‘She woke up and attacked us!’

    CASE NOTES
    Practitioner:
    Jim McBride, community addiction manager,
    and Paul McGivney, nurse team leader.
    Field: Addiction services.
    Location: Glasgow
    Client: Martin Gallacher is a 36-year-old man who
    uses drugs and was known to the city’s addiction services through
    his attendance at a methadone clinic. 
    CASE HISTORY: A woman not known to addiction
    services was seemingly in Gallacher’s company. Staff had seen her
    in the street and come into the building with Gallacher. She was
    heavily under the influence of drugs – and had certainly taken more
    than one substance. It became apparent that she had overdosed and
    as she approached the door to the reception she collapsed in the
    foyer. Immediately, an ambulance was  called and McBride and 
    McGivney were notified. 
    Dilemma: The woman was unknown to staff and so
    they were not sure how to react beyond the immediate need to try
    and resuscitate her, and the one person who might have information
    – Gallacher -proved unwilling to provide it.
    Risk factor: The reception area was busy and
    people, including children, were distressed at the sight of a
    possible fatality. Gallacher was volatile and angry, and should the
    woman be resuscitated nobody knew how she might react.
    Outcome: The woman was resuscitated but assaulted
    ambulance staff and ran away. Addiction services were keen to learn
    from the experience, and staff are now aware and trained for any
    future similar circumstances. 

    Reflecting on what you are doing or have done has long been a
    staple of professional social and health care practice. When it
    comes to learning, development and improvement the word
    “continuous” is almost synonymous.

    Over the past year, social work and health services in Glasgow have
    taken the various strands of and approaches to drugs and alcohol
    work and bound them into an integrated addiction service. And
    despite detailed planning, sometimes experience can be the only
    teacher. But with lessons learned, the organisation can only become
    stronger.

    This was the case following the collapse of a woman who had
    overdosed outside the reception of the city’s east end area
    community addiction team (CAT) office. She was unknown to the
    service but was seemingly in the company of service user Martin
    Gallacher. Staff called for an ambulance and notified senior
    management. Nurse team leader Paul McGivney helped with the
    resuscitation of the woman because staff were struggling to get a
    heartbeat from her.

    The reception area was busy with many children about. “We also
    sought to minimise the distress to them and moved everyone away
    from the area,” says community addiction manager Jim McBride.
    “Fortunately we have a treatment room and we were able to use a
    face mask to help with resuscitation. While Paul took control of
    that, I concentrated on trying to calm Gallacher down.”

    He initially denied knowing the woman. McBride challenged Gallacher
    again: “He admitted that he knew her but had only met her two days
    ago, and then admitted that he was seeing her. I then asked what
    drugs had she taken. At first he said it was an epileptic seizure.
    He then said she might have taken a few drugs, but then admitted
    that she had taken cocaine, heroin and about 30 Valium.”

    Although distressed at the circumstances, Gallacher’s attention
    seemed more diverted by the woman’s bag than her well-being. Says
    McBride: “We argued that wasn’t his property, assuming that she
    might have drugs on her. There weren’t any in the bag, but there
    were three mobiles and a set of underwear, which suggested that she
    may be a prostitute and that Gallacher might be pimping her or at
    least feeding his drug habit.”

    Meanwhile, McGivney was still tending to the woman: “She had a
    pulse by the time the ambulance crew arrived. But they were unable
    to resuscitate her and didn’t have any Narcan – an injected
    medicine that blocks the effects of opiates resulting in severe
    withdrawal symptoms. A paramedic car turned up but again no
    Narcan,” he says.

    A second ambulance was called. “This crew administered Narcan and,
    lo and behold, instant withdrawal and the woman wide awake. She
    immediately assaulted the crew and ran out of the ambulance and off
    up the road,” says McBride.

    This raised questions for the CAT about how to respond to potential
    fatal overdose incidents. “Our concern was that she had left the
    scene, had no desire to engage with us, and most worryingly, we
    suspected the first thing she’d do is try to buy more drugs. We
    have to see this in context of the wider drugs-death issues we face
    in Glasgow,” says McBride.

    The integrated addiction service has a critical incident report
    procedure, part of which crucially looks at lessons to be learned.
    Training has since been provided on overdose prevention and
    managing risks involved in engaging with people, particularly if
    they are not known. “We were also aware of the usefulness of our
    treatment rooms. We are now considering storing Narcan and training
    all health staff to administer this,” says McGivney.

    The service is looking to also train all staff in other health care
    issues so they don’t automatically look to health care staff when
    it comes to medicine, assessing injuries or dressing wounds.
    McBride adds: “There’s a culture perception: they’re nurses so they
    must know what they’re doing. But they’re not general nurses
    working on wards day in, day out. It’s about educating staff in the
    team that nurses are not necessarily better placed to administer
    first aid.” McGivney agrees: “From the nursing point of view,
    having nurses there doesn’t really help because we always say that
    nurses are not the best first aiders!”

    The incident has, according to McBride, had a positive impact on
    the service. “It reminded folk not to be complacent – and you can,
    at times, become desensitised about who comes through the door and
    what they present you with. We go onto automatic pilot: it’s the
    same circumstances, different names. But the incident made us
    realise we have to analyse continuously what works here and what
    doesn’t,” he says.

    Arguments for risk

    • There was a need for staff to act – an ambulance was called but
      the woman’s heart was struggling. The treatment room provided a
      safe place and equipment to help stabilise her until the ambulance
      turned up.
    • With McGivney taking control of the woman’s resuscitation,
      McBride sought to move people away from the area and then
      concentrate on calming Gallacher: “He was volatile, agitated, angry
      and upset, and he was inflaming the situation so I took him away,”
      says McBride. 
    • The team learned from the experience. It was reported to the
      critical incident panel that meets through the integrated
      management team which reviews practice. “We looked at it as a wider
      training issue across the city. It’s about making sure that if such
      an incident happens again, staff feel comfortable and confident to
      take it on without the worry or uncertainty,” says McBride.  

    Arguments against risk 

    • While recognising that working with people who misuse alcohol
      and drugs can bring an inherent risk to staff safety, staff have to
      be extra vigilant when coming across people unknown to the service.
      They are also putting themselves at risk if they try to medically
      help someone without the critical information – to assist such help
      – being available. The ambulance was called – that should have been
      the extent of the involvement.  
    •  The result of getting involved with the woman (and failing to
      get Gallacher to provide the information required – he couldn’t
      even be sure of her name) was that she assaulted ambulance crew –
      because they had the Narcon that resuscitated her. If staff had
      access to the medicine, which the service is now considering,  it
      may well be them who were assaulted.  
    • The concern with this woman, apart from not knowing who she is,
      is where is she now? Pressure was brought to bear on Gallacher but
      he refused to give more information.

    Independent Comment 
    This case is an example of a scenario that occurs
    everyday in some part of the country. There are several factors
    here but all are secondary to the life and death of the unknown
    woman. Staff rightly concentrated on this crucial point with the
    addiction services senior management taking control of situation,
    writes Andrew Horne.  

    Calling the ambulance and beginning resuscitation were essential
    first steps. It is disappointing to discover that neither the first
    ambulance nor the medical car were in possession of Narcan, when
    you take into account the number of overdoses and drug fatalities
    in the Glasgow area.

    It has long been argued that drug and homeless services should hold
    Narcan and that all staff should be trained to administer it. We
    may get a punch in the mouth for our troubles but we have saved a
    life.  

    When I have been involved in a similar situation and the service
    user has run off, I immediately contact all local A&E
    departments, the police and key services to give a description of
    the service user. In this case speed is vital because Narcan will
    put him or her into immediate withdrawal, increasing the likelihood
    of her trying to use again, thus increasing the chances of a second
    overdose.

    This particular case was well managed but would it have been if the
    two senior staff were not present in the building?

    Andrew Horne is operations manager, Addaction Scotland.
    Addaction is a leading UK charity working solely in the field of
    drug and alcohol treatment

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