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This is black-belt medicine (areas of uncertainty in health and social care)

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Recently I went to the HIUG.

This led to my visiting, with the matron, a very old lady at home.

HIUG is an ambulance service invention; it stands for High-Intensity User Group.

Explaining the acronym might make it more meaningful; is is a monthly meeting, where those people who phone 999 are discussed. Specifically, those who call for ambulances. I imagine there is a separate group for those who abuse the fire service or the police.

The group is attended by a variety of ‘services’ – police, social work, healthcare, voluntary sector representatives and others who discuss each case.

Some people call the ambulance a lot.

What’s a lot?

Maybe every other day, maybe 10 times a month.

You might think the ambulance service would wise-up to the same person calling again and again for presumably trivial issues and stop visiting; it is not that simple, as being unwell, needing help and over-using the NHS all sit in areas of uncertainty.

Here’s an example –

Patient has a heart attack; at discharge from the hospital the post-heart attack nurse will inform them to call an ambulance if they experience further chest pain that doesn’t settle within ten minutes of using a GTN spray (sub-lingual spray that relieves the symptoms of angina). And so, the person, sitting at home has pain, uses the spray, still has pain and calls an ambulance – they are just doing what they were told. The ambulance come and very often as, chest pain has many causes and degrees of severity, take the person to hospital where they will have heart tracings, blood tests and so on.

As they are reassured that this time, ‘It was just bad angina,’ they will be given the same advice – ‘Call if the pain doesn’t settle.’ And so on.

You might think that people after a time or two would wise-up and understand that perhaps the pain is not angina, or if, given 15 or 20 minutes it will settle spontaneously (as that is what happens when the paramedics turn-up); again, it is not straightforward.

Some of this relates to an individual’s understanding of health. (Academics call this health literacy).

Covid is a dramatic demonstration that people don’t understand health.

We are experiencing a global panic the likes of which have never been seen before.

Now, I am not belittling the infection; the circumstances are unique – the global population, international travel and things like that, yet, it isn’t the first time a virus has spread.

We only know about it now because there are tests.

If this had happened 20 years ago, people would have assumed that there was a bad seasonal flu; end-of. (as an aside, it is only in the past few years that doctors have been able to confidently state ‘influenza’ as a cause of death – because we have tests to detect the infection; a decade ago, the explanation would have been, ‘bronchopneumonia’ or some other similar.)

Now, this is getting off-track, although I couldn’t cope with not mentioning the virus, as it is on every headline and social media feed;

Yet, to me this is the same as the man who at three in the morning wakes with chest pain.

It may be OK for the HIUG to think, ‘This guy is taking the Mickey’ after he has called for an ambulance four times that month, with a well scripted, ‘The pain is in my chest, it’s into my left arm, I am short of breath, it is not going away when I use my spray,’ and, so on. Yet, for the patient this is real, and their understanding of disease, prognosis and probability is poor; also, what else can they do?

We, the clever outsiders realise the pain can’t be that significant if it has happened 10 or 20 times, ‘If it were something he’d be really ill,’ we say, yet, we all know no one thinks logically, particularly in relation to their or their family’s health.

What do you do?

Well, the purpose of the group is to work-out what can be done to help the patient; perhaps they need to see a cardiologist, perhaps a psychologist, maybe it is a housing issue and the stress of their neighbours playing loud music provokes the angina or at least the stress that feels like angina.

Needless to say, in some situations, people don’t have chest pain or even angina and they are abusing the system; calling-up for reasons that are often psychological or psychiatric. They maybe drink too much vodka and become melodramatic. These people are harder to help and sometimes this ends-up with the police, sanctions and legal proceedings.

Now, I started this describing an old lady and a matron. Where do they fit-in?

It is similar;

This time the person is 90, they are living on their own, with a bad chest and frailty; they fall frequently and are prescribed a multitude of medicines and tablets. On anyone’s scoring system they are the essence of not well.

They too experience pain or anxiety or breathlessness at three in the morning.

They too realise they are calling 999 too often.

Yet, they keep on calling.

What else can they do?

In many instances, this older person would be forced to move into a care home. That is often how society deals with such individuals, ‘They aren’t coping; they need to go into care,’ type conversations.

This can be done quite easily if the person lacks mental capacity; the decision makers – the doctors, nurses and social workers can make a best interest decision and voila the phone calls end.

When the person is capacitated; is insightful and aware of the issues but is just fearful the answer is less straightforward.

The conversations might be something like;

‘Morag, you have been calling the ambulance an awful lot recently.’

‘I know, I sometimes wake in the night and can’t breathe.’

How do you respond to this? Tell them to ‘chill,’ to wait for their breathing to settle-down? Ever been breathless at three in the morning? Do you have any strategies to sort yourself out, particularly when to begin you have a bad chest?

This was the type of conversation I had recently. Me, healthy doctor, matron, healthy nurse, talking with an old lady double our age who has seen and lived-through experiences we cannot imagine, trying to help; aspiring to avoid condescension or telling-off, trying to be sensitive, attentive, helpful.

‘I get breathless and I press my buzzer.’

This is what Morag is told to do, after all, you can’t really tell a 90-year-old who is feeling vulnerable in the night to chill and wait for things to settle (although that is a potential strategy).

Suffice it to say, we chatted, we had a laugh, we even turned her mattress over to make her bed more comfortable; we stopped some unnecessary medicines and held a drug amnesty, liberating multiple packets of antibiotics, aspirins and blood pressure tablets stashed away in cupboards dating back a decade; we returned the unused inhalers and steroids to the chemist for disposal; we agreed a plan to help, a strategy for us to work with the ambulance service, to help avoid the calls or unnecessary transfers to hospital.

It is hard holding-on to your sense of perspective in such situations.

Most of us want to focus on the easy wins; maybe giving antibiotics for water infections or addressing pain using the World Health Organisation pain ladder; following complex yet black and white algorithms; these are components of healthcare that are what I perceive as entry-level. Supporting an old woman who is losing their independence, who is failing whilst wanting to remain at home, is trickier.

This is black-belt medicine.

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Photos courtesy of NK

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