openly discussed and voted on and not done by stealth. Health should never be based on value judgements because when it is – that creates more health issues – when we are made to feel worthless we are more likely to end up back with the pissed off nurse/doctor. The way I’ve got this across in teaching is to ask staff – do you want to be yet another form of self-harm? If you do, carry on, if you don’t let’s have a think about what helps and what hinders and if you can’t deliver because you can’t get past your own emotional response or prejudice then please do not treat those patients but with the corollary that you have to find someone who can. You can either be part of the problem or part of the solution, you choose.
Yes, a great comment. I completely agree about sports injuries and so forth, and that everyone should be treated equally, but I completely disagree about the way to deal with staff. They shouldn't be permitted to choose to be part of the problem. They need to be shown how to behave (not just told, but actually shown), they need emotional support for the times when they can't cope, and they need to be sacked if, after all that, they can't deliver. The NHS mostly fails to do any of these three things.
ReplyDeleteBy the way, the Department of Health's NHS Future Forum is consulting the public on the education and training of health and care professionals. You can make your views known by commenting at Educating and training of health and care professionals or in any of the other ways listed at Future Forum: have your say. The consultation closes at the end of the month.
I’d prefer not to be treated by someone through gritted teeth so what I’m suggesting is those staff who are intractable to further support & training [and some are] are better off working with other patients so we are not exposed to iatrogenic damage. For a stubborn few, no amount of coaxing or demonstration makes any difference so they need to be removed from patients where they could do harm. We can only teach so much.
ReplyDeleteI've said this ad nauseum in the past and I'm going to say it again: You can not train someone to treat people as human beings, and anyone who needs that sort of training should not be in a caring role.
ReplyDeleteI have had the privilege of sitting waiting in a cubicle while three or four staff outside the curtain stand there and argue loudly over who doesn't have to stitch me. Did wonders for my self esteem, that...
It's experiences like that which lead me to doubt myself when I feel I need treatment for injuries; why I don't always go when I should, why I sometimes ask for reassurance from friends before seeking help, and why I sometimes [shamefully] end up actually overusing services e.g. going to a practice nurse or walk-in centre for a repair only to be told to go on to A&E instead of just going to A&E in the first place because I need to hear someone justify it to me that I should be there.
If a nurse or doctor has a particular aversion to self-harm then yes it's shit and yes they clearly need retraining and I believe it raises questions why they're in that job in the first place. As Joanna pointed out, a large proportion of A&E attendances could be seen as 'self-inflicted' in some way [e.g. sports injuries]. But if I could walk into an emergency department and know that whoever I see is going to treat me with respect and just like any other patient, it would make the world of difference. So yes, if there was a way to allow a member of staff to 'opt-out' of treating people who have self-harmed if they really disagreed with it, I'd welcome it. At least then I'd feel I could seek treatment and not be worried about whose shoe I'm going to need to scrape myself from by the end of the visit.
Off topic - Is "5 Quid for Life" still going? I don't see that anything's been updated on their site since July ...
ReplyDeleteAdventures in Anxiety Land
Hi BM, yes 5 Quid For Life is very much alive and kicking! I've heard rumours of an epic 5-hour-long meeting earlier on today; I'm sure we will hear of an awesome update soon:
ReplyDeleteThe 5QFL Website
The 5QFL Facebook Page
I'm a final year medical student so read this with interest. First off, did you know that guidlines dictate that every single encounter with patients with 'poor social habits' such as smoking, drinking, or obesity, must include advice to stop, education about risk of what they're doing, and arrangement of assistance with this?
ReplyDeleteThe problem with accident/emergency is that it's effectively a holding house until patients can be transferred to the right specialty. A and E staff aren't experts in treating liver failure, or COPD, or fractures, or self-induced injury - the psychiatrists are, and that is where patients will get the best care, from people with greatest interest and affiliation with their specialty. I'm not excusing people who are poor at communicating and give more harm than good, but at the end of the day, their job is to be the first point of contact, treat immediate stuff, refer on, and then start on the next patient. They chose that area because they like high patient flow, practical procedures, and variety - which is what A/E is.
Also, remember that you can complain if someone is an idiot - and it's actually the best thing you can do, as otherwise things won't be change. You can be part of the solution, too.
I’ve lectured to medical students Anonymous and have received feedback about training in different schools which varies considerably. Psychiatric lectures on self-injury [at the worst] have included consultant psychiatrists telling undergraduates such as yourself that ALL people who self-harm are ‘generally horrible people with no hope’ and that they ALL have Borderline Personality Disorder. They have also made statements such as ‘these people do this..’using the wrist cutting gesture I kid you not, a good friend noted these lectures verbatim in her 4th and 5th years. She also gave me chapter and verse on her psychiatric placement with examples of teaching and practise which defy belief such as a consultant not even knowing diagnostic criteria. Now not all medical schools are as dire as this, the one I’ve lectured in is very good and I know some of the psych lecturers personally, that school fares well. However, you’re mistaken if you believe that psychiatry are the best speciality to address self-harm/suicide. If you read some research papers which look at staff attitudes you will find that liaison psychiatry can add insult to injury quite literally with A&E staff exasperated at their complacency. An example of this is and A&E member of staff contacting liaison expressing concern for a patient to be met with the response of ‘oh yes we know her, she’ll probably kill herself but don’t worry you’ve got all your paperwork in order’.
ReplyDeleteLiaison and psychiatry’s response to self-harm is renowned as very poor, on a doctors website post the 1st set of NICE guidance there were posts stating how people who self-harm should be charged for treatment. Psychiatry is well aware of its lack of effective response and liaison assessments are often a tick box means to no end exercise.
Accident & Emergency does treat people as well as acting as a holding house, and for a proportion of patients A&E is their only point of contact with services for self-harm. At the least A&E is capable of suturing a wound when it is an external injury, and sometimes even that falls short in a variety of ways which would require a full blog post for me to fully explain. It’s not only about communication, it’s also about clinical assessment and treatment. Even with OD’s, before transfer to a medical ward or the liver unit whilst bloods are taken and IV’s are being set up they can make a disaster out of a crisis, again in more ways than I reply here. There are clinical issues.
As for complaining – er no – that can be the worst thing a patient can do if they are going to go back to the dept, and I always advise against it because it goes against you in many different ways [it can seal a diagnosis of BPD for example] aside from the fact that complaints procedures and anything even vaguely looking like litigation/negligence to a Trust illicits a shut down the ranks response – remember people with psych history are not viewed as having the same credibility as other patients. Ask any solicitor which cases are the hardest and they will tell you - medical negligence, even lower level complaints go nowhere – it’s amazing what gets lost or changed. The best protection is – advocacy – have someone with you to bear witness, explain, facilitate, and better communication makes it easier and safer all round. Then some form of advance statement – crisis card, letter from a mental health worker for A&E staff regarding treatment for self-harm, i.e. what will help the patient and staff. If anything it’s far better to write to service managers about decent treatment, explaining why it was helpful, what difference it made, because A&E staff don’t see what difference it makes.
Hi anonymous. No I didn't know they were supposed to talk about those things, and, other than when talking about it in terms of eating disorders [or not, see here for more about that] I've never had anyone in A&E talk to me about obesity. But then, isn't it also the guidelines that staff use some kind of pain relief when stitching wounds? and in my own experience that's horrendously rare [see here for my thoughts on that].
ReplyDeleteYou're telling it like it's supposed to be; the reality is quite different.
I do always try to tell staff when something has gone right, and most seem to appreciate it. I would never complain for the same reasons Joanna has outlined above, but I do try to talk to staff [if I'm able] and let them know when things have gone well. And it's not always just that people are idiots, I can handle an idiot, but some staff are downright cruel.
I don't go to A&E for psychiatric support. I go if I need a physical repair, that's all I ask of them and the only time I accept anything further is when it is forced upon me [with threats of police, sections etc if I do not comply]. And even if I did want that, the point of me going in the first place is still the injury and I don't think I'm asking too much if I want to receive adequate treatment the same as someone else would who had an accident putting up shelves or going skiing. I never ask for more than that, I just want to be treated the same, with a bit of dignity and respect.
anonymous again - for the wound stitching, often it's actually the case that injecting local anaesthetic is more painful than the stitches - so a bit arbitrary - which is why they're not always used.
ReplyDeleteI am something of an idealist; I will defend the NHS as long as it's going, and I love that we treat everyone regardless of ability to pay. As someone who spends an average of sixty hours per week in hospital, I am of course aware that some things do need to change - and would just stress again that most hospitals, and staff for that matter, welcome valid complaints and suggestions - and if you've got a second person who supports any view of poor treatment, all the better.
And I understand that you don't attend for psych support - but by the same token, all health problems, to some extent, have biological, psychological and social components and staff are just doing their job when they ask if you want further assessment - they're being thorough, as self harm, whether controlled or impulsive, has a psychological component, unlike an injury from putting up shelves.
Anonymous:
ReplyDeleteActually, no. It is not the case that injecting local would be more painful - not when the doctor draws up the lidocaine then leaves it on the side while laughing at you or smirking when you wince or saying you deserve it or teaching student nurses you shouldn't be feeling pain anyway as it was a self-inflicted injury, and then of course making sure to write in the notes that local was given. I do know of some occasions where it would be deemed acceptable to say it's not worth giving local and I would [and have] gone along with this, but these occasions are NOT what I refer to when I talk about doctors withholding pain relief as a punitive measure.
Like you, I also defend the NHS and what it stands for. And like I said before, where I can I always try to inform those involved when things have gone right - I say "where I can" because it's often the case in A&E that I can barely speak due to distress, but believe me I tell them when I can.
However what I will NEVER defend is cruelty for the sake of cruelty; treating people like animals [or worse]; viewing people as worthless just because they have what is deemed a socially unacceptable way of coping with extreme distress.
Yes you do seem to be an idealist. Even just today I have been privileged to hear personal accounts of treatment within emergency departments which you probably wouldn't even believe, it's that horrific. It's OK to have a positive view of things but please [this is a real plea on behalf of your future patients] don't let that idealism turn into rose-tinted glasses where you can't even believe such horrific treatment occurs and you actually try to find reasons to excuse it. It does happen and it continues to happen and sadly places like this blog are the only places some people can talk openly about such experiences. Either we are not believed or it is made light of or if we do complain we get far worse treatment the next visit [or refusal to be treated at all].
When I said "I don't go to A&E for psych support" I was referring to your previous statement that A&E is a holding house for the psychiatrists. I understand there are certain procedures staff must follow [although these are hugely inconsistent, but that's a whole other discussion...] and where I'm able I do comply with staff's requests. For example: I will explain to staff that a psych assesment is not beneficial to me and will actually be damaging in the long term [including reasons why, thanking them for the offer etc etc]. However if staff insist, I *will* sit and wait and endure the psych assessment - purely because it just makes life easier to go along with it and prevents things like police breaking in to my home, section papers, etc... BUT: my point was that no matter what the secondary treatment that may or may not be given such as psych intervention, my primary reason for going is physical repair. And no matter what else happens or is offered during my visit to A&E, I surely deserve to be treated with the same respect and dignity as someone who injured themselves putting up shelves.
That is all I've ever asked; some people have said in the past that online I come across as demanding, perhaps a troublesome patient, that I would kick up a stink if I wasn't treated like royalty. That is absolutely not true at all. All I ask is that I am treated EQUALLY, that I receive the same standard of care as anyone else. Isn't that all anyone would ask?
For 2-3 sutures yes Anonymous [but even that should be with the patients consent], but not for 20-30 sutures, not for 15 staples, that is not clinically justified.
ReplyDeleteNeither is doing so but recording in the notes that LA has been used, or injecting LA into one side of a wound and not the other so half the suturing is felt and shouting at the person when they flinch. The RCP, BCSW and other surveys have repeatedly shown that the withholding of LA and inadequate administration of LA [more than 3 sutures] is not that uncommon. When you are told directly that it is being withheld to ‘teach you a lesson’ or that pain relief cannot ‘matter’ because you were able to bear the pain of the injury it’s pretty clear what is happening and that is never defensible clinical practise. There are many ways in which people can be put in pain as a punishment or in the mistaken belief that this will ‘deter’ a person from injuring again, such as plastics ripping off Jelonet dressings which have adhered to the wound bed after 2 days before surgery without bothering to get a few sachets of saline to soak it off. It’s not pleasant when fat ends up being torn out with the dressing and the surgeon can see how painful that is, for want of a bit of saline.
Before NICE guidance reviewed the use of gastric lavage it was known how that procedure could also be used punitively i.e. used beyond the point at which it would be clinically useful. Some of us do have some knowledge of proper medical practise [I’ve worked in the health service].
I’ve experienced being discharged after a GA vomiting in front of nursing staff and having to ask for a bowl to walk out with, since when were patients discharged after surgery still vomiting? Imagine experiencing the above and much more over many years - it doesn’t have to be this way because when depts have a more positive approach it makes for better job satisfaction as well as helping patients, and I want staff to feel better about what they are doing too.
I too defend the NHS and support [what should be your right] to less working hours per week with adequate support and supervision. It is hospital Trusts which don’t deal with complaints very well as opposed to individual staff, this is well known and to suggest otherwise is not idealistic but naïve, see only today: http://www.bbc.co.uk/news/health-15340914
It’s very difficult for people to complain when they have been effectively physically and verbally assaulted and left feeling worthless. There’s no denying psychological aspects of self-harm, but the fact that self-harm is an expression of mental distress means that it is less likely to be taken seriously, there have been many cases of complaints going nowhere, which is why I always suggest to write in about the positive experiences because they have a greater chance of being heard so that managers may consider well if this is a better approach then let’s encourage others. Consistency is key here and lacking.
The psychosocial assessment is not thorough or thought out, it’s simply Trust policy and a tick box list, most patients experience little happening from it.
A further point about psychosocial assessment – it is not acceptable for patients to have treatment within the dept withheld or made contingent on that assessment happening first [this doesn’t happen with overdoses]. If you attend A&E with a fractured leg, you are x-rayed, the fracture is treated in the appropriate manner and you go home with an appt for the fracture clinic or are transferred to the orthopods. You are not expected to fill out a health & safety questionnaire about the cables you tripped over in your office resulting in the fracture and how you will prevent this from ever happening again before any assessment and treatment of the fracture.
ReplyDeleteIt’s ludicrous for patients to sit there watching the surgeon in the dept they know they will need to see because they are waiting on 3-5 liaison questions which are not about enquiring about what has happened to a person emotionally and what do they need. Some will clearly state that they don’t care what people do to themselves, they just have to find out if they’re suicidal or not, because self-harm assessments are suicide/does this person need an admission biased, they could effectively just hand a person a list to tick. Not all depts are this bad, but enough are.
When I made a formal complaint years ago I had 3 witnesses [over 8 hrs] to my poor treatment [one a nurse] and my complaint still went nowhere, no one apologised to me. It was very stressful process over a year which culminated in a meeting with a consultant who wouldn’t let staff speak and addressed me as “missy”.
I guess the answer lays in taxes! Sport, alcohol and tobacco all generate more than they cost. Self harm doesn't.
ReplyDelete