Wants food!! Left AMA!

[LaBusqueda]

Now, not to try to be original or epic in any way...and this is something we see on a shiftly basis...but Iost my stuff with a of the other day when a pt ended up leaving AMA.
Talked to him multiple times to no avail.

Comes in with pretty classic flash pull edema. Very, very, hypertensive. Ended up on Cardene gtt. Was doing "better" but still looked like could end up on biPAP. So asked to keep NPO for a little bit (anyone else have someone yak on biPAP?). So person ended up throwing a conniption and storming out of ED because we would not feed him and of course....
We weren't doing anything for him anyway!!!!

As "Charles In Charge" once said: "it's like talking to styrofoam".

I wold give substantially to an nationwide policy of NO FOOD IN THE ER, ever.

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[erdoc00]

No food in th ER you say?

Let us see how this polls in our consumer test groups and we'll get back to you...

 

[Old&InTheWay]

I'm just curious: would it be safer for the patient to just let them eat AMA (rather than leave the ED altogether)?

 

[DeadCactus]

I'd rather give to a policy where I'm not held responsible for babysitting patients. I'd rather have the freedom of giving my opinion on what the patient should do and walking away than the power and responsibility of forcing their hand...

 

[WilcoWorld]

Didn't you know that "ER" stands for "Emergency Restaurant"?

 

[Promethean]

Some people cannot be saved from themselves. If you sincerely tried to talk to him, to educate him about the risk he was taking by walking out, you did your bit.

 

[KarlPilkington]

It seems like it would have been much easier to just let the patient eat. I have folks vomit on BiPAP from time to time, in an awake talking patient with intact gag reflexes it's rarely more than a mess to clean up.

Patients leaving AMA are risky from all angles. More likely to have bad outcomes, more likely to be upset about their care, more likely to turn around and sue me. I do what I can to keep folks in the department who I feel actually need to be in the department. I've gone as far as to walk out to the parking lot with a patient so they could smoke in order to keep them from leaving (septic joint needing a washout).

 

[gman33]

Food in the ED should only be for hypoglycemic patients.
If your main priority is to eat, you probably don't need to be there.

That being said, a guy like that I would rather feed than have them leave AMA.

 

[Arcan57]

In general flash, pulmonary edema due to massively increased afterload tends to follow a pretty predictable course in the absence of complicating factors (bad COPD, concomitant AMI, long acting sympathomimetic OD come to mind). If they are feeling "better" and they're not on BiPap, it's going to be pretty rare that they then suddenly worsen.

In the ED, there aren't a lot of diseases that we "fix". In general, we rule out the life threatening things and provide symptomatic treatment. It sucks to be hungry and we have an intervention that reduces that discomfort. If you honestly believe that the threat to the patient's health from eating outweighs the discomfort of not eating, then NPO it is. Otherwise, let them eat. It's the decent thing to do.

 

[Birdstrike]

Now, not to try to be original or epic in any way...and this is something we see on a shiftly basis...but Iost my stuff with a of the other day when a pt ended up leaving AMA.
Talked to him multiple times to no avail.

Comes in with pretty classic flash pull edema. Very, very, hypertensive. Ended up on Cardene gtt. Was doing "better" but still looked like could end up on biPAP. So asked to keep NPO for a little bit (anyone else have someone yak on biPAP?). So person ended up throwing a conniption and storming out of ED because we would not feed him and of course....
We weren't doing anything for him anyway!!!!

As "Charles In Charge" once said: "it's like talking to styrofoam".

I wold give substantially to an nationwide policy of NO FOOD IN THE ER, ever.

I guess I'm just a little puzzled as to what is odd or out of the norm with this scenario. Seems par for the course to me.

 

[WilcoWorld]

I guess I'm just a little puzzled as to what is odd or out of the norm with this scenario. Seems par for the course to me.

When I read the post my first thought was "Oh, looks like Peter Gabriel went to LaBusquenda's ED." We have a guy who comes in about once every 2 weeks (always via EMS) and either gets admitted to our ICU or signs out AMA (then demands a cab voucher) every time.

He's still alive...

 

[LaBusqueda]

I initially was wanting to hold and told him just for a little bit. Not unreasonable. Had a couple vomit on biPAP and not a pretty sight.
BUT I told him he could eat, to just give it a few min.
Even after that when I told the nurse to let him stuff himself, he was still irate and saying we were not doing anything for him, bla bla bla.
We could not talk him into staying.

I do not feel bad, I am just sometimes taken aback even after many years, of how idiotic people can be.
And of course my desire to have food free ED was not serious...but boy would it be nice.

 

[LaBusqueda]

It seems like it would have been much easier to just let the patient eat. I have folks vomit on BiPAP from time to time, in an awake talking patient with intact gag reflexes it's rarely more than a mess to clean up.

Patients leaving AMA are risky from all angles. More likely to have bad outcomes, more likely to be upset about their care, more likely to turn around and sue me. I do what I can to keep folks in the department who I feel actually need to be in the department. I've gone as far as to walk out to the parking lot with a patient so they could smoke in order to keep them from leaving (septic joint needing a washout).

Perhaps. But to my own demise, I rarely do what is easier:/

It is risky, but there is only so much we can do.
I/we offered everything we could to get to stay. Discussed and charted to the nines. Did what I could.

 

[Birdstrike]

I do not feel bad, I am just sometimes taken aback even after many years, of how idiotic people can be.

Yes, it is amazing and also frustrating, especially if you're someone that actually does want to help people beyond just collecting a paycheck. You can try to help people, but some people just won't let you. Sometimes there's nothing you can do.

And of course my desire to have food free ED was not serious...but boy would it be nice.

It makes sense, but our current environment is not driven by what makes the most sense according to us as doctors, what's healthiest or what's most ethical for a given patient. Instead it is driven by "customer" demand and patient satisfaction ie "instant gratification" first, to bring on the greatest hospital and corporate revenue.

This is the way the government (CMS), hospital boards of directors, insurance companies and customers/patients want it. Therefore, being the lone wolf in the wilderness demanding what "makes the most sense" and doing what is right, can be very hard.

 

[Spinach Dip]

Comes in with pretty classic flash pull edema. Very, very, hypertensive. Ended up on Cardene gtt. Was doing "better" but still looked like could end up on biPAP. So asked to keep NPO for a little bit (anyone else have someone yak on biPAP?). So person ended up throwing a conniption and storming out of ED because we would not feed him and of course....
We weren't doing anything for him anyway!!!!

Intubation is a sure-fire method to prevent someone from leaving AMA.

 

[Vandalia]

Back around 1980, the public education complex came up with a great phrase, "You have the right to fail." I don't know exactly why, but we seemed to hear it a couple of times a week from the teachers and the Junior High principal.

I have learned to repeat to myself on occasion, "patients have the right to die." Often they do not have the capacity to make that decision, and in any case, I never have to help them die. But if they want to value a Big Mac over life-saving treatment, well, they have the right to die.

 

[engineeredout]

I love when you get the patient who has been in the ED for an hour or two, complaining about some bull****, usually at 3am, they want to eat, at most we have graham crackers at that time, and we get the response of "you don't have anything real to eat?!?! I haven't eaten in over 24 hours!!!!!" Meanwhile I'm wondering why that has anything to do with me. I am not responsible for your food choices prior to entering the ED

 

[takeurmeds02]

Haha, I'm a scribe in the ED. We had a guy come in the other day, etoh in the 400's, gown on, IV in, etc. He elopes the ED, goes down to the liquor store around the corner, (in his gown with IV in mind you), buys a fifth of whiskey, and brings it back to his room in the ED. It was beyond epic. We still can't figure out how he was able to buy liquor in a gown with an IV....I love the ED.

 

[TooMuchResearch]

Haha, I'm a scribe in the ED. We had a guy come in the other day, etoh in the 400's, gown on, IV in, etc. He elopes the ED, goes down to the liquor store around the corner, (in his gown with IV in mind you), buys a fifth of whiskey, and brings it back to his room in the ED. It was beyond epic. We still can't figure out how he was able to buy liquor in a gown with an IV....I love the ED.

Probably with money.

 

[Arcan57]

Probably with money.

That's certainly a more pleasantly imagined scenario than the alternatives.

 

[Spinach Dip]

Probably with money.

*rimshot*