heroin overdose.

[winkleweizen]

For the guy who presents unresponsive, responds to narcan. Now is walky, talky and alert and orientedx4 and now wants to sign out AMA.


Do you guys let him leave and just explain to him the narcan will probably wear off before the heroin(methadone,norco or whatever) or do u let him leave?

I've had attendings tell me different things.

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[link2swim06]

A trend I have noticed recently in my residency seems as though a lot are titrating for 'barely breathing' but not really awake. This leads to everyone giving baby doses and avoids the mad man who wants to run away.

Doesn't really answer your question...just a recent observation.

 

[pianoman511]

I stick with two hours of observation from the time of administration which corresponds to the max duration of action of narcan. I think you can argue that they are competant to AMA but if they come back dead you may have problems. Given the wait time in most ers, the two hours really isn't that long.

 

[Daiphon]

For the guy who presents unresponsive, responds to narcan. Now is walky, talky and alert and orientedx4 and now wants to sign out AMA.


Do you guys let him leave and just explain to him the narcan will probably wear off before the heroin(methadone,norco or whatever) or do u let him leave?

I've had attendings tell me different things.

Need to wait at least 90-120 min, as this is the maximum duration of action of naloxone.

Anything less & you risk him/her becoming re-obtunded; if they get in trouble as a result, you're on the hook.

A patient is not capable of declining care until you're reasonably sure they are no longer intoxicated... artificially creating this state doesn't count. So, need to wait to ensure they won't decompensate.

-d

PS - remember, we determine *capacity* not *competence*

 

[WilcoWorld]

I also prefer not to fully reverse my opiate OD's. I start with 0.2mg of naloxone - a tenth of the dose that was given I started training. If I get someone who is fully reversed and wants to go I recommend observation, and if they decline I somehow take a loooong time to get their discharge papers ready, but I don't force people to stay. I'm not sure I have legal grounds to even do so (stated otherwise - I'm not sure I could convince a judge to give me a court order).

This study suggests that observation is not even necessary.

 

[WilcoWorld]

A patient is not capable of declining care until you're reasonably sure they are no longer intoxicated... artificially creating this state doesn't count.

Why not?

 

[Birdstrike]

A trend I have noticed recently in my residency seems as though a lot are titrating for 'barely breathing' but not really awake. This leads to everyone giving baby doses and avoids the mad man who wants to run away.

Doesn't really answer your question...just a recent observation.

This is absolutely the best case scenario. Titrate small amounts until safely ventilating but not so awake that they aren't still sedated enough to,

1-Keep blissfully mellow, well past your shift end, or

2- Be stoned enough to not care about and be unable to sign AMA papers.

But if you do sign them out AMA in that lucid interval you better document the sh¡iiit out of the chart. (Also, beware of methadone with a half life of up to days.). Another option is to throw some ativan on board at some point then you have claim to say they're impaired from your treatment alone. Then document the crap out of the sedation need, ie, "chemical restraints" and any physical restraints used. These patients are yummy, balls of tangled up medical-legal conundrums, and they're the types (and with family members) that would just loooooooooooooooooooooooooooooooo
ooooooooooooooooooove to have a nice fat med-mal settlement check to put up their veins. Yippie!

Bottom line: stay objective and clinical, act in the best interest of the patient, document your reasoning, and you should be fine in the end because if you do so, most juries, prosecutors, and medical boards are overwhelmingly more likely to side with you than an off-the-rails hell-bent-on-hitting-self-destruct-button, heroin addict.

"Welcome to the jungle baby"-Axl Rose

 

[Daiphon]

Why not?

Because the antidote does not enhance elimination of the poison; rather it just masks its effects. The patient remains intoxicated in that there is still opioid in the system.

The offending opioid still needs to be metabolized. When the narcan wears off, if this hasn't occurred to a sufficient enough degree, the patient will again become inebriated and/or impaired. Usually not an issue with heroin, but can be with longer acting opioids.

-d

 

[Janders]

So yes, giving little doses and keeping them from waking up in a fit of withdrawal-rage is good.
And yes, telling them they need to stay, and being slow to get D/C papers, are lovely techniques to keep them around for a few minutes.

Let's not pretend that the smoke and mirrors are going to actually stop a raging bull.

... what do you do with the guy who was barely breathing in a parked car after shooting up, who shows up s/p 2mg nasal-narcan by bystander / cop / BLS crew. He's awake. He's alert. He's pissed. He's large and muscular. He's had Narcan 5x before in his life. He isn't interested in detox. He's withdrawing. You can smile and make him calm down enough to understand he is lucid, able to ambulate easily, able to extensivly explain he understands the risk of death from narcan-wear-off if he leaves. He succeeds on all your basic thumbnail tests of capacity. He also makes the hairs on the back of your neck stand up; this guy might sucker punch you in the face given half the chance.

Now its been 5 minutes, he's dressed, he's in the hallway shouting he's walking out the door, and daring anyone to try and stop him.

Option A-- Watch him walk, compose an eloquent chart about his full capacity and rights to leave AMA despite your protests against it.
Option B-- Gather your nurses, techs, and that semi-retired security guard and, like a pack of rusty velociraptors, surround him and pounce. 4 points, 10mg Haldol, and 4 hours later MAYBE he can get up and leave. Hopefully no one gets hurt.
Option C-- Call the local police, wait 5 minutes for response, and see what happens. Perhaps they chase him down, perhaps they shrug their shoulders, perhaps they give you a lecture about illegally imprisoning people against their will (I've seen all 3...).

 

[Daiphon]

So yes, giving little doses and keeping them from waking up in a fit of withdrawal-rage is good.
And yes, telling them they need to stay, and being slow to get D/C papers, are lovely techniques to keep them around for a few minutes.

Let's not pretend that the smoke and mirrors are going to actually stop a raging bull.

... what do you do with the guy who was barely breathing in a parked car after shooting up, who shows up s/p 2mg nasal-narcan by bystander / cop / BLS crew. He's awake. He's alert. He's pissed. He's large and muscular. He's had Narcan 5x before in his life. He isn't interested in detox. He's withdrawing. You can smile and make him calm down enough to understand he is lucid, able to ambulate easily, able to extensivly explain he understands the risk of death from narcan-wear-off if he leaves. He succeeds on all your basic thumbnail tests of capacity. He also makes the hairs on the back of your neck stand up; this guy might sucker punch you in the face given half the chance.

Now its been 5 minutes, he's dressed, he's in the hallway shouting he's walking out the door, and daring anyone to try and stop him.

Option A-- Watch him walk, compose an eloquent chart about his full capacity and rights to leave AMA despite your protests against it.
Option B-- Gather your nurses, techs, and that semi-retired security guard and, like a pack of rusty velociraptors, surround him and pounce. 4 points, 10mg Haldol, and 4 hours later MAYBE he can get up and leave. Hopefully no one gets hurt.
Option C-- Call the local police, wait 5 minutes for response, and see what happens. Perhaps they chase him down, perhaps they shrug their shoulders, perhaps they give you a lecture about illegally imprisoning people against their will (I've seen all 3...).

A... but it's an elopement, not an AMA.

If one wants to document it as an AMA, then they need capacity, plain & simple. I don't believe they have capacity until my narcan has worn off & they meet clinical sobriety.

If they disappear, then that's another thing entirely... and if they end up dead, then the family looking for a posthumous paycheck will have a much harder time hanging anything on you. It's semantics, but defensible semantics.

Just my $0.02,
-d

 

[deleted547339]

A... but it's an elopement, not an AMA.

If one wants to document it as an AMA, then they need capacity, plain & simple. I don't believe they have capacity until my narcan has worn off & they meet clinical sobriety.

If they disappear, then that's another thing entirely... and if they end up dead, then the family looking for a posthumous paycheck will have a much harder time hanging anything on you. It's semantics, but defensible semantics.

Just my $0.02,
-d

I disagree. If you argue that they are too intoxicated to be allowed to AMA, I think you'd be liable if they elope. If I have a patient like this, I would get them a sitter.

We either DC immediately or will let these guys AMA all the time so long as it's just heroin. Heroin doesn't last long. I feel like 99% of these patients give me the same story:
1) new dealer
2) have been clean for a few months, fell off the wagon. Used the normal dose but don't have a tolerance.

By the time these guys have received 1 dose of narcan, been in the back of an ambulance and waited long enough for a bed, I discharge them.

 

[deleted109597]

People have left intoxicated before and the hospital/doctor not held responsible. You're not the cops. You can call the cops, and then it's up to them.

 

[WilcoWorld]

Because the antidote does not enhance elimination of the poison; rather it just masks its effects. The patient remains intoxicated in that there is still opioid in the system.

The offending opioid still needs to be metabolized. When the narcan wears off, if this hasn't occurred to a sufficient enough degree, the patient will again become inebriated and/or impaired. Usually not an issue with heroin, but can be with longer acting opioids.

-d

I agree with everything you're saying about the pharmacology. I think where we disagree is on capacity. To me, capacity is based on their mental state and how they process information, not on the concentrations of certain chemicals in their serum.

On the other hand, I think you are spot on that elopement is a much less sticky dispo than AMA in these cases.

 

[Daiphon]

I agree with everything you're saying about the pharmacology. I think where we disagree is on capacity. To me, capacity is based on their mental state and how they process information, not on the concentrations of certain chemicals in their serum.

On the other hand, I think you are spot on that elopement is a much less sticky dispo than AMA in these cases.

Fair.

I just think of it like this: if I had an acutely delirious patient from, say, Jimson Weed or some other anticholinergic agent, and I gave physostigmine, I would be remiss in discharging AMA shortly thereafter knowing the muscarinic is still active... just blocked.

I don't feel they have capacity until I can reassess after my intervention has worn off... but I agree with your point that it's about info processing, and that's seemingly intact after antidote administration.

Goes to the gray areas of "clinical sobriety;" and, TNR, didn't say someone wouldn't try to nail me... just that elopement is a tougher situation to get blame to stick than AMAing. It's all in how the documentation gets done.

-d

 

[The White Coat Investor]

I do not know of a single emergency physician who ever lost a criminal (unlawful incarceration? kidnapping?) or civil (what are the damages-4 lost hours of your life? pain and suffering?) court case where he tied a patient down and forced him to stay in the ED for his own good. It is so easy to make the person you tied down look like an idiot, and so easy to make you look like his savior, that it seems nearly impossible. Can you imagine what would happen in society if one of these suits was successful?

But guess what the settlement was for the patient who got out of the ED and ran onto the freeway and was killed?

Tie em down. Knock em out. Jot down a paragraph about why you did it. Quit worrying about it.

 

[Spinach Dip]

I was working at an academic institution where these individuals were referred to as "resident intubation practice".

They also rarely signed out AMA before the tube was removed.

 

[engineeredout]

I keep running into all different thoughts on how much to Narcan our heroin ODs. I understand the mentality of not reversing them 100% with 2mg of Narcan right off the bat to avoid precipitating a vomiting, unpleasant, miserable human being. However, I've also had the OD who comes in, cyanotic, respiration rate of 0, who I don't particularly feel like giving little aliquots of narcan to and hope they start breathing spontaneously before getting a nice anoxic brain injury. Had a 19YO girl the other day who was carried in blue, I started bagging her, nurses got an IV somehow, slammed 2mg of narcan and she woke up after what felt like a long time but was probably about 10 seconds. Got crap from my attending about not starting with small amounts, but this really wasn't the patient I felt like screwing around with. At that moment I didn't care how unpleasant she became, I wanted her wide awake and screaming over the state she came in.

 

[Hamhock]

I keep running into all different thoughts on how much to Narcan our heroin ODs. I understand the mentality of not reversing them 100% with 2mg of Narcan right off the bat to avoid precipitating a vomiting, unpleasant, miserable human being. However, I've also had the OD who comes in, cyanotic, respiration rate of 0, who I don't particularly feel like giving little aliquots of narcan to and hope they start breathing spontaneously before getting a nice anoxic brain injury. Had a 19YO girl the other day who was carried in blue, I started bagging her, nurses got an IV somehow, slammed 2mg of narcan and she woke up after what felt like a long time but was probably about 10 seconds. Got crap from my attending about not starting with small amounts, but this really wasn't the patient I felt like screwing around with. At that moment I didn't care how unpleasant she became, I wanted her wide awake and screaming over the state she came in.

Unless you were unable to BVM (rare with adjuncts in such a patient) or LMA ventilate, I doubt it was the narcan that saved her. Apenic patients are usually easier to ventilate than the erratic, slowly breathing patient.

The dose and frequency of narcan admin seems unrelated.

HH

 

[Rendar5]

the patient doesn't need to breath spontaneously to avoid anoxic brain injury...you just have to bag them. I had an OD the other day carried in blue. I bagged him and he was no longer blue. the 0.4mg of narcan, which the nurses protested twice, got them at 12/min after about 15-20 seconds, long after their sats were normal. And I didn't have to deal with teh vomit over my scrubs, the nurses scrubs, in the patient's airway, or a screaming patient leaving AMA or eloping before their OD wore off. Plus in my state they are as likely to OD on IV oxy's or other narcotic as much as heroin, so it's not really safe for them to leave AMA unless I know what they had (unliek where I trained where all of these were heroin OD's)

 

[deleted547339]

the patient doesn't need to breath spontaneously to avoid anoxic brain injury...you just have to bag them. I had an OD the other day carried in blue. I bagged him and he was no longer blue. the 0.4mg of narcan, which the nurses protested twice, got them at 12/min after about 15-20 seconds, long after their sats were normal. And I didn't have to deal with teh vomit over my scrubs, the nurses scrubs, in the patient's airway, or a screaming patient leaving AMA or eloping before their OD wore off. Plus in my state they are as likely to OD on IV oxy's or other narcotic as much as heroin, so it's not really safe for them to leave AMA unless I know what they had (unliek where I trained where all of these were heroin OD's)

Fair enough. I would say we have about 10 heroin OD's for every 1 PO rx.

 

[throckmortonDO]

I used to give them 2mg IV narcan and then 2mg IM narcan on the backside when at the county hospital. most of those were likely pure heroin ODs. they all eloped quickly after the 2mg IV so I figured the IM dose would at least keep them up for a few more hrs without returning.

Community ED, I try to give them 0.2-0.4mg bumps to get them breathing on their own and admitted for observation. in my experience these tend to be the methadone/oxycontin pill melters who mainline the stuff and mix it with etoh and other stuff, many times narcan doesn't work well and you usually end up tubing them. likely tox-screen rainbow. call it 'likely polysubstance OD with poor response to narcan' and admit after treating other toxidrome if present. sometimes medicine is aggressive and wants to put them on narcan drips. they can do that if they want, not me.

if EMS/police/whoever gave them 2-4mg IV and they come in screaming I do the following: puking? sedate, intubate for aspiration/airway protection, let the narcs wear off for extubation upstairs. Violent? security and techs hold them down for Geodon/ativan/restraints, admit for observation for drug induced psychosis/psych consult. if they get past security, document 'assaulted security and they were unable to restrain, police alerted'. you did your due diligence, you aren't security or the cops, that's all you can do. Don't risk your nurses and techs.

If wake up from narcan from EMS 2-4mg, reasonable, non-violent, wants to leave, I give them 2mg IM, let them elope, document elopement, notify police.

if narcanned and wake up and compliant, observe for 4 hrs, obtain tox screen. if methadone/oxy admit overnight for possible rebound, if fine after 4 hrs dc home.

Don't AMA these people. many times "AMA" actually rescinds their initial 'consent' to be treated, as rediculous as it sounds. it can be construed as breach of duty towards the patient in court.

 

[Interpolfanclub]

An AMA rescinds their initial consent? I've never heard that anywhere.

Amazing the difference of opinions on this. I used to practice in a location with one of the highest rates of heroin abuse in the country and I would send people out AMA regularly after giving narcan for a heroin overdose. I never sedated or held those patients against their will and all of my colleagues had a similar practice. Maybe it was because we saw so much heroin that there was no way we could possibly admit or obs all of our heroin overdoses. In 8 hours it would not be unusual to see 3 or 4 heroin overdoses (community hospital.)

I documented that they only used heroin, they understood the risk of leaving against medical advice, had them sign the papers and sent them out. I don't know how you argue that you can hold someone against their will when they are awake and understand the consequences of leaving etc. In my experience people who get narcan are perfectly lucid and able to understand the risk they take when leaving.

 

[TooMuchResearch]

An AMA rescinds their initial consent? I've never heard that anywhere.

Amazing the difference of opinions on this. I used to practice in a location with one of the highest rates of heroin abuse in the country and I would send people out AMA regularly after giving narcan for a heroin overdose. I never sedated or held those patients against their will and all of my colleagues had a similar practice. Maybe it was because we saw so much heroin that there was no way we could possibly admit or obs all of our heroin overdoses. In 8 hours it would not be unusual to see 3 or 4 heroin overdoses (community hospital.)

I documented that they only used heroin, they understood the risk of leaving against medical advice, had them sign the papers and sent them out. I don't know how you argue that you can hold someone against their will when they are awake and understand the consequences of leaving etc. In my experience people who get narcan are perfectly lucid and able to understand the risk they take when leaving.

I also treat people as having capacity after waking with Narcan. Most of my non-intubated overdoses have been reasonable about hanging out for a couple hours but I would AMA if they want to go. If they demonstrate capacity, they demonstrate capacity.

 

[d2305]

Vivitrol would fix them for a month. Too bad it's a grand per dose.

 

[alpinism]

An AMA rescinds their initial consent? I've never heard that anywhere.

Amazing the difference of opinions on this. I used to practice in a location with one of the highest rates of heroin abuse in the country and I would send people out AMA regularly after giving narcan for a heroin overdose. I never sedated or held those patients against their will and all of my colleagues had a similar practice. Maybe it was because we saw so much heroin that there was no way we could possibly admit or obs all of our heroin overdoses. In 8 hours it would not be unusual to see 3 or 4 heroin overdoses (community hospital.)

I documented that they only used heroin, they understood the risk of leaving against medical advice, had them sign the papers and sent them out. I don't know how you argue that you can hold someone against their will when they are awake and understand the consequences of leaving etc. In my experience people who get narcan are perfectly lucid and able to understand the risk they take when leaving.

Holy crap.

Sounds like Charm city...

For anyone who hasn't seen the now famous tumblr:

http://thatguysonheroin.com

 

[Hair Police]

Tangentially related - what do you all think about narcan to go for opioid ODs dc'd from the ED? Either with an autoinjector, or with a script for one? (They would be given teaching as well, just like with Epi pens)

 

[Birdstrike]

Tangentially related - what do you all think about narcan to go for opioid ODs dc'd from the ED? Either with an autoinjector, or with a script for one? (They would be given teaching as well, just like with Epi pens)

I think from an ED perspective it would be a bad habit to get into sending patients home with narcan autoinjectors, with the obvious reason being, if you think they're at high enough risk that they could go home and die needing narcan, then it would obviously be better to admit them. But I think you're talking about those refusing to be admitted after a narcan dose. These patients put everyone in a terrible positing creating terrible dilemmas. There are few easy answers. Narcan home injectors are out there.

Interestingly, there is a movement now for doctors (PCPs, Pain) to send their high dose chronic opiate patients home with narcan autoinjectors.

http://projectlazarus.org/patients-families/what-naloxone

I personally have mixed thoughts about it. I feel that from the perspective of those doctors managing patient's chronic pain medicines, if you're about to click on the "narcan autoinjectors" button on the EMR, that probably should be a brain queue to go back and un-click the high-dose opiate button and consider taking your patient off the drug regimen you think could kill them. At the same time, I realize we've inherited a legacy generation of patients on ridiculous regimens of high dose opiates that we have to deal with, many of whom have legitimate problems making these dilemmas very difficult to solve easily, and that policies like this could possibly reduce accidental ODs from a public health policy perspective. I wish I had easier answers for these dilemmas.

 

[TooMuchResearch]

I think from an ED perspective it would be a bad habit to get into sending patients home with narcan autoinjectors, with the obvious reason being, if you think they're at high enough risk that they could go home and die needing narcan, then it would obviously be better to admit them. But I think you're talking about those refusing to be admitted after a narcan dose. These patients put everyone in a terrible positing creating terrible dilemmas. There are few easy answers. Narcan home injectors are out there.

Interestingly, there is a movement now for doctors (PCPs, Pain) to send their high dose chronic opiate patients home with narcan autoinjectors.

http://projectlazarus.org/patients-families/what-naloxone

I personally have mixed thoughts about it. I feel that from the perspective of those doctors managing patient's chronic pain medicines, if you're about to click on the "narcan autoinjectors" button on the EMR, that probably should be a brain queue to go back and un-click the high-dose opiate button and consider taking your patient off the drug regimen you think could kill them. At the same time, I realize we've inherited a legacy generation of patients on ridiculous regimens of high dose opiates that we have to deal with, many of whom have legitimate problems making these dilemmas very difficult to solve easily, and that policies like this could possibly reduce accidental ODs from a public health policy perspective. I wish I had easier answers for these dilemmas.

My assumption was that the question is whether to send Narcan with the addicts you are discharging.

I'm for giving them prescriptions for reversal agents since they are at high risk of overdosing again.

 

[Birdstrike]

My assumption was that the question is whether to send Narcan with the addicts you are discharging.

I know. I acknowledged that in my post.

I'm for giving them prescriptions for reversal agents since they are at high risk of overdosing again.

...and hopefully a detox addiction/psych referral.

 

[Hair Police]

I think from an ED perspective it would be a bad habit to get into sending patients home with narcan autoinjectors, with the obvious reason being, if you think they're at high enough risk that they could go home and die needing narcan, then it would obviously be better to admit them. But I think you're talking about those refusing to be admitted after a narcan dose. These patients put everyone in a terrible positing creating terrible dilemmas. There are few easy answers. Narcan home injectors are out there.

Interestingly, there is a movement now for doctors (PCPs, Pain) to send their high dose chronic opiate patients home with narcan autoinjectors.

http://projectlazarus.org/patients-families/what-naloxone

I personally have mixed thoughts about it. I feel that from the perspective of those doctors managing patient's chronic pain medicines, if you're about to click on the "narcan autoinjectors" button on the EMR, that probably should be a brain queue to go back and un-click the high-dose opiate button and consider taking your patient off the drug regimen you think could kill them. At the same time, I realize we've inherited a legacy generation of patients on ridiculous regimens of high dose opiates that we have to deal with, many of whom have legitimate problems making these dilemmas very difficult to solve easily, and that policies like this could possibly reduce accidental ODs from a public health policy perspective. I wish I had easier answers for these dilemmas.

I feel the same on some of the points you mention. But let's assume it was a patient who has cleared their OD (i.e., NOT the patient who just received narcan and now wants to leave AMA). Sub ab referral is a given.

For further discussion, let's say we have a different patient with a benign complaint and they are about to be discharged home when you notice they have a high daily regimen of opiates (and therefore at high risk of accidental OD). should they get an autoinjector?

 

[link2swim06]

I feel the same on some of the points you mention. But let's assume it was a patient who has cleared their OD (i.e., NOT the patient who just received narcan and now wants to leave AMA). Sub ab referral is a given.

For further discussion, let's say we have a different patient with a benign complaint and they are about to be discharged home when you notice they have a high daily regimen of opiates (and therefore at high risk of accidental OD). should they get an autoinjector?

I'd say yes. The risk of narcan is pretty low.

The counterpoint is that it will make people more reckless with opiates as they have a "safety net" hence more likely to OD, I don't know if that has ever been proven.

 

[shookwell]

I agree with using small amounts of narcan, I start with 0.05 mg. But if they get reversed and want to leave I do not stop them.

But guess what the settlement was for the patient who got out of the ED and ran onto the freeway and was killed?

Tie em down. Knock em out. Jot down a paragraph about why you did it. Quit worrying about it.

NY state's highest court said that you are not allowed to keep intoxicated patients against their will: http://www.wilsonelser.com/writable/files/Client_Alerts/kowalski_v_stfrancis.pdf

 

[The White Coat Investor]

I agree with using small amounts of narcan, I start with 0.05 mg. But if they get reversed and want to leave I do not stop them.



NY state's highest court said that you are not allowed to keep intoxicated patients against their will: http://www.wilsonelser.com/writable/files/Client_Alerts/kowalski_v_stfrancis.pdf

Interesting! Seriously thank you for sharing this as it may come in valuable for someone in the future, maybe even me.

Of course, in this case, clearly it would have been better if they had tied the guy down against his will. What's the risk here? Seriously. That I get sued civilly for the value of 6 hours of someone's time? That I get sued criminally for kidnapping where I was clearly acting in what I felt to be their best interest? Not worried. I'll tie them down every time.

Actualy, I shouldn't say that. I let lots of heroin ODs go after narcan. But I agree the wisdom is in small doses of narcan. But I have a pretty low threshold to tie people down. Safer for everyone.

 

[Dred Pirate]

I understand about doing the small baby doses (that is what we do in house for patient that hit their PCA a few too many times), but what about when EMS brings in a guy and have 4-10 mg of narcan? then he wants to sign out?

 

[The White Coat Investor]

Delay, delay, delay until he elopes.