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COVID - Catch 22

BAM!

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Oct 5, 2004
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What to do?

Patient actively coughing with SOB and fever refuses to wear a mask despite all persuasion attempts.

On the one hand, physicians need a safe environment.
On the other hand, EMTALA.

N95? PAPR? Doorway medicine? Don't see them? What if you don't have sufficient PPE?

Discuss.
 
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Feb 4, 2017
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  1. Attending Physician
What to do?

Patient actively coughing with SOB and fever refuses to wear a mask despite all persuasion attempts.

On the one hand, physicians need a safe environment.
On the other hand, EMTALA.

N95? PAPR? Doorway medicine? Don't see them? What if you don't have sufficient PPE?

Discuss.

sadly I’d be more afraid of EMTALA in this situation.


full PPE as if intubating (N95 or respirator or PAPR, face shield, eye protection, gown).

neg pressure room if available.

if purposely coughing on staff that is a crime I believe in most states, so maybe police. def if doing so and known pos.
 
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BoardingDoc

Don't worry. I've got my towel.
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  1. Attending Physician
What to do?

Patient actively coughing with SOB and fever refuses to wear a mask despite all persuasion attempts.

On the one hand, physicians need a safe environment.
On the other hand, EMTALA.

N95? PAPR? Doorway medicine? Don't see them? What if you don't have sufficient PPE?

Discuss.
Generally agree with mantis above, but depends on circumstance.

Normal vitals and no respiratory distress and they're an ass? Discharge immediately.

Tachy and in moderate distress? Full PPE and business as usual.
 
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docB

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We've run into this almost daily since the start of the pandemic. It's the intoxicated patients. They don't care about anyone else. They don't really know what's going on and they don't remember what they're told from one moment to the next. They can't be summarily discharged because they're altered. And they present a very difficult nursing dilemma in that they can't go in an iso room unsupervised because of the AMS. It's a mess.
 
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BoardingDoc

Don't worry. I've got my towel.
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We've run into this almost daily since the start of the pandemic. It's the intoxicated patients. They don't care about anyone else. They don't really know what's going on and they don't remember what they're told from one moment to the next. They can't be summarily discharged because they're altered. And they present a very difficult nursing dilemma in that they can't go in an iso room unsupervised because of the AMS. It's a mess.
IM Haldol + patient on monitor until sober then DC. Explain to them that this is what will happen to them if they don't sit still and stop doing whatever it is they're doing. If they keep it up you just document that the patient was heavily intoxicated, not following commands and was a danger to both themselves and others which required immediate chemical restraint.
 
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bravotwozero

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IM Haldol + patient on monitor until sober then DC. Explain to them that this is what will happen to them if they don't sit still and stop doing whatever it is they're doing. If they keep it up you just document that the patient was heavily intoxicated, not following commands and was a danger to both themselves and others which required immediate chemical restraint.

There's a reason I give haldol out like it's candy. Mostly no more than 2mg, but still...
 
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docB

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We routinely sedate people but it's often not that simple. First off it can significantly extend their visit. Often they act the same way once they wake up from the sedation. So unless you roll them outside while they're still asleep hoping they'll wake up and wander off you're just kicking the can down the road.

My point was more that we're in such a subservient position to the patients we can't really alter what we do based on their inappropriate behavior. We are expected to keep quiet and keep seeing them.
 
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WilcoWorld

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I don't have enough information.

What's the patient's pulse ox? What is their arterial CO2? Have they been tested for COVID-19 in the last 2 weeks? What is the serum alcohol level? Have you applied our institutionally sanctioned communication techniques?

Just kidding.

In real life, after determining from the door that the pt wasn't in respiratory distress, I'd probably tell the patient to put a mask over his nasal cannula or GTFO. After that I would document, in explicit detail, everything that I and my staff had done to try to help the patient (which, when you start typing it out, you realize is typically over and above the call of duty).

If I thought the behavior was motivated by air hunger/hypoxia/hypercarbia I'd have an N-95 donned crew administer a B52 or something like that, and proceed to do the workup.
 
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thegenius

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I would never go into a room if I felt the patient may harm me. One way to harm is breathe and cough a deadly, infectious agent on you. Another way is brandishing a knife. Or punching you. These are all the forms of harm.

The patient gets no medical care until it's safe for people to deliver medical care.

I would doctor from the door, much like WilcoWorld above, and not go in until the patient cooperates.

If I literally felt like they were dying (say they weren't on a monitor) by looking on them, then I would don PPE.

If there was no PPE, and they were dying, and you have reason to believe the patient might harm you, why go into the room?

Would you go into a room if someone had a gun pointing at you and said "I have chest pain, help me now?"
No f'ing way.
 
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oldiebutgoodie1211

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I would never go into a room if I felt the patient may harm me. One way to harm is breathe and cough a deadly, infectious agent on you. Another way is brandishing a knife. Or punching you. These are all the forms of harm.

The patient gets no medical care until it's safe for people to deliver medical care.

I would doctor from the door, much like WilcoWorld above, and not go in until the patient cooperates.

If I literally felt like they were dying (say they weren't on a monitor) by looking on them, then I would don PPE.

If there was no PPE, and they were dying, and you have reason to believe the patient might harm you, why go into the room?

Would you go into a room if someone had a gun pointing at you and said "I have chest pain, help me now?"
No f'ing way.

this is gonna be controversial in court..although I don’t necessarily disagree with you..
 
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