Worst AMAs

docB said:

We've all had pts AMA on us (for noobs that's leave the ER Against Medical Advice). Usually I don't really mind and often I think that the pt is just doing what I would do in his spot. However, most of us have had pts that just won't listen to reason and no matter how many times you tell them "YOU WILL DIE!" they insist on leaving. I'll start:

57 yo M with chest pain and clear ST elevation MI on EKG. "I can't afford this."

45 yo F, came in for hot red leg and fever. Dx with cellulitis, new onset diabetes. The internist, the nurse and I all begged her to stay. "I'll treat it at home with herbs and supplements."

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You did your job in trying to make it clear; you can't always win against Darwin, although we often do.

mike

mikecwru said:

. . .you can't always win against Darwin, although we often do.

mike

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Mike, I'm not certain we should always try!

My worst ED AMA: Guy swallows bottle of herbicide/insecticide- AMA'ed out of another hospital because they weren't "nice" to him!

Worst in-house AMA: Mass surrounding superior vena cava

Hoping would AMA: 39 yr old Coke dealer with end stage CHF making deals in his hospital room. Had to give him a private room because he was upsetting his roommates too much!

Dx. Ectopic preg. (big fat fetus in tube on BS U/S), lotsa bleeding, pain etc.

Attending's plea-"you will likely die and will definitely be sterile/sorry if you leave without surgery"

Pt's reason for leaving-"I have to let my dog out before 5...I'll come right back"

Upshot-Concerned RN dramatically stops pt. in parking lot and arranges for neighbor to let out pup via cell phone.

Cost-to-humanity=pt. remains breedable today

well.. not really an AMA.. but when i was 3rd year med student.. i had a patient with active TB and suicide ideation just walk out of the hospital one night to buy a pack of cigarettes.. never ended coming back..

fuegorama said:

Dx. Ectopic preg. (big fat fetus in tube on BS U/S), lotsa bleeding, pain etc.

Attending's plea-"you will likely die and will definitely be sterile/sorry if you leave without surgery"

Pt's reason for leaving-"I have to let my dog out before 5...I'll come right back"

Upshot-Concerned RN dramatically stops pt. in parking lot and arranges for neighbor to let out pup via cell phone.

Cost-to-humanity=pt. remains breedable today

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Upside: At least the puppy's okay.

28 years old, photophobia, neck stiffness, constant headache, 103.2 Temp, daughter with recent bacterial meningitis, claims he hates antibiotics and needles. AMA sans even PO meds. I hope his headache feels better...

docB said:

We've all had pts AMA on us (for noobs that's leave the ER Against Medical Advice). Usually I don't really mind and often I think that the pt is just doing what I would do in his spot. However, most of us have had pts that just won't listen to reason and no matter how many times you tell them "YOU WILL DIE!" they insist on leaving. I'll start:

57 yo M with chest pain and clear ST elevation MI on EKG. "I can't afford this."

45 yo F, came in for hot red leg and fever. Dx with cellulitis, new onset diabetes. The internist, the nurse and I all begged her to stay. "I'll treat it at home with herbs and supplements."

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I sorta had the same situation as stoic. Working as a first-aid attendant at an NHL game at the stadium. Dispatch calls me on radio for a pt. who slipped and fell on his head in the aisles as he is trying to leave. He's got a GCS of 15, but a laceration on the head, neck pain when I palpate, and he says his hands are tingling "but they always do that". I was barely able to get him to sign the AMA section before he took off. I always wonder what happened to him.

50 something year old woman with acute onset of bilateral blindness, which turned out to be secondary to inflammation around the orbits due to connective tissue disease (can't remember which).

Reason for leaving: She didn't believe in medicine. Was going home to try some herbs and pray.

Good luck.

50 something year old man comes in with Inferio-lateral MI,+ troponins. He refuses medical therapy (even asa) and tells us he has to go take care of business. He leaves, writes up a will, then comes back a day later in cardiogenic shock.

Q

I'm always saddened by the level 4's that walk out of the waiting room @ 4 am. Just sad... sad I tell 'ya!

AMA's like the chest painers above (leaving because they couldn't afford enzymes) and that I have seen myself, are a big reason I support socialized medicine.

The AMAs that drive me truly crazy are the ones who are doing exactly what I would in their position. They're the ones with ligitimate problems that have been in the department for, roughly, three years because we can't get our **** together and make things happen any quicker.

I know there are all sorts of reasons for this (nursing shortage, lots of patients, boarders, etc) but the bottom line is we aren't getting the job done. Very frustrating.

Sadly, its the patients that are a royal pain in the butt that never seem to want to leave AMA.

Take care,
Jeff

QuinnNSU said:

50 something year old man comes in with Inferio-lateral MI,+ troponins. He refuses medical therapy (even asa) and tells us he has to go take care of business. He leaves, writes up a will, then comes back a day later in cardiogenic shock.

Q

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And somehow, despite great documentation and practically begging the patient to stay, you will still get sued....Sad world we live in.

My worst AMA was first week of internship... 50-something guy with renal failure who decided he didn't actually need dialysis anymore... came in for syncope, felt miserable, had EKG changes from his K, was in DIC for unkown reason, and left before any labs came back because "he was tired... needed to just go home and get some sleep". Wife couldn't talk him out of it, and when I called him later on when the labs came back to tell him he was going to die, he said, "I'll just get some sleep and come back in the morning doc, alright?" Never saw him again...

got another one. i was CCU intern who came down to do an admission on a guy in the ED with Dyspnea on Exertion. I did a bedside echo with our sonosite and he had a pretty large pericardial effusion. Couldnt' see if the RV was collapsed or not but it was a pretty big one. He couldn't walk for than 5 feet without being winded, and his pressure hung around 100/70. He and his WIFE refused admission because they had just come down to Tampa and didn't know much about the hospitals, so they were going to fly back up to Philly where they were from. Maybe Scrubs saw him.

I remember the wife saying "I have FEAR." (Regarding hospitals not where she is from).

Q

QuinnNSU said:

I remember the wife saying "I have FEAR." (Regarding hospitals not where she is from).Q

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Ya gotta just wonder when, after deciding to walk into an ED unknown to her, did she develop this fear?

Take care,
Jeff

margaritaboy said:

50 something year old woman with acute onset of bilateral blindness, which turned out to be secondary to inflammation around the orbits due to connective tissue disease (can't remember which).

Reason for leaving: She didn't believe in medicine. Was going home to try some herbs and pray.

Good luck.

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Why do patients like this come to the ER in the first place?

I think mine might be the worst one of all...

I had a patient who took too much Coumadin comes in with melena, hemoptysis, and an INR of 12 and a crit of 17, gets admitted, walks out the next day because we wouldn't let him off the unit to smoke.

Seriously.....

I don't even blink any more when patients go AWOL to smoke. Sometimes the come back, sometimes not.

Last labor day a 50yo/m comes in after getting drunk on his roof and then falling to the group. Obvious deformity on right forearm. When he bolted to smoke he has 2 IV's in - he just took the bags with him as he bolted past the nurses in nothing but a hospital gown.

He didn't come back.

Don't have my own cases yet, but this one is an actual case we were given to present in small group:

40YO business man traveling to Kenya declines malaria prophylaxis b/c he's going to be in the Nairobi Hilton the entire time. Changes his mind when he gets there and spends a night in a game park. About a week after his return, presents to ED with clear malarial Sx, blood smear confirms P. falciparum.

Signs out AMA b/c the hospital doesn't have a private room.

Returns by ambulance after having a grand mal seizure, dies 4 days later.

I wonder about these AMA's in people with potentially altered mental status(meningitis, cerebral malaria, SAH, renal encephalopathy etc...) I have no problem letting people I don't think have anything seriously wrong with them sing out AMA. Even the ones with serious medical problems are fine if the medical problem doesn't effect their judgement. I'm very nervous about letting AMA's go if the have a potentially mental status altering diagnosis. The first thing the lawyer will say is they were out of their head when you let them sign out AMA. It's not good enough to document A&Ox3. You probably need to document a normal mini-mental status and an extensive discussion showing that the patient understands all the implications of their decision.

I remember a case from a few years ago when a rich business women staying at a downtown hotel called EMS for a severe headache and then refused transport saying she just wanted them to give her some tylenol. Paramedics called control for the AMA refusal saying she was A&Ox3. My friend spoke to her on the phone and felt that although she was A&Ox3 that she was pretty wacky and forced EMS to bring her in. She raised holey hell in the ED and tried to sign out AMA a few more times. 2 weeks later when she was released from the SICU after having her leaking aneurysm clipped she thanked us.

This happened to a friend of mine's sister.

She was an EMT who went to pick up a rich man who was sick from (something - I don't remember what). He refused transport. She decided he needed treatment and forced him to come to the hospital. He was treated and got better.

He found her later, thanked her, and offered to PAY HER WAY through medical school. She probably graduated a year or two ago.

ERMudPhud said:

I wonder about these AMA's in people with potentially altered mental status(meningitis, cerebral malaria, SAH, renal encephalopathy etc...) I have no problem letting people I don't think have anything seriously wrong with them sing out AMA. Even the ones with serious medical problems are fine if the medical problem doesn't effect their judgement. I'm very nervous about letting AMA's go if the have a potentially mental status altering diagnosis. The first thing the lawyer will say is they were out of their head when you let them sign out AMA. It's not good enough to document A&Ox3. You probably need to document a normal mini-mental status and an extensive discussion showing that the patient understands all the implications of their decision.

I remember a case from a few years ago when a rich business women staying at a downtown hotel called EMS for a severe headache and then refused transport saying she just wanted them to give her some tylenol. Paramedics called control for the AMA refusal saying she was A&Ox3. My friend spoke to her on the phone and felt that although she was A&Ox3 that she was pretty wacky and forced EMS to bring her in. She raised holey hell in the ED and tried to sign out AMA a few more times. 2 weeks later when she was released from the SICU after having her leaking aneurysm clipped she thanked us.

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What is this A&O business?

aphistis said:

What is this A&O business?

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A&Ox3 = alert and oriented times three

Alert and Oriented to 1)person, 2)place, 3) time

ERMudPhud said:

I wonder about these AMA's in people with potentially altered mental status(meningitis, cerebral malaria, SAH, renal encephalopathy etc...)

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This was my argument with the malaria case, that he should not have been allowed to make the decision, but my group leader, who was involved with the case, said that cerebral malaria had not set in when he presented the first time and there would have been no basis for holding him. Worse, the guy was sent home without meds (he was supposed to report back in the morning).

We just talked about a case in conference relating to this issue... guy came into the ER with an allergic reaction to fish... got benadryl and felt better. Also had admitted to drinking 1 glass of wine at dinner. Guy AMA'd without speaking to the doc (nurse had him sign the papers), got in his car and drove off a cliff. BAL was >200 + "toxic level of benadryl". Doc and hospital got nailed to the wall.

The chart sucked, but did note that the guy did not seem altered and was AOx3. The expert witness in court said that an AMA form does not give a patient the right to sign their life away.

Soak that one up... "does not give a patient the right to sign their life away". What the hell is it good for then? Our AMA is EXTENSIVE... really meant to CYA. You have to explain all relavent and possible outcomes... including death, paralysis, loss of sexual function (yes that's really on our AMA). It goes through mental status documentation... offer to transfer the patient... call family... truly painful unto itself.

All that and you still need to medically 302 folks if their decision is the "wrong" one.

edit: This case did not occur in one of my hospitals

AznTrojan-MS said:

well.. not really an AMA.. but when i was 3rd year med student.. i had a patient with active TB and suicide ideation just walk out of the hospital one night to buy a pack of cigarettes.. never ended coming back..

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Okay... That's shady as hell!!! Your ED must be shady as hell too for letting him just walk out for numerous reasons...

First of all, If the patient has TB he needs to be put in isolation. Under no circumstances should the patient be able to leave his isolation room for threat that he could spread a disease which is potentially airborne and lethal.

Second of all, TB is a federally reportable disease under the CDC guidelines and if a patient has active TB he MUST receive medical treatment (even if he refuses!!!!). Under federal law you have the legal right and ethical obligation to quarantine him for treatment.

Thirdly, if the patient had suicidal ideations then he difinitely needs close monitoring/psych consult, and if he had a plan than it warrants admission even if it is AGAINST HIS WILL (there's no-- "I'm going out to smoke a cigarette for a sec" allowed) If he were to go walk outside unsupervised and blow his head off, you guys would be liable.

It seems your ED has forgotten about the 3 universal psychiatric/medical admissions which are irrespective of patient agreement. Your ED missed 2/3.

1) Potential threat to himself (i.e. suicidal ideations)
2) Potential threat to others (i.e. homocidal ideations, life-threatening contagious diseases such as TB)
3) Unable to care for self

This was not a bad AMA.... this was negligence of your emergency department!

Some states do not require commitment for TB. PA definately does, but as a student I rotated in NYC and was told I couldn't "hold" a patient who refused treatment for active TB. Not sure if this has changed, but it certainly shocked me!

The SI definately shouldn't have gotten away anywhere though...

Scrubbs said:

Some states do not require commitment for TB. PA definately does, but as a student I rotated in NYC and was told I couldn't "hold" a patient who refused treatment for active TB. Not sure if this has changed, but it certainly shocked me!

The SI definately shouldn't have gotten away anywhere though...

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NYC has recently changed its policy to be more similar to, say Baltimore's (where we throw you in jail and cram the medicine down your throat if you won't take it nicely for the public health official who comes to your house). Their TB problem is gradually getting better. You are absolutely right that a CDC guideline does not equal a federal law.

VienneseWaltz said:

NYC has recently changed its policy to be more similar to, say Baltimore's (where we throw you in jail and cram the medicine down your throat if you won't take it nicely for the public health official who comes to your house). Their TB problem is gradually getting better. You are absolutely right that a CDC guideline does not equal a federal law.

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There is also a difference in management between "active" vs. "latent" TB. A person who has latent TB is what you are referring to. He can have a public official go to his or her house and have his medicines administered to him under direct visual supervision to ensure that he is treated prophylactically before his disease turns active (some never will). He can also be in public because he is thought not to be actively contagious and his disease is not airborne transmissible because it is being suppressed in granulomatous tissue by his immune system. In fact, these type of people are sometimes not necessarily treated b/c we are not even sure if they all actually have TB to begin with, we only assume based on their risk factors and a corresponding positive PPD test. An example is an eldery man with servere liver disease. If his PPD comes back positive, many physicians may choose not to treat him b/c the medications such as isoniazid may push him into end stage liver disease when he may not even have TB to begin with (positive PPD does not equal latent TB in the absence of positive cultures) and furthermore, if he had latent TB then it will not kill him if it remains latent. Following this type of patient for progression to active TB is an option.

The management is very different for "active" TB (hemoptysis, cavitations, night sweats, chills, positive cultures, etc.). This is the patient that is what I was referring to and is what I assumed the original post was referring to. He is extemely contagious and warrants treatment despite his consent. He is a health hazard to anyone he comes in contact with and must be placed in isolation. The police should be notified if he leaves.

Respectfullly disagreeing with the above post. I've just spent the last month working in the local county health dept. TB clinic, and that characterization of TB management sounds grossly inaccurate.

First, the original post said the pt. had "active" TB, not that he was just PPD pos., so we have to assume that was the case.

Second, even with someone with active disease, are you really going to stick them in isolation in house for weeks to months at a time to completely cure them of TB? As far as I know, once a pt has had 3 negative sputa (sputums?) and is otherwise asymptomatic, they can go home. Now that's not to say they should go hang out at the mall, but they don't need to be isolated as an inpatient. These pts will then get the directly observed therapy (DOT) for the rest of their 6-month course.

Third, there is absolutely no indication for DOT in latent TB. In fact, if the pts we see that are newly PPD positive but otherwise asymptomatic and chest X-ray negative don't want to take the INH, we don't make them. Assuming they are otherwise immunocompetent, they only have about a 10% chance over their lifetime of developing active TB. And there are so many of these people (including some healthcare workers), there's no way that public health nurses could possibly get to all of them every day for 9 months.

I know its off-topic, but wanted to put this out there.

They come to the ED because they want the pill we have which will make all their problems go away and look twenty years younger in a single dose. We, of course, all hold it back from them and keep it for ourselves because we're all just a bunch of jerks. : )

USCDiver said:

Why do patients like this come to the ER in the first place?

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waterski232002 said:

The management is very different for "active" TB (hemoptysis, cavitations, night sweats, chills, positive cultures, etc.). This is the patient that is what I was referring to and is what I assumed the original post was referring to. He is extemely contagious and warrants treatment despite his consent. He is a health hazard to anyone he comes in contact with and must be placed in isolation. The police should be notified if he leaves.

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Your description of "active TB" is exactly what I was referring to... 3 years ago, in NYC, this was not grounds for holding a patient. I agree with you that its a public health hazard, and I'm glad that they have changed the policy, but as of only 3 years ago it wasn't the law. I would assume that if NY has only recently changed, there are likely other states that don't require medical hold for active TB.

Should they? Of course! Do they? Not necessarily.

There are some fantastic points being made and very true points...just because a patient wants to go AMA doesn't mean they can. One can make the point that 1.pain 2. medical condition 3. toxicology/intoxication impairs judgement and therefore rendering the AMA form useless.

THe patient that left ama with the herbicide intoxication could EASILY say he was impaired when he left. THat is a lawsuit waiting to happen REGARDLESS of what he signed. Worse scenerio would involve bystanders that were harmed based upon his actions if he left the hospital impaired.

waterski232002 said:

Okay... That's shady as hell!!! Your ED must be shady as hell too for letting him just walk out for numerous reasons...

First of all, If the patient has TB he needs to be put in isolation. Under no circumstances should the patient be able to leave his isolation room for threat that he could spread a disease which is potentially airborne and lethal.

Second of all, TB is a federally reportable disease under the CDC guidelines and if a patient has active TB he MUST receive medical treatment (even if he refuses!!!!). Under federal law you have the legal right and ethical obligation to quarantine him for treatment.

Thirdly, if the patient had suicidal ideations then he difinitely needs close monitoring/psych consult, and if he had a plan than it warrants admission even if it is AGAINST HIS WILL (there's no-- "I'm going out to smoke a cigarette for a sec" allowed) If he were to go walk outside unsupervised and blow his head off, you guys would be liable.

It seems your ED has forgotten about the 3 universal psychiatric/medical admissions which are irrespective of patient agreement. Your ED missed 2/3.

1) Potential threat to himself (i.e. suicidal ideations)
2) Potential threat to others (i.e. homocidal ideations, life-threatening contagious diseases such as TB)
3) Unable to care for self

This was not a bad AMA.... this was negligence of your emergency department!

Click to expand...

to clarify.. this was not the ED's fault.. he was my IM patient when i was a 3rd year med student..

unfortunately.. the guy just walked out and never came back..

trust me on this one.. i worked with social work.. psychiatry.. infectious disease as well as public health.. and the fool still ends up walking out..

right then and there.. i knew IM wasn't for me

VienneseWaltz said:

NYC has recently changed its policy to be more similar to, say Baltimore's (where we throw you in jail and cram the medicine down your throat if you won't take it nicely for the public health official who comes to your house). Their TB problem is gradually getting better. You are absolutely right that a CDC guideline does not equal a federal law.

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To clarify about what you are required to do under federal law-- It is required to report all cases of TB to the health department (not just a CDC guideline). Actually treating TB and having a patient quarentined is not a requirement by law, but is something that is probably considered standard of care in the best interest of the patients health, and as a public health issue.

NateatUC said:

Respectfullly disagreeing with the above post. I've just spent the last month working in the local county health dept. TB clinic, and that characterization of TB management sounds grossly inaccurate.

First, the original post said the pt. had "active" TB, not that he was just PPD pos., so we have to assume that was the case.

Second, even with someone with active disease, are you really going to stick them in isolation in house for weeks to months at a time to completely cure them of TB? As far as I know, once a pt has had 3 negative sputa (sputums?) and is otherwise asymptomatic, they can go home. Now that's not to say they should go hang out at the mall, but they don't need to be isolated as an inpatient. These pts will then get the directly observed therapy (DOT) for the rest of their 6-month course.

Third, there is absolutely no indication for DOT in latent TB. In fact, if the pts we see that are newly PPD positive but otherwise asymptomatic and chest X-ray negative don't want to take the INH, we don't make them. Assuming they are otherwise immunocompetent, they only have about a 10% chance over their lifetime of developing active TB. And there are so many of these people (including some healthcare workers), there's no way that public health nurses could possibly get to all of them every day for 9 months.

I know its off-topic, but wanted to put this out there.

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You are right about 3 sputum cultures being negative and the patient being okay to have the remaining treatment course as an outpatient, but he should still be admitted and isolated/treated until that time.

waterski232002 said:

To clarify about what you are required to do under federal law-- It is required to report all cases of TB to the health department (not just a CDC guideline). Actually treating TB and having a patient quarentined is not a requirement by law, but is something that is probably considered standard of care in the best interest of the patients health, and as a public health issue.

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Regardless of what's in the patient's best interest, if they adamantly refuse treatment (and you are in a state that doesn't give you legal backing) then you would be assaulting the patient if you committed them for treatment. My example patient from 3 years ago would have required 4-pt leather restraints and a one-to-one until his sputums were clear. I completely agree that he should've been treated - for both his own well-being as well as for public safety. No argument. However, he was completely oriented, not suicidal/homicidal, understood risks and benefits, and was wrong but rational. Psych evaled him and deemed him competent for medical decision making. Unfortunate, but true...

Scrubbs said:

Regardless of what's in the patient's best interest, if they adamantly refuse treatment (and you are in a state that doesn't give you legal backing) then you would be assaulting the patient if you committed them for treatment. My example patient from 3 years ago would have required 4-pt leather restraints and a one-to-one until his sputums were clear. I completely agree that he should've been treated - for both his own well-being as well as for public safety. No argument. However, he was completely oriented, not suicidal/homicidal, understood risks and benefits, and was wrong but rational. Psych evaled him and deemed him competent for medical decision making. Unfortunate, but true...

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In NC you have the legal backing to quarentine and lock-down a patient with culture proven TB. But if the patient does not carry a definitive diagnosis, we can not hold him (he can leave AMA if he chooses).

I have actually had 3 cases of r/o TB on my service this week and 1 left AMA while we were in the middle of the work-up. He had typical symptoms, cavitary lesions on CXR, but was unable to produce an adequate sputum Cx. We wanted to Bronch him, but he was adamant about leaving. We consulted ID to clarify what we could do and they reiterated the same thing--you can only hold the patient if it's a definitive diagnosis (at least in NC).

But in regards to the original post, my point was simply that the patient was obviously mishandled. His case was much different than the tangential case you gave above... He was a suicidal man with active TB (and as others have stated in this thread--we're assuming that means a definitive diagnosis). Thus, it is standard of care to place him in isolation while he is your patient. At the minimum he needed to be informed of the consequences of his decision to leave the ED with possible TB if he so chooses. And he definitely should have been supervised because he was SUICIDAL. He should NOT have been able to just wander outside and go "buy a pack of cigarettes" (1-b/c he was suicidal, 2-b/c he should have been in isolation). This isn't even AMA-- you need to GIVE medical advice first in order to actually leave "against medical advice". I stand by my original statement... this was sketchy as hell to leave this guy unsupervised, unadvised, and allowed to just walk out of isolation without someone attempting to talk sense into him. (obviously SOMEONE was aware he was leaving b/c they knew where he went--so it's not like he had to sneak out)

diabetic with 3 day old cat bite to hand. circumferential erythema and induration to shoulder level.fever= 104.
reason" I have to go move my couch or my landlord will throw it out"
wtf