I first met Kelly on a fairly standard Friday afternoon in the Emergency Department.  The type of presentations are starting to become a bit more "weekend-typical", and there is the usual rush of late-week GP referrals to our colleagues in the surgical and medical services.  The Department has had 70 patients and their relatives arrive in the last 2 hours, and we are working through their triage and assessment as rapidly as we can.

I say I met Kelly, but I am not sure I have ever met the genuine version.  That Friday, she has decided to kick-start her weekend with a couple of drinks and our latest nemesis in Emergency Medicine, "Burst".  This is one of the more recent legal highs or "New Psychoactive Agents" that are available over the counter and on the internet (all badged "not for human consumption" of course) and particularly potent, especially when injected.

Kelly is 24yrs old, with no medical history as far as we can ascertain, and is probably a lovely person.  That Friday, she is accompanied into hospital by 2 ambulance technicians, an ambulance paramedic, and 2 police officers, who are all struggling just to keep her on the ambulance trolley, and Kelly looks like something out of the Exorcist.

She looks like the embodiment of pure terror.  Wide staring bloodshot eyes, drenched in sweat, screaming and howling a torrent of abuse and paranoid rantings.  She is spitting and scratching, raging and thrashing against her 5 caring professionals with the superhuman strength of the delirious and threatened.

This is modern recreation?

We move her into one of our resuscitation rooms, not only because this level of agitation is particularly dangerous and distressing to Kelly, not to mention other patients, relatives and staff, but also to treat her in this profoundly agitated state. 

With a team of 8 of us, we manage to restrain her enough to get an intravenous drip into her arm, and start to give repeat doses of sedative medication to settle Kelly down.  This is important to prevent the body from overheating, the muscles from self-destructing and causing profound kidney damage, and to replace all the lost fluid from her exertions and rage. 

After enough sedative to put any "normal" patient into a coma for a couple of days, Kelly has quietened down, we have started resuscitating her effectively, and the team can return to looking after the other multitudes of patients.

This is the early phase of the legal high journey.  If Kelly is fortunate, she will avoid any physical and kidney damage as a result of her misadventure.

Unfortunately, I meet Kelly again the following Wednesday.  This is the late phase of the legal high journey.

Kelly had recovered physically over the 24 hours or so following her first admission, and was physically and mentally well enough to go home (with some clear advice regarding life choices).  However, Kelly, for whatever reason, was one of the increasing number of recreationalists that re-present with late psychiatric effects from legal high use. 

4 days after her initial symptoms had all recovered, she developed increasingly paranoid and delusional thoughts, topped off with some auditory hallucinations.  These were so convincing and threatening that Kelly took a knife to her wrists and her neck.

When she is brought back to the Emergency Department, she is again mentally agitated, but in a more resigned and withdrawn way.  She is not trying to tear her carers heads off, which makes things slightly easier, but she has lost a reasonable amount of blood and we need to replace this and treat her wounds in rapid time.

If there is some fortune in this episode, it is that she has not severed any of the major blood vessels in her neck.  Early signs suggest that she has damaged one of the arteries in her wrist, as well as one of the major wrist tendons.  These injuries will need formal repair in theatre by our colleagues in the plastic surgery unit at St John's Hospital, who will do all they can to avoid permanent disability in this young woman's hand.

The last phase of the effects of Burst are yet to play out for Kelly.  Long-term mental health and possibly physical issues are being reported by our colleagues in psychiatry and medical specialties.  The burden on our hospital and community services (including police and social work) from these agents is incredibly high, and in a time of increasing pressure on our services, will come at the cost of our ability to provide for other patients in need.

It would not be unusual for 5 patients a day to be presenting to the Emergency Department at the Royal Infirmary alone with effects from legal highs, and the variability of these agents and their effects makes their use for recreation baffling to those of us that are seeing their very serious consequences. 

 With the NHS taking centre-stage as another election approaches, perhaps we need to have an honest debate focussed on what health and community services should be focussed on, as they cannot continue to be the all-encompassing societal safety-net they are at the moment.  We simply don't have the resources. 

That may also mean that our fabulous Scottish NHS may need to be taken an arm's length away from all politicians.