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drive home after an epidural?

Discussion in 'Pain Medicine' started by Intubate, 09.02.08.

  1. Intubate

    Intubate ASA Member

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    In general, I require a patient to have a driver following an injection. I (almost) never use local (saline and steroid), but usually (70-80%) give a little sedation. On rare occasions, I've let a patient drive home if they did not get local or sedation. I've never thought much about it, but one of my partners had a little fit when he heard about one. This is not addressed in ISIS (or other) practice guidelines (as far as I can tell).

    Input? Slams? Anyone?
  2. lobelsteve

    lobelsteve www.stevenlobel.com Lifetime Donor

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    If not using sedation or local anesthetic, this would not be any different than driving home after a trigger point injection.

    With sedation: you are risking your career.
    With local anesthetic into the epidural space or along a nerve root, you would have a difficult defense if there was an MVA.

    Knew or should have known that LA would cause weakness/sensory alteration that could start 20 minutes after leaving your office contributing to the MVA.

    You cannot drive home after sedation (driver signature on the consent form)
    You can drive home after an ESI, provided the leg is not weak, heavy, and no decrease in sensation, and no LA was injected into the epidural space or onto the root.
  3. Intubate

    Intubate ASA Member

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    Thank you for your reply. I obviously agree. Is there a statement from any organization that you know of that states similar policies? I would like to have some literature to back up my logical and reasonable argument to my partner.

    thanks again. any additional input is welcome.
  4. Tenesma

    Tenesma Senior Member

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    all procedures require a driver home

    i will allow rare exceptions for certain procedures, and in those exceptions, I will make the patient wait in the recovery area for 1 hour with a documented strength exam.

    i also rarely (<1%) use sedation
  5. PMR 4 MSK

    PMR 4 MSK Large Member SDN Advisor

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    I use rare sedation. I have some patients drive themselves home, even though they brought a driver - usually older gent who does all the driving for him and the mrs. Since I don't use local in ESI's I don't require a driver, just strongly recommend it. I've heard of requiring an informed consent be signed prior to letting someone drie themself home.

    I know of no concensus statement on this.
  6. mille125

    mille125

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    i follow the same procedures as tenesma...
  7. Tenesma

    Tenesma Senior Member

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    holy cr*p - mille, are you hitting on me !
  8. mille125

    mille125

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    i cant believe it either
  9. pain_central

    pain_central New Member

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    would anyone allow someone to drive after a facet? SI? or hip injection? given no sedation but LA used at those sites.
  10. PMR 4 MSK

    PMR 4 MSK Large Member SDN Advisor

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    In general, yes, but I still recommend a driver for potential reactions, delayed vaso-vagal, etc.
  11. pmrmd

    pmrmd

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    every day for some 30 years...
  12. lobelsteve

    lobelsteve www.stevenlobel.com Lifetime Donor

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    So what about flu vaccines?
    IM Toradol?
    The list could go on and on.

    Sedation certainly requires a driver for the liability standpoint.
    Neuraxial anesthetics fall into the same category.

    But everything else should be fairly open to the docs comfort level.
  13. PMR 4 MSK

    PMR 4 MSK Large Member SDN Advisor

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    Some ER docs won't let you drive home after these injections. GP's here and there.

    Our ASC and local hospital policy is everyone has a driver. If they don't bring one, the question comes to me, and the nurse documents that I gave permission for the pt to drive to cover the nurse and facility. Now I have to document my reasons why I went against the facilty policy. I doubt "patient convinience" will help me much in the rare event of a problem. As I tell patients - "don't blame me for the policies, blame the lawyers."

    CYA
  14. ampaphb

    ampaphb

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    remarkably, that does not make it either right or likely to hold up in court

    intra-articular facet injections frequently decompress, but you will only see that if you distend the capsule. since most docs put in just enough contrast to document that they are in the joint, you have no way of knowing whether that particular capsule is intact. as a result, a good number of facet injections are non-specific, and produce spinal nerve analgesisa and weakness. To me, allowing someone to drive after a facet injection, seems unwise.
  15. pmrmd

    pmrmd

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    all i know is i haven't seen a court room. i've done plenty of them too. am i reckless or are others over-cautious?
  16. Pain_doc

    Pain_doc New Member

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    Interesting phone call today. A patient who was referred for a LESI called. She was involved in a car accident the day following the injection. She was calling because her auto insurance wanted to know if the epidural had anything to do with it. Trying to pass the buck.
  17. lobelsteve

    lobelsteve www.stevenlobel.com Lifetime Donor

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    Are you still using 4cc of 4% lidocaine with epi per joint and doing b/l L2-3, L3-4, L4-5, and L5-S1 IA facets? Cause that could be enough local to cause some leg symptoms.

    Seriously, if you inject 1cc Omnipaque, then 0.5cc .25% Marcaine or 1% lidocaine- is that going to cause epidural anesthesia to any degree in x % of the population?
  18. brori

    brori

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    First message (long time lurker--really enjoy the posts).
    Of interest, I had an ASC administrator tell me that I couldn't have a patient go home in a taxi cab (the patient had to know the person driving them home post ESI) The argument was that a "responsible person" has to drive the post procedure patient home, and the physician can't guarantee the taxi driver's competence.

    I didn't have time to argue and had to specifically write on post op orders that it was OK for the patient to go home in a taxi cab.

    Yet another ASC whipping.
  19. ampaphb

    ampaphb

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    "couldn't"??? Then what did they propose the patient do - be kept against their will?

    In similar circumstances, we generally have a member of our staff drive the patient home if they are local. Alternatively, we have them sign AMA. Next time if the administrator is THAT concerned, tell him to drive the patient home himself!
  20. brori

    brori

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    Good one. How much do you think the administrator would charge? Overestimate mileage by how much?
  21. clubdeac

    clubdeac

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    I deal with this **** on a daily basis. If they've had a mbb, SIJ or ILESI w/o local I usually say it's fine but I get a call from the recovery nurse and the patient has to sign out AMA. Kinda annoying. Anything change for anyone since these posts 3 yrs ago??
  22. PMR 4 MSK

    PMR 4 MSK Large Member SDN Advisor

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    I'm still the same as above.
  23. Gauss

    Gauss Damnit Jim!

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    Driver = less paperwork, less calls, less waste of my time

    I have bigger battles to wage with ASC's about anticoagulation and nsaids
  24. willabeast

    willabeast

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    i looked into this in 1995. at that time, some parts of the country allowed driving oneself home and some did not after injections. where i practice, the local university and and the local clinics insisted on a driver, so that was the apparent standard of care, so we have insisted on a driver since.
    what i have always wondered is how dentists get away with it...
  25. bedrock

    bedrock Member

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    One of the best "side effects" of requiring a driver is that my no-show rate for procedures is almost zero. Much better my no-show rate for office visits.

    Other positive "side effects" include less whining when I tell patients their procedure isn't going to be the same day as their office visit, since over half of them are there alone for the office visit.
    I cover my ass legally, get paid more in total for office visit and the procedure, my procedure schedule is more efficient since I'm not flying by the seat of my pants mixing this and that, and patients are scheduled for exactly the right amount of time for their procedure and anatomy, with very few no-shows so my procedure days are super efficient and productive.

    I can beat that one. The office of the doc who did my Lasik (Harvard-trained), let me drive myself home. (I actually had a ride waiting outside), but no one knew that or said anything as I picked up my keys and headed for the door to the parking lot...... after my eyeballs were lasered!
  26. ctts

    ctts

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    Bringing up an old thread here...

    We generally require a driver for most procedures. The thing is, some patients try to get around this by saying, "My driver is waiting for me outside" or "My ride will come pick me up" and they we see them walking out the door to their own car and driving themselves home. So we were considering requiring their driver to be present in the office before the procedure is done, to make sure they really do have a driver. But it makes me feel like we are policing them, and I wonder if that is overkill... If they say they have a ride arranged, even if we don't know for sure, is that good enough?

    Put another way...if a patient tells us they have a driver, but we don't have visual confirmation of a driver, and they sneak out and drive themselves home and get into an MVC...could we be liable because we didn't make sure they really have a driver?

    Thanks!
  27. willabeast

    willabeast

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    this does not answer your question, but FYI all the MVA's my patients have been in were driving to the clinic rather than leaving it.
    to answer your question, i think it depends a lot on the community you live in, and what the standard of care is. so you are going to get lots of different answers, all correct.
  28. Ducttape

    Ducttape Lifetime Donor

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    if they get sedation, i want visual confirmation.

    i essentially discharged one patient for violating this, when he was witnessed driving himself home after IV sedation.

    i let LESI's drive home, or take a bus home, but they have to stay longer - usually 40 min.
  29. pmrmd

    pmrmd

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    Agree with above. IV sedation = driver, obviously. Otherwise they can wait a bit and drive themselves home.
  30. ampaphb

    ampaphb

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    All patients must have a driver after ESIs, facets, and mbb in my practice. If they insist on driving, we make them sign AMA.

    I know this seems extreme, but my malpractice carrier advised that, if they get into an accident, and you have given them permission to drive, you are liable. If the patient injures third parties, you may well be personally liable, as your malpractice insurance extends only to your Dr./Patient relationship, NOT injuries to third parties. You are PERSONALLY liable in this instance.
  31. NOSfan

    NOSfan

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    +1
  32. epidural man

    epidural man ASA Member

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  33. clubdeac

    clubdeac

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    +1 unfortunately that's the America we practice in
  34. mille125

    mille125

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    For once I totally agree with you.
  35. emd123

    emd123

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    Do you realize what you are doing here?

    Having the patient sign an AMA form does nothing to protect you from the liability of a patient crashing into someone else. If you're truly worried your ESI patient (that didn't get local or sedation) is going to crash into someone else, they shouldn't get the chance to sign out AMA anymore than a drunk driver or sedated driver should get the chance to sign out AMA and still drive, high on versed/fentanyl or alcohol. AMA is a patient consenting to risk to themselves, not consenting to risk to others.

    I agree, however, that lawyers and greedy sue-happy people have eff'd everything up to the point we have to make absurdly ridiculous requirements like this. (I know where you all are coming from).

    Do you need a driver after getting dental work? No.

    Do you need a driver after getting your ears pierced? No.

    Do you need a driver after donating blood? No.

    Do you need a driver after getting stitches? No.

    Requiring a driver after a knee injection, trigger point, or SI joint is pointless, and makes no sense. Delayed vagal reaction? What the hell is that? You either vagal, or you don't.

    If you truly believe in a "delayed vagal" reaction (whatever the hell that is) why is it safe for them to be at home alone after they've been driven home?

    What if their ride drops them off, then they still have a "delayed vagal" episode and drown in their pool, bathtub, or fall down the stairs?

    Yet, lawyers will make absurd arguments in court and win, by confusing the crap out of juries of people who can't figure out how to get out of jury duty. So as a response, we make absurd rules to make ourselves feel better. Sad.

    Here's what I think is reasonable, like others have mentioned:

    1-Sedation or local in epidural space or nerve block affecting use of arms or legs- driver mandatory. No AMA option at all! Crashing and killing others after signing AMA isn't an option. Think of how crazy that is: documenting their risk then letting them drive increases your liability, since you've documented their a danger in the road yet you still let them drive. That's a lawyer's dream scenario! If they get behind the wheel with IV sedation on board, or motor block, the cops are called.

    2-Other spinal injections, fluoro injections without nerve block or sedation, or epidural with local- have a policy such as driver strongly recommended or mandatory observation period afterwords, in office (ie 60 minutes). If there's no motor block or vagal response after one hour, it's not going to happen. Even anaphylaxis will occur within 20-30 min. "Delayed vagal" is made up. Don't even post such a thing online for the lawyers to latch onto to start using in court ("delayed vagal one hour later, three hours later, the next day, etc...)

    3- Minor injections, such as trigger point, joint, there is absolutely no reason to require a driver. If there's no symptoms during or within 20 minutes after an injection, it's not going to happen. In fact, if I went to a doctor that required that, I'd never go back. Otherwise, any restaurant should require any patron that eats, to have a non-dining driver to take them home in case the customers have a delayed vomiting or choking episode after eating. Drivers required after every tetanus shot, or pneumovax vaccine... Drivers required for every wart or mole removal in the podiatry or derm offices...

    It's absurd.
    Last edited: 07.26.13
  36. mille125

    mille125

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    I disagree with your AMA statement. In your scenario are you suggesting that I physically tied the person down to not let them leave. Legally you are protected if someone does something against your advice (ask your lawyer). I have had a few patients who said that they had drivers and subsequently did not. They sign out AMA.
  37. emd123

    emd123

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    I wish you were right. AMA cases are legally very complex, unfortunately. Not only does AMA not necessarily protect you from liability, it can in some cases increase it. In your case, you absolutely are increasing your liability. Dramatically. Follow me:

    1-Impaired patient signs out AMA = slam dunk for malpractice lawyer because since they were impaired enough by sedation to require a driver, they were too impaired to legally consent to risk. These are the patients you are signing out AMA.

    2- "... unhappy patients do sue more often and patients who leave AMA are certainly dissatisfied. When physicians and hospitals have been sued following AMA discharges, the plaintiff has often been successful."

    That quote is from an article documenting several cases where patients who left AMA sued and won.

    http://www.aaos.org/news/aaosnow/nov12/managing5.asp

    3-"...The physician must determine and document that the patient is functionally competent. If the [physician] deems the patient incompetent, then the refusal of care is invalid. If a life threat exists, the physician may treat the patient under the doctrine of constructive consent (also known as the “emergency doctrine”)."

    Here's three more examples of docs sued successfully after AMA releases, with the second being the classic impaired patients you have been signing out AMA:

    http://www.thesullivangroup.com/risk_resources/against_medical_advice/against_medical_3_refusal.asp

    http://www.thesullivangroup.com/ris...vice/against_medical_4_patient_competence.asp

    http://www.thesullivangroup.com/risk_resources/against_medical_advice/against_medical_5_ama.asp

    What you are doing is legally very risky. It offers zero protection from you being sued by the family of the person run over and killed, let alone your sedated patient. In fact, you document very nicely for that lawyer, that you sedated someone, you had an AMA discussion while they were IMPAIRED by virtue of being sedated, and by definition not legally capable of legally consenting to anything, then you allowed them to drive partly sedated and kill someone else and themselves. Yes, you absolutely should restrain someone who is intoxicated, and about to get behind the wheel, and call the police or EMS. Not only is it an option, it is your duty as the one who gave the sedation. This has been well established in med-mal cases.

    ERs do this every day, over and over and over again. Giving someone versed and fentanyl, having them legally consent to getting behind the wheel while impaired, absolutely is malpractice.

    In an ER or in the hospital, if an intoxicated patient, psychotic/suicidal patient, incoherent patient with dementia, or sedated patient post-procedure tries to sign out AMA, you absolutely cannot sign them out AMA while impaired. They are chemically restrained with something like IM Haldol/Ativan, Geodon or droperidol and then put in four point restraints, until they are awake, alert, free of all impairment, and able to coherently have an AMA discussion. If you aren't prepared to do this, you aren't prepared to sedate people.

    If your person is awake and alert, all sedation is out of their system, they've been observed and are no longer under the influence, sure, they can sign out AMA at that point, but at that point they are back to baseline and can drive.

    The same exact elements requiring competency for driving, are those that are required for signing out AMA. You can't have it both ways. I wish it were that easy.
    Last edited: 07.27.13
  38. ampaphb

    ampaphb

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    Your rant has missed the point entirely.

    Even when no sedation is on board, patients required to have a driver after a lumbar ESI, in my practice. Many folks are still have wobbly legs, and slowed braking time. I have them sign AMA when they are mentally competant, but, in my medical opinion, suboptimal to drive safely.

    You are liabler to third parties when your patient drives, and has not been advised it is unsafe to do so. Having them sign AMA DOCUMENTS that that discussion has been had, and that the patient chose to get behid the wheel fully knowing and understanding the inherent risks to doing so.

    FORCING them to stay against their will is tantamount to kidnapping.
    Last edited: 07.27.13
  39. emd123

    emd123

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    My post was long, but no rant was intended. I too, used to think an AMA form absolved us completely of risk and was shocked to find out it doesn't. Lawyers have found many ways around them and it's a fairly complex area of medical malpractice law.

    I was talking about post-sedation patients, in particular. Forcing a sedated, impaired driver to stay isn't kidnapping. It's required.

    An ESI patients with local, who has wobbly legs, is different. Such patients are able to sign an AMA form and consent to leaving AMA. However, again, having them sign an AMA form does nothing to protect other people on the road or pedestrians from the wobbly legged person crashing in to them and killing them. Forcing such a patient to stay in office isn't as clear cut as a sedated patient, but legally speaking, we as physicians have a "duty to protect." Your obligation would be at a minimum, to inform the police that you think a patient is leaving your office as a danger to others on the road, so they could pull the patient over.

    This is for the same reason you ask a patient if they have suicidal ideations or homicidal ideations in a psych exam. If they have suicidal ideations, you do force them to stay if capable or at a minimum call police and emergency commit them. This is not kidnapping. You can't sign them out AMA. As a physician, your medical license empowers you to prevent the person from leaving, and in fact obligates you to do so.

    If someone is homicidal, or a threat to others, you do have a "duty to warn" and holding them also is not "kidnapping." It's called a "72 hr hold". Again, there is an obligation to protect others and as a physician our role is different than the man on the street as far as the courts are concerned. You can't sign a homicidal patient out AMA and expect liability protection from the family of the murdered person's family.

    If you truly think a patient has legs weak enough they might crash and kill someone, should you let them get behind the wheel and sign them out AMA?

    On the other hand, if you really don't think they are a risk, and you're just having them sign the paper as a CYA thing for an added layer of protection because lawyers will sue anyone for anything (which is where I think most people are coming from), then fine. I don't blame you. I've had many patients sign many an AMA form. But I also, know many of the loopholes the lawyers use to get around them and try to plug those holes ( one example: have the nurse sign as a witness so they can't argue that you never really discussed the risks, but instead just handed them a form and said, "Sign this). This country is definitely lawsuit happy. I'm just trying to make the point that AMA situations have some legal risk, and subtleties that not everyone thinks about, that's all.

    We can agree to disagree.
    Last edited: 07.27.13

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