Oh, I have so much to tell you. LOTS of things have happened since my last post. There was getting threatened with my first law suit, trying to deal with intern isolation, operating as a doctor for the first time, and of course my ongoing battle with leaving my patients at the hospital when I get to go home, or maybe my first end of life conversation with a family. It's been a busy, busy week. I really don't know which if these I ought to tackle first so I think I'll just go chronologically.
On Sunday I admitted a gentleman with bilateral near circumferential second degree burns to his upper extremities. They needed to be treated surgically. But, this man did not want surgery. So, we made a deal with him if he showed us there was someone at home who could do his dressing changes, if he was cleared by hand therapy and if he showed no signs of infection he could go home on tuesday. Well, by Sunday night we were pretty sure this man's burns were infected. We told him that and asked that we be allowed to start IV antibiotics because that would provide the best efficacy. He was not happy.
He refused that pain meds at that time and said he was leaving in the morning. Over night he got a fever and his wound edges were turning red. Again we told him that he needed IV meds. He refused until we took the dressings down to change them and he saw how bad they looked. He agreed to a day's worth of antibiotics and insisted on leaving the next day. So Tuesday roles around they day we had said he could go if he could do his own dressing changes, clear hand therapy and not be infected. Well, 2 out of 3 really wasn't enough and we told him we wanted him to stay to finish the IV antibiotics. He said he wanted to leave.
Now, as this point if a patient leaves when aren't ready to discharge we call that leaving "Against Medical Advice." By clarifying it as such we absolve ourselves of any legal ramifications should their choice prove detrimental to their overall health and well-being. It also requires that you sign a paper stating that you are leaving AMA and will not sue the hospital, if for instance, your hand were to fall off because you weren't treated with the appropriate antibiotics.
I knew that a lot of my patient's concern was over incurring hospital bills without proper insurance coverage. Now seeing as I work at a state hospital I don't give two shits about a person's insurance. The state covers it. As a resident I am specifically told not to know about patients' insurance standings. It makes me a better doctor. So, with this patient I was at a loss I couldn't understand his refusal so I involved patient relations, risk management, financial planning . . . everyone I could think to include so that this patient would not leave and come back with necrotising fasciitis.
But, the more I badgered him to stay the more frustrated he got. He threatened to sue me, he threatened to "whoop my ass" not to mention my Chief's ass, my Attending's ass and the asses of any security guards foolish enough to stand in his way. This from a man with his hands bandaged from finger tips to elbows. Oh, and of course, we'd be responsible for worsening his condition because we'd made him fight.
I was literally at a loss, I had no idea how to proceed. Conveniently my Chief, the Fellows and the Attending were all in the weekly Burn Morbidity and Mortality conference so I couldn't really go to them for advice because this man was about to take me out on his way to the door. I called the hospital lawyers to find out what I could and could not give this man. I settled him down long enough to tell him he could leave AMA, I could give him prescriptions for oral pain meds and antibiotics (useless for skin infections) but no IV meds (we don't send people home with IV meds, we just don't) but he would have to sign the AMA paperwork.
This caused an even bigger ruckus than before. He flat out refused to sign anything saying he was leaving against AMA. But, he would sign it to say he wasn't going to sign it. And he even added a little note "I'm not signing this cause I'm leaving because I was told one thing and then another thing happened." I think this is in reference to the deal we'd made earlier in the week. I don't think the patient fully believed that he got an infection, and if he did I think he believes we gave it to him on purpose, Hippocrates be damned.
I urged him to come back to our clinic on Thursday so we could reassess his burns there and give him more meds, dressing supplies. Well, my Chief came waltzing into the Burn unit on Thursday afternoon and said he had a special, special surprise for me. I thought this might have something to do with the promise that I might get in the OR that day. Instead he handed me a stack of admit papers and asked if anything looked familiar. It turned out Mr. AMA had indeed returned to clinic, hours early for his appointment because his infection had spread, the man was convinced he was going to lose his hands.
I saw him as he was being wheeled back into the unit and he lunged off the bed in an attempt to grab me. Luckily the transport tech was a burly guy and held him down. Mr. AMA started screaming obscenities at me. It turns out that I should never have let him leave, I shouldn't have been so stingy with the meds, I should have cleaned his wounds personally, I should have let him keep his IV and a whole litany of other "I-done-him-wrongs."
We'll operate on him next week . . . hopefully we can save his limbs and their function.
No comments:
Post a Comment