Sunday, 18 July 2010

No Answers

Saturday night, the scourge of all police officers and ambulance crews. These days, all nights are busy, but weekend nights are often like being in a war zone. Trust me. I've done both. Sometimes I think that it was safer in the other one. As I work only nights, my weekend night shifts come round more often than most, and without fail, I regret them.

A list of a weekend night's proceedings often resembles a list of the wives of King Henry VIII. Divorced, Beheaded, Died. Divorced, Beheaded, Survived.

A Saturday night on the street runs something like this: Drunk, Assaulted, Trashed. Drunk, Assaulted, Crashed. The last of these might only appear once a night. If that. If you work in the centre of London, there are probably even fewer. I work out in the suburbs, so there's a chance that once the pubs, clubs and fast food shops have shut, I may actually have to treat someone who genuinely needs an ambulance. By that time, I'm tired, cranky, and struggling to give them my best attention and care. That which they genuinely deserve.

Last night, I tweeted about treating drunks, by asking a simple question. Do you think that people who call ambulances because they've had too much to drink, should be charged?

All dozen or so replies were positive. Some just said "Yes". Someone said "Yes, without a shadow of a doubt". And one even went as far as saying "YES!! YES!!!! A THOUSAND TIMES YES!!!" It seems that I received some support for the idea.

It's a knee-jerk, almost default position by health care professionals, and even some who aren't in the medical field at all: You're drunk. It's of your own doing. You should know your limits, or suffer the consequences. You don't need an ambulance. You don't need to be in A&E. And we most certainly don't want to be the ones who have to clean up all the bodily fluids you emit in your sorry state. Therefore, we all want to charge you. I'm as guilty of it as the next person. Not so much the drunk bit, but the wanting to charge bit. But there's a problem with this thought, once taken to one of its logical conclusions.

We should charge those who overdose on drugs. The heroin addicts who should know their limits, but who take a little more than their normal amount, end up not breathing, and who we administer Naloxone to to get them breathing again, ready for their next hit.

We should charge drunks who wonder out into the middle of a busy road and get hit by the car whose driver had no chance of avoiding them. Or by the same account, charge the drunk driver who's hit the lamp post that's sat on the pavement for years, but suddenly jumped into the middle of the road.

We should charge the wrist-slitters, crying for attention at the age of 18 after being dumped by the love of their lives, and who next week will have another life's love.

We should charge drunks who we convey not for being drunk, but whose drunken state has led to some sort of illness or injury.

We should, therefore, charge anyone who should have had some degree of responsibility for their own presenting condition.

Smokers with emphysema? Charge.

Footballers with broken legs? Charge.

Diabetics with high blood-sugars? Charge.

So how far do we take this knee-jerk reaction, this desire to charge drunks? Is it a question of all or nothing, in which case we charge everyone, or do we continue as we are, charge nobody, and just have to keep putting up with it, whilst we all, as taxpayers, foot the bill? Once upon a time, drunks were taken to police cells, given a mattress to sleep on and sober up, generally ignored, and were then sent home in the morning. Just that cost money.
Now, they get an emergency ambulance, often accompanied by the FRU, as they are frequently supposedly unconscious or not alert. If they're in town, they might get the dedicated "booze bus", a multiple-patient-transporting, baby-sitting service staffed by EMTs and paramedics who are clearly a lot less averse to dealing with alcohol-induced vomit than I am. They get a hospital bed, an overworked nurse, a disinterested doctor, and sometimes a bag of fluids as well. All very often whilst abusing those who are caring for them. And that's if all they have is a serious case of overindulgenceitis. That's a lot more expensive, and a lot more frustrating, which is part of the reason we feel that we want to charge. But is it right? In the overall spirit of the NHS, free to all at the point of treatment, can we really justify it? And if we are going to start charging, who do we charge, what for, and how much?

I have lots of questions when it comes to charging drunks.

I just wish I had some decent answers.

What do you think?


Anonymous said...

I think it's getting to the stage where something will have to be done. I, by some bad luck, ended up at St Thomas' hospital on a Saturday night shift not long ago. I work a long way out of town, it was just one of those nights. All but 2 of the patients there were drunk. The department was full - maybe 50 patients, only 2 of whom were sober. That is a disgraceful waste of NHS resources - the vast majority of those patients needed to bloody pull themselves together and go home to bed. It's ridiculous...

Anonymous said...

Ok... I think the simplicity has been lost in the justification.

The only time an ethanolic person should be charged for an amb is if they are so drunk as to be unable to get themselves home in order to sleep off their drunken stupor. These people don't require hospital. They require educating as to their responsibilities when out on the razz. To suggest that a pt with COPD as a result of their smoking habit be charged is ridiculous as is the suggestion that a drunk person be charged if they get hit by a car and require an amb.

Contrary to most medical issues, this one is clear cut. Black and white. No grey areas.

If you are so drunk as to be unable to make your own way home and an amb is called for you - you get charged. Simple...


Sharp Incisions said...

Along the lines of what Anonymous said, would a reasonable policy be charging anyone who calls for an ambulance without an in-good-faith expectation that the situation constitutes a medical emergency? You'd need to lean on the side of assuming they did, and it'd be difficult to administrate, but in principle, that seems like a reasonable idea to me.

Kath said...

Great post. In my first 6 months on the road I followed a similar train of thought, with the same conclusions. It seems clear cut to be judgemental about drunks, but beyond that there’s so much grey area... I thought you illustrated this well. And I think the fact of the matter is that if you start judging some patients, you start judging them all. And before you know it you’re with an overweight patient who’s smoking in your face as they complain of chest pain and you find yourself thinking that it’s their own fault. There’s too many ambulance staff who basically dislike all of their patients, except tiny babies and maybe very old people, and I think they end up in that state because they can find blame with everyone in between. It makes for some pretty uncompassionate care, but I can see how they get to that point – I think it’s easy to slip there unless you’re paying attention.

When I’m not working I go rock climbing out in the country. I know it’s risky when I’m clinging on 6m off the ground trying to put a first bit of gear in to attach myself to – I know that if I fell off I’d damn well want a spinal board. And if I did, I’d presume that the lovely mountain rescue folks would have my back, and hopefully the Air Ambulance would nip down and get me, and I’d be straight into Resus at our trauma hospital. And from working in both the ambulance service and Resus, I’m pretty sure I’d get treated well and get seen as a ‘proper’ patient. But when it comes down to it, I take it upon myself to climb up bits of rock for fun, take risks and presume that other people will pick up the pieces at great expense if something should go wrong. I try to remember this when I find myself deciding who deserves me attention and sympathy. Maybe all ambulance workers should have a stupid and reckless hobby to keep things in perspective...

SaintPara said...

Tis a very grey area. I think Anon2 has oversimplified massively here. What about the asthmatic whom we blue into hospital nebulising them on the way only to find them, as we drop off our following patient, standing outside smoking? It is very difficult to come down on one group of people and not another....

I don't think the NHS will be able to charge for drunkeness. It is an absolute minefield. While, like InsomniacMedic I too have a part of me that would love to see us charge them for the time and effort we put into them just because they had one (two, three or more) too many and are now so blended they can't get themselves home I do think it may well be unworkable.

However, if it was simpler for the police to charge people for being drunk and disorderly (or perhaps it should be drunk and incapable) then perhaps this would make people think.

Don't get me wrong, I am not a kill joy. I have no problems with people going out and getting wasted. What I have a problem with is people getting so wasted that they can't get themselves home. And where are these peoples "mates"? The only time I plan to get so bladdered is perhaps a stag do, or a big birthday. But then i'd expect my mates to look after me! I just think that individuals and society as a whole needs to take resposibility.

And perhaps a £300 fine for being drunk and incapable, plus your name on a police record may make people think twice. It may prevent them from having a few too many, or perhaps it may make their mates look after them to prevent them from getting the fine etc.

This way, they are still looked afer, they still get medical care and can't drown in their own vomit or get hypothermia, but to acompany the wapping great headache in the morning, the knowledge that they now have a criminal conviction (all be it a minor one) and their wallet is £300 lighter may make them think twice about doing it next week end.

And yes, I do realise that many of the people we pick up in this state may not have the means to pay this fine, but that is another issue all together and a can of worms I wish not to open!

RapidResponseDoc said...

I'm overweight, and eat too much. If, G-d forbid, I get unwell, should I have to pay? Free health care for all, at the point of access, is the system we all work in.

Steve said...

@ Kath, I totally agree with that. I'd probably go so far as to say that a fair few ambulance people do have reckless and dangerous pursuits, think of how many of us ride motorbikes, own a fast car, or have hobbies such as scuba diving or rock climbing. It's a large percentage, even if it's not a majority. I think the job attracts people with a certain pragmatic mindset, who often enjoy the challenge of dangerous hobbies.

As for the drunks, it would be very satisfying to hand a drunk a £300 bill once I've taken them to hospital, but it's not my place to judge people, that's the job of the justice system.
A lot of our alcohol related calls could be dealt with by the police, who are now reluctant to take anyone into their cells who isn't 100% healthy and capable, thanks to our litigenous culture. I think if the police were given a little more protection from the law they enforce, an offence such as 'drunk and incapable', carrying with it a fine and the promise of community service (potentially cleaning up vomit outside nightclubs?) would be an excellent deterrent. I could imagine the prospect of being arrested would magically sober up most people that would normally lie back, pass out and let us deal with their overindulgence.

mack505 said...

It doesn't matter anyway. The extreme you describe is the current American system, where everyone pays.

You would think it would cause people to evaluate their need before calling an ambulance or going to the hospital. It doesn't.

The end result is the same, with the difference that here the drunks are the ones who end up on government support and are the only ones who don't pay.

oneunder said...

The solution is already there, it just needs to be used.

It is an offence to be drunk and incapable in a public place.
It is an offence to be drunk and disorderly in a public place.

Drunks still need to be taken to hospital (as a place of safety) but that does not prevent them being arrested and prosecuted under the law.

Rastas000 said...

I am of the opinion that intoxicated persons (at risk) is just another part of the job. It is, for me, better to deal with them, not judge them, and get to the next job.

Underlying serious conditions may be few and far between, but they still pop up from time to time and I would hate to be the one allowing my prejudices to get in the way of my job.

Frustrating, YES.. However, for some for the recidivist arseholes we deal with, I wish I could just slap them about the head, kick there arses from here to tomorrow nights dinner and back...

Ambulance Amateur said...

I'm against charging drunks (financially).

If they are drunk in a public place, legislation already covers that - let's use it.

Would you also charge overweight people (like me, although I'm losing it well) if they had cardiac/diabetic problems?

Lifestyle often has an effect on health. Should we tax people on their choice of lifestyle? Why single out drinkers? They pay lots of tax on every pint/bottle anyway.

InsomniacMedic said...

Dear All...
I'm sorry I haven't replied to your comments - I read them as soon as they come in, but am very bad at replying sometimes....
I'm glad I've generated a discussion which shows that I'm not the only one struggling with the concept. Thanks to those of you suggesting that the police should be the ones doing the fining. I think that's probably the nearest we'll get - and isn't a bad solution!!! Keep the comments coming!

Anonymous said...

The police doing the fining is an okay idea. But why should the service be free in the first place?

Can it not be a chargeable service like prescriptions? £10 per call. I have called an ambulance a few times in my life (maybe 10) as an FAW and SJA member, in each case I would have been happy to pay.

If people who get the free service and abuse it could be monitored and regular abuse the free service could be then withdrawn. (Yes ok after 200 warnings but once it happened a few times people will realize it will happen).

Anonymous said...

I'm not a medic, just a lay person.

Thoughts on this - if the person is experiencing a medical emergency, then they need an ambulance, regardless of whether they are sober or drunk, or under the influence of drugs....

So - drunk comatose in street, or in phone box dialling 999 and trotting off the right answers to get an ambulance - no, ambulance not needed. Drunk knocked over by car s/he didn't see - ambulance quite possibly needed. Heroin addict suffering from overdose - ambulance quite possibly needed. Ditto obese smoker with severe chest pain.

It should go on medical need rather than on whether or not the person has taken action that has led to that need.

And I think people that misuse the service and call an ambulance out needlessly SHOULD be charged.