At what point can you refuse to treat a patient in the ED?

[funnybanana]

I’m curious as to what point you can refuse to treat a patient who is belligerent, rude, and unwilling to comply with your medical exam. I know that is emergency physicians we often see people at their worst, but sometimes patients are so downright disrespectful that you may not feel to treat them. However, this could be an EMTALA violation. So my question is at what point can you call security to have a patient escorted out of the emergency department and not be at risk of an EMTALA violation. One of my biggest peeves is to have 14–15 active patients and somebody just dragging you down and making your life miserable thereby diverting energy away from those who truly need it.

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[valianteffort]

I think it all comes down to documentation. You just have to determine 1) if they have the capacity to leave and 2) you clinically feel they aren’t at risk of an emergent condition (maybe a frontal tumor and increased ICP causing AMS - I know that’s extreme). I think personally if I know someone is intoxicated and acting up, what are they going to do in the outside world walking down the street? If there’s a chance they will misbehave and run into the street, of course I’ll medicate them. If they are just downright rude due to wait times or towards the nurse, you’ll get one or two redirects and be let go. EMTALA’s ‘medical exam’ is kind of gray and I think that helps towards our Benefit. You must document you did a medical exam and to me , that can be extremely minimal and your note can reflect a medical exam even with a verbal encounter with the patient attempting to ease their attitude.

 

[Arcan57]

I think it all comes down to documentation. You just have to determine 1) if they have the capacity to leave and 2) you clinically feel they aren’t at risk of an emergent condition (maybe a frontal tumor and increased ICP causing AMS - I know that’s extreme). I think personally if I know someone is intoxicated and acting up, what are they going to do in the outside world walking down the street? If there’s a chance they will misbehave and run into the street, of course I’ll medicate them. If they are just downright rude due to wait times or towards the nurse, you’ll get one or two redirects and be let go. EMTALA’s ‘medical exam’ is kind of gray and I think that helps towards our Benefit. You must document you did a medical exam and to me , that can be extremely minimal and your note can reflect a medical exam even with a verbal encounter with the patient attempting to ease their attitude.

Depending on the state, chemically/physically restraining a patient just because they're intoxicated is not permitted. I think if someone that's belligerant has a bad outcome because they eloped, you're probably going to be on the hook regardless of documentation. I'd document that I tried to get them to let me examine them, that they were an acute threat to staff attempting to treat them without any evidence of attempt at self-harm, and that I thought the risk of injury to the patient via attempted restraint outweighed risk of a treatable acutely progressing medical condition. We're not a drunk tank and if an intoxicated patient gets hit by a car, you're probably fine.

In terms of who I'll restrain, patients that can't engage in a discussion at all and people with markedly abnormal vital signs usually will get the nod. The drunk pt shouting that they know their rights is (probably) fine, the pt that isn't oriented and is being aggressive probably isn't.

 

[BoardingDoc]

I think it all comes down to documentation. You just have to determine 1) if they have the capacity to leave and 2) you clinically feel they aren’t at risk of an emergent condition (maybe a frontal tumor and increased ICP causing AMS - I know that’s extreme). I think personally if I know someone is intoxicated and acting up, what are they going to do in the outside world walking down the street? If there’s a chance they will misbehave and run into the street, of course I’ll medicate them. If they are just downright rude due to wait times or towards the nurse, you’ll get one or two redirects and be let go. EMTALA’s ‘medical exam’ is kind of gray and I think that helps towards our Benefit. You must document you did a medical exam and to me , that can be extremely minimal and your note can reflect a medical exam even with a verbal encounter with the patient attempting to ease their attitude.

You can't restrain / sedate a patient just because they're drunk. While I understand that this happens all the time, there is case law which supports the viewpoint that being intoxicated does not equal a lack of capacity to make medical decisions.

The case in question is a guy who came to the ED drunk asking for detox. He was hammered by labs, but then decided to elope... walked onto the highway ... ped struck --> Quad. Sued the hospital and the ED doc. Patient lost, as the court ruled that not only did the hospital and doc NOT have a duty to forcibly keep him from leaving, but also that they DID NOT HAVE THE LEGAL RIGHT TO DO SO in the first place.

Wilson Elser Moskowitz Edelman & Dicker LLP — Law Firm

Wilson Elser Moskowitz Edelman & Dicker LLP — Law Firm

www.wilsonelser.com

 

[BoardingDoc]

Depending on the state, chemically/physically restraining a patient just because they're intoxicated is not permitted. I think if someone that's belligerant has a bad outcome because they eloped, you're probably going to be on the hook regardless of documentation. I'd document that I tried to get them to let me examine them, that they were an acute threat to staff attempting to treat them without any evidence of attempt at self-harm, and that I thought the risk of injury to the patient via attempted restraint outweighed risk of a treatable acutely progressing medical condition. We're not a drunk tank and if an intoxicated patient gets hit by a car, you're probably fine.

In terms of who I'll restrain, patients that can't engage in a discussion at all and people with markedly abnormal vital signs usually will get the nod. The drunk pt shouting that they know their rights is (probably) fine, the pt that isn't oriented and is being aggressive probably isn't.

Agree about documenting for the douchecanoes who you need to have escorted out. I document whatever exam I was able to do and then strongly reiterate that I attempted to do X/Y/Z to work the patient up but that the patient refused to allow me to perform even a basic MSE. Document that you explained to the patient that if they did not allow you to perform a MSE, that you would be unable to rule out any dangers to their health, and that the patient expressed understanding of this but continued to behave in an aggressive fashion and refused to allow an MSE to be performed. As the patient was capable of making medical decisions but refusing medical care and impeding the care of others, they were subsequently escorted off the property.

 

[TrailRun]

You can't restrain / sedate a patient just because they're drunk. While I understand that this happens all the time, there is case law which supports the viewpoint that being intoxicated does not equal a lack of capacity to make medical decisions.

The case in question is a guy who came to the ED drunk asking for detox. He was hammered by labs, but then decided to elope... walked onto the highway ... ped struck --> Quad. Sued the hospital and the ED doc. Patient lost, as the court ruled that not only did the hospital and doc NOT have a duty to forcibly keep him from leaving, but also that they DID NOT HAVE THE LEGAL RIGHT TO DO SO in the first place.

Wilson Elser Moskowitz Edelman & Dicker LLP — Law Firm

Wilson Elser Moskowitz Edelman & Dicker LLP — Law Firm

www.wilsonelser.com

I wonder if it’s really that clear cut…. In my mind intoxicated could sometimes imply a lack of capacity. Of course I would love to not keep these people in the ER. But in other legal cases aren’t there times when someone very intoxicated can’t consent to intercourse or similar?

I was also trained to not get a blood alcohol level (as they did in this case) since legally that could theoretically hurt you as they metabolize slowly and would likely still have significant elevation even at the time they are walking steadily and not slurring their words. But of course getting an ethanol level if you’re not sure whether they’re intoxicated or head injury, Etc

 

[southerndoc]

There are a lot of EMTALA violations that have occurred with security escorting a patient off property. This has led to some hefty fines and sanctions against facilities. At least one occurred after a patient assaulted a nurse, was cleared by an ED physician to go to jail, and was arrested for the assault. OIG argued the patient did not receive medical attention despite having an on-call psychiatrist as he was mentally ill. (Floyd Medical Center, Rome, GA 2016).

Unfortunately, CMS/OIG seems to think that EMTALA requires us to take abuse and just treat the patient. It's probably more why they are being abusive. EMTALA enforcement actions do not seem to agree with court decisions (e.g., an intoxicated patient having capacity). It's one of those things where you're screwed either way.

 

[Arcan57]

There are a lot of EMTALA violations that have occurred with security escorting a patient off property. This has led to some hefty fines and sanctions against facilities. At least one occurred after a patient assaulted a nurse, was cleared by an ED physician to go to jail, and was arrested for the assault. OIG argued the patient did not receive medical attention despite having an on-call psychiatrist as he was mentally ill. (Floyd Medical Center, Rome, GA 2016).

Unfortunately, CMS/OIG seems to think that EMTALA requires us to take abuse and just treat the patient. It's probably more why they are being abusive. EMTALA enforcement actions do not seem to agree with court decisions (e.g., an intoxicated patient having capacity). It's one of those things where you're screwed either way.

I will take an EMTALA complaint all day long vs. being injured or having staff injured because of a violent patient.

 

[bravotwozero]

I wonder if it’s really that clear cut…. In my mind intoxicated could sometimes imply a lack of capacity. Of course I would love to not keep these people in the ER. But in other legal cases aren’t there times when someone very intoxicated can’t consent to intercourse or similar?

Therein lies the crux of the issue. It isn't clear cut. In terms of documenting, this can easily just boil down to semantics. Patient is intoxicated, BUT acting belligerently, slurred speech, not oriented, ataxic gait, is THUS a clear danger to self and others, and thus needs physical/chemical restraints. If this person just assaulted someone, what more evidence do you need that he/she is at minimum a danger to others, if not to self? So you're not restraining them 'just for being intoxicated', but everything else mentioned above.

In our area, the local prison facilities have their own psychiatric units that can treat prisoners. If they assault someone, all I need to do is clear them medically and they can receive psychiatric care while being in prison. We do have inpatient psych, and our social workers are extremely helpful in clearing these patients to go to jail anyway.

 

[CajunMedic]

Agree about documenting for the douchecanoes who you need to have escorted out. I document whatever exam I was able to do and then strongly reiterate that I attempted to do X/Y/Z to work the patient up but that the patient refused to allow me to perform even a basic MSE. Document that you explained to the patient that if they did not allow you to perform a MSE, that you would be unable to rule out any dangers to their health, and that the patient expressed understanding of this but continued to behave in an aggressive fashion and refused to allow an MSE to be performed. As the patient was capable of making medical decisions but refusing medical care and impeding the care of others, they were subsequently escorted off the property.

Same here. I'll also document that they were able to get up unaided, walk around, yelling/screaming, etc. to paint the picture that they had no appearance of distress or apparent injury.

 

[namethatsmell]

I’m curious as to what point you can refuse to treat a patient who is belligerent, rude, and unwilling to comply with your medical exam. I know that is emergency physicians we often see people at their worst, but sometimes patients are so downright disrespectful that you may not feel to treat them. However, this could be an EMTALA violation. So my question is at what point can you call security to have a patient escorted out of the emergency department and not be at risk of an EMTALA violation. One of my biggest peeves is to have 14–15 active patients and somebody just dragging you down and making your life miserable thereby diverting energy away from those who truly need it.

1) Assess and clearly document capacity. If pt has this, proceed…
2) If patient is refusing an exam, then do as much of an MSE as you can and clearly document this. If there are no red flags, proceed…
3) Explain to patient option of cooperating vs discharge. If patient starts arguing, benign neglect. Most of the time there’s no need for security. If they get disruptive, document and call security.

 

[ScepticSkeksis]

Absolutely nothing is worth being killed or injured for. I don’t care about EMTALA, admin, or complaints. I’ll take all of that and kick a patient out rather than risk a physical altercation. It’s just a job at the end of the day.

 

[AlmostAnMD]

I will take an EMTALA complaint all day long vs. being injured or having staff injured because of a violent patient.

Same! I have discharged clear-cut admission patients for chest pain and sepsis, though rarely. If they're sober but physically attacking staff or wildly verbally abusive i will not suck off emtala or bend to customer satisfaction. I'll document from a staff safety stand point and the rest is up to fate. Not worth losing sleep or staff over.

 

[EctopicFetus]

“Patient uncooperative with exam, refusing treatment. Patient has capacity to make medical decisions dc at this time told to return if they want to be reevaluated. “

 

[Brigade4Radiant]

https://assets.hcca-info.org/Portals/0/PDFs/Resources/Rpt_Medicare/2016/rmc032816.pdf

Hospital settled for 50k but if the nurse was injured she could have sued the hospital for a lot more.

 

[thegenius]

I’m curious as to what point you can refuse to treat a patient who is belligerent, rude, and unwilling to comply with your medical exam. I know that is emergency physicians we often see people at their worst, but sometimes patients are so downright disrespectful that you may not feel to treat them. However, this could be an EMTALA violation. So my question is at what point can you call security to have a patient escorted out of the emergency department and not be at risk of an EMTALA violation. One of my biggest peeves is to have 14–15 active patients and somebody just dragging you down and making your life miserable thereby diverting energy away from those who truly need it.

If I have a verbally and/or physically abusive patient, I will not see them. If I think they have an emergency I'll wait for them to calm down. if they are there for some nonsense reason I'll just ask them to leave.

I sure as hell document the hell out of that encounter and ask that nurses do the same thing.

 

[thegenius]

You can't restrain / sedate a patient just because they're drunk. While I understand that this happens all the time, there is case law which supports the viewpoint that being intoxicated does not equal a lack of capacity to make medical decisions.

The case in question is a guy who came to the ED drunk asking for detox. He was hammered by labs, but then decided to elope... walked onto the highway ... ped struck --> Quad. Sued the hospital and the ED doc. Patient lost, as the court ruled that not only did the hospital and doc NOT have a duty to forcibly keep him from leaving, but also that they DID NOT HAVE THE LEGAL RIGHT TO DO SO in the first place.

Wilson Elser Moskowitz Edelman & Dicker LLP — Law Firm

Wilson Elser Moskowitz Edelman & Dicker LLP — Law Firm

www.wilsonelser.com

Yeah finally a good outcome for docs. Seems like it never happens.

 

[nikolaite]

It all comes down to decisional capacity in the patient. If you discern his/her capacity, document the four indicators which demonstrate that capacity.

Don’t ever speak about or document your declination to proceed with a patient as a “refusal” on your part. This could come back to haunt you and is inaccurate. You should consider “acquiescing” to a patient’s manifest or verbalized will when he/she opposes medical intervention. If redirect is not possible in a capable patient, offer a brief patient education at the patient’s level (“I can only help if you work with me” sort of thing) with the admonition to return if medical attention is desired or required. Document observations from a quick non-tactile once-over, whether any EMC is evident. Document patient-reported goals for encounter and whether these are outside the scope of the ED. Thank the patient, then order discharge.

You can’t stop people from suing you, but you can comport yourself in a likable fashion for your colleagues (pt follow-up and expert witnesses), med boards, and juries. Don’t ever note an “us vs. them” attitude.

If the patient lacks capacity, even drunk, and has an obvious EMC, four p hold, then IM chem restraint to IV sedation. I believe Good Samaritan laws allow for this.

As always, if you are coming up with gaps in knowledge in practice, check what admin policy is, and maybe schedule a meeting with risk management and legal to develop a written policy if none is in place.

Good luck!

 

[Janders]

It all comes down to decisional capacity in the patient. If you discern his/her capacity, document the four indicators which demonstrate that capacity.

Don’t ever speak about or document your declination to proceed with a patient as a “refusal” on your part. This could come back to haunt you and is inaccurate. You should consider “acquiescing” to a patient’s manifest or verbalized will when he/she opposes medical intervention. If redirect is not possible in a capable patient, offer a brief patient education at the patient’s level (“I can only help if you work with me” sort of thing) with the admonition to return if medical attention is desired or required. Document observations from a quick non-tactile once-over, whether any EMC is evident. Document patient-reported goals for encounter and whether these are outside the scope of the ED. Thank the patient, then order discharge.

You can’t stop people from suing you, but you can comport yourself in a likable fashion for your colleagues (pt follow-up and expert witnesses), med boards, and juries. Don’t ever note an “us vs. them” attitude.

If the patient lacks capacity, even drunk, and has an obvious EMC, four p hold, then IM chem restraint to IV sedation. I believe Good Samaritan laws allow for this.

As always, if you are coming up with gaps in knowledge in practice, check what admin policy is, and maybe schedule a meeting with risk management and legal to develop a written policy if none is in place.

Good luck!

Philosophically and practically, I agree with you. However, ED MDs have gotten in trouble for holding the obviously drunk against their will. Also have gotten in trouble for releasing. We can’t win legally, as far as I can tell.

 

[LChristmas]

Anyone else just call PD in these cases? If they're drunk and don't need a doctor, but you're still worried they might walk into traffic or whatever.

Jail: the place for people who are a danger to themselves and/or others.

At the very least it's a way to buff the chart.

 

[bravotwozero]

Oh yes, don't forget sobering centers. Can be taken there once medically cleared.

 

[TooMuchResearch]

Anyone else just call PD in these cases? If they're drunk and don't need a doctor, but you're still worried they might walk into traffic or whatever.

Jail: the place for people who are a danger to themselves and/or others.

At the very least it's a way to buff the chart.

No, police routinely drop drunk people off in the ED. They don't want them jailed.

 

[TooMuchResearch]

Philosophically and practically, I agree with you. However, ED MDs have gotten in trouble for holding the obviously drunk against their will. Also have gotten in trouble for releasing. We can’t win legally, as far as I can tell.

If I don't think it's safe for the patient without capacity to leave, I do what I can to stop them. This may be state dependent and also depends on if you have security.

 

[GonnaBeADoc2222]

Philosophically and practically, I agree with you. However, ED MDs have gotten in trouble for holding the obviously drunk against their will. Also have gotten in trouble for releasing. We can’t win legally, as far as I can tell.

I have never heard of an ERMD getting in trouble for holding a drunk against their will. I routinely droperidol these people and haven't heard anything.

 

[Rendar5]

I have never heard of an ERMD getting in trouble for holding a drunk against their will. I routinely droperidol these people and haven't heard anything.

The converse is also true. I’ve never heard of an ERMD get in trouble for not holding a drunk against their will. if my nurses don’t want to deal with a drunk I let them elope or leave ama. If my nurses don’t want them to leave then I medicate and then let them sober up if they can’t be reasoned with and they lack capacity

 

[Jabbed]

I don’t really find this line of logic very convincing. If somebody is clearly intoxicated (slurred speech, can’t tell me where they are, dramatically falling over themselves in the hallway), they do not have any medical decision making capacity. My ability to evaluate them for an emergency medical condition is also severely compromised since they can’t verbalize any intelligible complaints and those that they do are ambiguous for emergent pathology vs drunk assholery (“I can’t feel my legs”). My physical exam is also limited as they can’t cooperate with formal motor strength exams, their belly is always tender, and they always have urinary/fecal incontinence. I cannot confidently just perform a MSE and say “no emergency here”.

So I have somebody that isn’t capacitated and has a moderate probability of having acute pathology that I can’t exclude without doing a million dollar workup (that will be taxing on nursing/tech staff) or monitoring for several hours while they’re yelling in the department, urinating on the floor, and just overall being a detriment to society. Lose-lose.

20 mg geodon. Adult swaddle. See you in 6 hours.

 

[Rendar5]

I don’t disagree with you on much except to say that there is not a moderate probability of finding I something wrong with them. The chance of acute pathology in my drunks hovers around 1% or less. As in I see 1-3 per shift and see actual acute pathology maybe once every year or two. (I’m forced to work up a lot of them because our local 👮‍♀️ love to put them on involuntary psych holds ).

 

[WilcoWorld]

If a patient becomes belligerent I make my best attempt to chill them out.
If that doesn't work I say plainly and directly what I am concerned about. I explain my plan in clear, calm language - especially if they're yelling at me.

If that doesn't work, I get out of the way. They leave or decide to stay. If they stay, I treat them. If they leave, I document that I communicated my concerns and explained my plan, then they left and I did not have grounds to obtain a court ordered committal, so I did not purse. Then I place an order for PCP follow up and close the encounter.

 

[Janders]

It isn’t clear cut, courts have ruled both ways (and not unanimously)—

New York's High Court Rules Hospital Is Not Liable for Failure to…

Since ancient times, caring for alcohol-intoxicated patients in the emergency department has always been troubling and risky for emergency physicians and hospital staff. In a high-profile case in New York, the state's highest court essentially held that physicians and hospitals are not thy…

www.reliasmedia.com

Is the case people always talk about where a drunk man walked out of a NY ER, got hit by a car and paralyzed, sued, and lost with the court ruling the ER MD / Hospital should not/could not have legal restrained him…

Dean Leavitt vs Brockton Hospital, Inc., & others is more local to me, and had a similar outcome, this was a ped struck after walking off perhaps confused from his colonoscopy drugs… the responding police officer was injured badly in their response, and THEY sued the hospital.

The MA courts ruled similarly—
Absent a special relationship with a person posing a risk, there is no duty to control another person's conduct to prevent that person from causing harm to a third party, and there was no special relationship between the hospital and the patient that would give rise to such a duty in the circumstances of this case.

Massachusetts courts do not recognize a duty to a third person of a medical professional to control a patient (excluding a patient of a mental health professional). The court cited cases where appeals court judges held that (a) a hospital had no right or ability to control outpatients; (b) a hospital owed no duty to unidentified third parties to control a patient and prevent her from driving upon release; and (c) a medical center's policy, which required staff to ensure that no colonoscopy patient was sedated unless patient had another person to drive patient from hospital, imposed no duty to control the patient and restrict her ability to leave the medical center.


Anyway, its sticky

 

[Tenk]

So I have found that ignoring these types usually gets them to walk out. Just don’t pay attention to them, don’t give them what they want, and they will usually get bored and leave. Then you document patient eloped with a steady gait unassisted despite you wanting to order xyz and move on with your day.

 

[turkeyjerky]

So I have found that ignoring these types usually gets them to walk out. Just don’t pay attention to them, don’t give them what they want, and they will usually get bored and leave. Then you document patient eloped with a steady gait unassisted despite you wanting to order xyz and move on with your day.

How do you get nurses and security to buy in to the fact that benign neglect is fine in these cases? It's one thing if you've been working w/ them for a while and know them, but occasionally you'll be working w/ high strung nurses or overaggressive security guards, and if you not careful the patient will end up in 5 points before you can defuse the situation. I'm talking about the type of patient who, by the book, you can't sign out AMA b/c they either can't, or refuse to, understand the risks thereof, but also isn't so crazy as to be holdable against their will.

 

[Tenk]

How do you get nurses and security to buy in to the fact that benign neglect is fine in these cases? It's one thing if you've been working w/ them for a while and know them, but occasionally you'll be working w/ high strung nurses or overaggressive security guards, and if you not careful the patient will end up in 5 points before you can defuse the situation. I'm talking about the type of patient who, by the book, you can't sign out AMA b/c they either can't, or refuse to, understand the risks thereof, but also isn't so crazy as to be holdable against their will.

None of my staff are like that because we get these people dumped on us all the time.

Also, think about it, these people exist like this EVERY DAY. The only reason, THE ONLY REASON, you are seeing them today is because someone called the cops because they were doing something stupid or found them and brought them in. They survive this the other 364 days of the year doing stupid crap just fine. They don’t need you interfering.

 

[thegenius]

None of my staff are like that because we get these people dumped on us all the time.

Also, think about it, these people exist like this EVERY DAY. The only reason, THE ONLY REASON, you are seeing them today is because someone called the cops because they were doing something stupid or found them and brought them in. They survive this the other 364 days of the year doing stupid crap just fine. They don’t need you interfering.

+ 1

Actually, more like +230,000

 

[turkeyjerky]

None of my staff are like that because we get these people dumped on us all the time.

Also, think about it, these people exist like this EVERY DAY. The only reason, THE ONLY REASON, you are seeing them today is because someone called the cops because they were doing something stupid or found them and brought them in. They survive this the other 364 days of the year doing stupid crap just fine. They don’t need you interfering.

I know it, you know, the American People know it! (RIP)

But how do you get some high-strung nurse not to write you up about it? (blah, blah, endangering patients, something blah).

So, a year ago I was at a shop with a, well let's say, particular culture. Had a patient who was obviously crazy, but probably at their functional baseline (think highly anxious, maybe bipolar but not psychotic), come in w/ multiple nonsensical physical complaints. 10-15 min after I saw her, a nurse comes up to me in a huff "THAT PATIENT WANTS TO SIGN OUT CAN SHE LEAVE!!!" I look up, see this woman surrounded by 4 nurses, trying to run and weave through the ER, two security guards in the background licking their chops waiting to pounce.

I over-dramatically sit down in a chair and cross my legs, slow the cadence of my voice and respond, "well, I don't really think she's holdable but if she doesn't understand risks of leaving she can't really sign AMA" "AARGH! I DONT KNOW WHAT THAT MEANS!!!!!" "well, let's just stop to think about this for a minute. let's just calmly ask her to stay to complete her workup. She came her of her own free will, and hasn't said or done anything that would indicate she's suicidial or an immenient safety risk to anyone else, right? So, I don't think we have the right or duty to physically restrain her at this time....(goes on for a little bit as she walks out in the background)".

 

[RustedFox]

I know it, you know, the American People know it! (RIP)

But how do you get some high-strung nurse not to write you up about it? (blah, blah, endangering patients, something blah).

So, a year ago I was at a shop with a, well let's say, particular culture. Had a patient who was obviously crazy, but probably at their functional baseline (think highly anxious, maybe bipolar but not psychotic), come in w/ multiple nonsensical physical complaints. 10-15 min after I saw her, a nurse comes up to me in a huff "THAT PATIENT WANTS TO SIGN OUT CAN SHE LEAVE!!!" I look up, see this woman surrounded by 4 nurses, trying to run and weave through the ER, two security guards in the background licking their chops waiting to pounce.

I over-dramatically sit down in a chair and cross my legs, slow the cadence of my voice and respond, "well, I don't really think she's holdable but if she doesn't understand risks of leaving she can't really sign AMA" "AARGH! I DONT KNOW WHAT THAT MEANS!!!!!" "well, let's just stop to think about this for a minute. let's just calmly ask her to stay to complete her workup. She came her of her own free will, and hasn't said or done anything that would indicate she's suicidial or an immenient safety risk to anyone else, right? So, I don't think we have the right or duty to physically restrain her at this time....(goes on for a little bit as she walks out in the background)".

"I AM A NIRSE AND YOU NEED TO RESPEXT THE NIRSINGS BECAUSE NIRSINGS IS NIRSINGS AND BECAUSE OUR INPUT IS PATEINT CAREZ."

Christ, the cult of nursing.