Escorting Patients Out

[deleted77919]

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[gman33]

It's rare that I need to escort a patient out, but I had to do it twice this week.
After seeing this story, I'm not sure what I'll do next time.

It's really tough in the patients that are reporting symptoms where this is no definitive test (vague neuro stuff)

 

[The White Coat Investor]

Twice in a week? I think maybe some introspection is in order. This sort of thing should be VERY rare in your career. I can't remember the last patient I had to call police or even security to get them to leave. I think I can count an entire career's worth on one hand. I mean, different populations are going to be different, but still, this shouldn't be an every shift occurrence.

 

[hoot504]

There's a thread on Sermo where some people aired a few details regarding this case. Just to clarify, this apparently was a patient who had been seen in that particular ER literally hundreds of times in 2015 alone. This is not your run-of-the-mill ER patient.

 

[GeneralVeers]

Narc-seekers I will have escorted out every day of the week and as quickly as possible.

If they actually have medical complaints, then I'm more cautious. I'll order the workup on these patients, and can often just convince them to elope either through benign neglect (ignoring them), or not giving them what they want (drugs, tests, secondary gain). It's best for me if they simply walk out, so I can document that I started the workup, and that they declined to stay and finish it and were ambulatory and capable of making decisions.

 

[Hercules]

Twice in a week? I think maybe some introspection is in order. This sort of thing should be VERY rare in your career. I can't remember the last patient I had to call police or even security to get them to leave. I think I can count an entire career's worth on one hand. I mean, different populations are going to be different, but still, this shouldn't be an every shift occurrence.

In the past 6 years since finishing residency I think I may have had 1 patient escorted out by security. I can usually handle it myself by setting clear limits from the beginning of the encounter and showing empathy but explaining what will or will not happen in no uncertain terms. I had a female colleague point out that I'm a larger guy so I don't tend to get as much of the threatening/intimidating tactics by patients. That may be true but I think it's more about quickly establishing rapport and knowing how to deescalate a situation. Of course there are times when all of the above will break down, but I agree with WCI that it should be a pretty rare occasion.

 

[WilcoWorld]

Gman33 specifically said it's a rare occasion. Sometimes rare things will happen twice in the same week.

 

[UnderwaterDoc]

Try working all nights in a county hospital in the middle of the ghetto. When the ghouls come out you will be having people escorted out on a regular basis

This is completely proportional to what type of population you see.

 

[goodoldalky]

Twice in a week? I think maybe some introspection is in order. This sort of thing should be VERY rare in your career. I can't remember the last patient I had to call police or even security to get them to leave. I think I can count an entire career's worth on one hand. I mean, different populations are going to be different, but still, this shouldn't be an every shift occurrence.

Haha, you and I deal with very different patient populations. I'm not saying this is q shift but this stuff is not that unusual and in some places, this can be a regular occurrence (sounds like UnderwaterDoc feels me).

 

[alpinism]

Was about to say the same thing. Hell I've had as many as 3 or 4 in one shift.

Between all the psych, intoxicated, and homeless patients security stays busy most nights.

 

[AlmostAnMD]

Just to clarify, this apparently was a patient who had been seen in that particular ER literally hundreds of times in 2015 alone. This is not your run-of-the-mill ER patient.

Seems like a conflicting statement

 

[gman33]

In residency, plenty of patients needed a helping hand from security everyday.

I still work in a rough area, but it's very rare now.
Just had bad luck this week.
Will do everything possible to avoid this now.
The one thing I won't allow is for my staff to be put in harms way.

 

[WilcoWorld]

This case sounds terrible on first blush. But there may be some things we don't know.

I had a regular patient who had to be escorted off of our hospital campus more often than monthly. Usually from the ICU, but sometimes from the ED. He died last summer. I have a current regular patient who has to be escorted off of our hospital campus occasionally. I really hope she never dies after I discharge her, but it could happen.

Now, I have NEVER recommended discharge for either of these patients. Both of them got escorted out after refusing testing and treatment then becoming verbally abusive and physically threatening to staff when they did not get exactly what they wanted.

I do view it as a failed patient encounter when this happens, but sometimes such failures are inevitable.

 

[The White Coat Investor]

In the past 6 years since finishing residency I think I may have had 1 patient escorted out by security. I can usually handle it myself by setting clear limits from the beginning of the encounter and showing empathy but explaining what will or will not happen in no uncertain terms. I had a female colleague point out that I'm a larger guy so I don't tend to get as much of the threatening/intimidating tactics by patients. That may be true but I think it's more about quickly establishing rapport and knowing how to deescalate a situation. Of course there are times when all of the above will break down, but I agree with WCI that it should be a pretty rare occasion.

Right. I find little resistance when I tell patients what I will and will not do. At that point, staying becomes very unattractive to most, especially drug seekers. Now bed seekers/sandwich seekers/taxi voucher seekers etc are more of the issue. The more they delay the more likely they are to get what they want.

 

[filhodeinferno]

There's a thread on Sermo where some people aired a few details regarding this case. Just to clarify, this apparently was a patient who had been seen in that particular ER literally hundreds of times in 2015 alone. This is not your run-of-the-mill ER patient.

These types of people kill themselves. We have many of them at the ER I work at. Every time I see one I think "one of these days this person will actually be sick and nobody will know." Just hope I'm not the one stuck with the hot potatoe when it drops.

 

[goodoldalky]

A lot of times these are chronically ill patients who actually would benefit from admission all other things being equal. Sometimes you run into the personality, though, that doesn't want to be treated for that problem X, nor be admitted for it, they want Y and Z, and when you offer them X and not Y and Z because they don't need it, and they refuse and they want Y and Z and make a scene about it sometimes you get into a hairy situation. I think most ED docs can relate to this... not a great answer other than trying to do what is best for the patient and writing a really long and consistent chart (making sure your nursing documentation etc is all consistent and accurate as well).

 

[CraftyMed]

Try working all nights in a county hospital in the middle of the ghetto. When the ghouls come out you will be having people escorted out on a regular basis

This is completely proportional to what type of population you see.

Half of my shifts are at a similar sounding location and I'm all nights too. With the winter weather coming in, so are the psychs, drunks, and homeless. I think the difference between my patients and the patient from the news story is that my regular crew doesn't really have any complaints beyond hypo-turkeysammich-itis. While the story doesn't give details, it seems to convey that this woman was reporting some type of a medical complaint. So while several of our patients are 'encouraged' to leave by staff/security after the sun comes up, those that require forcible removal are more rare. This patient in the news seems to have been an admitted patient at some point during the story and was needing to be handcuffed by police and there might have been more than one officer involved. That is more effort than most of our patients require.

 

[UnderwaterDoc]

Half of my shifts are at a similar sounding location and I'm all nights too. With the winter weather coming in, so are the psychs, drunks, and homeless. I think the difference between my patients and the patient from the news story is that my regular crew doesn't really have any complaints beyond hypo-turkeysammich-itis. While the story doesn't give details, it seems to convey that this woman was reporting some type of a medical complaint. So while several of our patients are 'encouraged' to leave by staff/security after the sun comes up, those that require forcible removal are more rare. This patient in the news seems to have been an admitted patient at some point during the story and was needing to be handcuffed by police and there might have been more than one officer involved. That is more effort than most of our patients require.

Just like you the ones I have kicked out are the secondary gain and personality disorders with no real disease who refuse to leave. I don't know anything about that particular case other than what has been said in the news. However my strategy with the sick and also manipulative is to set ground rules from the start, like it was said before by others.

I tell these people my plan, I never bargain and I never let them dictate their care, I make sure I have witnesses with me and I document a squeaky clean chart. I work up and recommend admission if indicated. I have a good relationship with our security and detail staff and I make sure I communicate if I feel somebody needs to be wheelchaired out versus handcuffed and dragged out.

Frail, sickly people, a$$holes or not, do not get forcibly removed. They are gently placed on a wheelchair and brought to our waiting room where a cab is called for them 🙂

Gotta always remember to keep your cool and cover your ass in this lawyer-worshipping society of ours.

 

[southerndoc]

This person's past visits will most likely not be allowed to be presented as evidence by the defense unless the plaintiff uses it to their advantage (that the patient's repeat visits made them not take her seriously). It's odd how the legal system works.

 

[Zebra Hunter]

These types of people kill themselves. We have many of them at the ER I work at. Every time I see one I think "one of these days this person will actually be sick and nobody will know." Just hope I'm not the one stuck with the hot potatoe when it drops.

Yup, my roommate got burned by this. Had a chronic drunk, frequent flyer come in complaining of weakness and slight neck pain after being found down outside a bar. Pt was acting drunk, he did a half-assed neuro exam, documented it as wnl, handed the patient off. About 3 hours later after the oncoming resident realized that despite sobering up, he was still complaining of weakness and is now worsening. They got a CT cervical spine, demonstrating an unstable cervical spine fx. Pt had not been in a cervical collar. From the last note my roommate looked up, the pt appears to be a quadriplegic.

 

[d2305]

I think the physical exertion with the police exacerbated her asthma/copd/pulmonary hypertension.

 

[deleted77919]

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[Tenk]

This person's past visits will most likely not be allowed to be presented as evidence by the defense unless the plaintiff uses it to their advantage (that the patient's repeat visits made them not take her seriously). It's odd how the legal system works.

You'd have to be either insane or have an OJ Simpson team of lawyers to ever take that case to court. Gonna settle.

 

[Perrin]

Yup, my roommate got burned by this. Had a chronic drunk, frequent flyer come in complaining of weakness and slight neck pain after being found down outside a bar. Pt was acting drunk, he did a half-assed neuro exam, documented it as wnl, handed the patient off. About 3 hours later after the oncoming resident realized that despite sobering up, he was still complaining of weakness and is now worsening. They got a CT cervical spine, demonstrating an unstable cervical spine fx. Pt had not been in a cervical collar. From the last note my roommate looked up, the pt appears to be a quadriplegic.

Had somewhat similar episode about a year ago. Two of our regular homeless drunks were brought in after getting in a scuffle. First drunk did most of the beating and just had some cuts on his hands. Xray neg and d/c. Other drunk had a few facial cuts and a good hematoma on head. He was pretty intoxicated, neuro intact other than lethargic and slurred speech. He came back from CT very lethargic and I ended up intubating him. Pulled up the CT and there's a large SDH with shift.

Police show up to make a report. They ask how the two guys are doing. I told them guy 2 looks pretty bad and outlook is poor. Told them guy 1 is hanging out in the lobby and they might want to have a talk with him.

I almost always CT drunks if I have a hint of them possibly hitting their head even with a normal neuro exam. If anything medically bad happens, there are scores of family members who couldn't be bothered to help the guy out, but was their favorite uncle/brother/son when they file the lawsuit.

 

[deleted77919]

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[shoal007]

I've seen drunks with head trauma now a lot in my 6 months in the community. Cops keep bringing them in for clearance, well you're gonna get a ct head and neck. I'm not gonna save the system.

Sent from my VS986 using Tapatalk

 

[Daiphon]

I've seen drunks with head trauma now a lot in my 6 months in the community. Cops keep bringing them in for clearance, well you're gonna get a ct head and neck. I'm not gonna save the system.

Sent from my VS986 using Tapatalk

I've always looked at "jail clearance" as covering the cops, and not the arrestee... I don't look to save the system, I seek to protect the officers.

 

[filhodeinferno]

Dan Quayle is that you?

Haha derp.

 

[gro2001]

Yup, my roommate got burned by this. Had a chronic drunk, frequent flyer come in complaining of weakness and slight neck pain after being found down outside a bar. Pt was acting drunk, he did a half-assed neuro exam, documented it as wnl, handed the patient off. About 3 hours later after the oncoming resident realized that despite sobering up, he was still complaining of weakness and is now worsening. They got a CT cervical spine, demonstrating an unstable cervical spine fx. Pt had not been in a cervical collar. From the last note my roommate looked up, the pt appears to be a quadriplegic.

That's just stupid. If they are drunk and there is any indication of cervical trauma, it doesn't matter if their exam is normal or not. If you don't want to scan them, you should collar them till they sober up and then reassess. Or just scan them already. Neither scanning nor collaring is not a sensible plan.

 

[Zebra Hunter]

That's just stupid. If they are drunk and there is any indication of cervical trauma, it doesn't matter if their exam is normal or not. If you don't want to scan them, you should collar them till they sober up and then reassess. Or just scan them already. Neither scanning nor collaring is not a sensible plan.

He was two months into intern year. I'm quite sure you, as well as every other attending on this board has done something stupid that early in your training, my roommate was just unlucky enough that his mistake actually had consequences (although it's questionable whether a cervical collar would have actually prevented anything...not that this matters when sued).

 

[da8s0859q]

He was two months into intern year. I'm quite sure you, as well as every other attending on this board has done something stupid that early in your training, my roommate was just unlucky enough that his mistake actually had consequences (although it's questionable whether a cervical collar would have actually prevented anything...not that this matters when sued).

What came of this as far as your roommate is concerned?

 

[Zebra Hunter]

What came of this as far as your roommate is concerned?

We had an M&M for the case, no legal action has been taken, at least yet. Our faculty used this as a good learning case regarding documentation and how to deal with frequent flyers and drunks.

 

[gman33]

An additional learning point for trainees.
Make sure you learn how to give and get signout.

What really sucks is that the person who got this case get screwed for someone else's mistake.

Signout is a very high risk time.
Make sure you understand what was done and that you agree with the plan.

If you don't agree start over or if something crazy was done, refuse the signout. This will get people pissed off, so only do this was a terrible oversight.


Also understand that others may be more risk adverse than you.
If you know a patient is going to get signed out, make sure you work the patient up in the most conservative way.

I hate the signout of, this guy is drunk.

No I didn't check anything, he's just sleeping it off.

I don't always think an intoxicated patient needs anything except observation, but i always want to protect my colleagues from disaster.

 

[engineeredout]

This type of stuff makes me nervous. We have our inner city in-the-ghetto hospital that is a constant stream of drunk/high/psych. 99% are just drunk/high/psych, the other 1% turn out to be drunk/high/psych + surprise SDH. I know sooner or later all the frequent fliers will eventually show up truly sick. I just hope I'm not the one that misses it.

The media/public don't want to hear it, but these daily (sometimes twice daily) visits to the ED with nonsense is as high risk a behavior as shooting up heroin, but nobody puts the patient at fault.

Think back to the boy who cried wolf. The moral of that story is not that the townspeople were bad people, it's that the boy brought it on himself.

 

[Cerberus]

Try working all nights in a county hospital in the middle of the ghetto. When the ghouls come out you will be having people escorted out on a regular basis

This is completely proportional to what type of population you see.

I'm with you on this. I've had patients threaten myself, other staff, and other patient's. I have had patients arrested for destroying hospital equipment when they didn't get what they wanted. I work with a special population and it's not that uncommon for us to have patient's escorted out. It's not something I enjoy, but when a patient is threatening violence, being violent, or destroying what little equipment we have, I will not hesitate to have them removed.

 

[Apollyon]

4 groups will screw you EVERY time - the very old, the very young, the very drunk, and the very crazy. We never think about the accidents we didn't have driving - when everything was safe. If you go back and replay it, but make one different decision, you're dead or injured. As someone else who is not literate above (joking! I'm joking!) said, after a sort, you don't want to be the one without a seat when the music stops. You don't want to be "that guy".

 

[UnderwaterDoc]

An additional learning point for trainees.
Make sure you learn how to give and get signout.

What really sucks is that the person who got this case get screwed for someone else's mistake.

Signout is a very high risk time.
Make sure you understand what was done and that you agree with the plan.

If you don't agree start over or if something crazy was done, refuse the signout. This will get people pissed off, so only do this was a terrible oversight.


Also understand that others may be more risk adverse than you.
If you know a patient is going to get signed out, make sure you work the patient up in the most conservative way.

I hate the signout of, this guy is drunk.

No I didn't check anything, he's just sleeping it off.

I don't always think an intoxicated patient needs anything except observation, but i always want to protect my colleagues from disaster.

Signout being a huge risk was hammered into us during residency from day one. I hate giving/getting signouts but it's part of the job.

I treat each signout like a new patient. I go see them from the start, review the workup and add/remove what I feel is necessary. Doing things this way has saved my butt a couple of times (including a signed out "metabolize to freedom" drunk guy that ended up having a fricking epidural hematoma with Cushing's triad in full display when I saw him).

 

[CraftyMed]

(including a signed out "metabolize to freedom" drunk guy that ended up having a fricking epidural hematoma with Cushing's triad in full display when I saw him).

I'm much bigger fan of MTE: metabolize to exam

The receiving doc should re-evaluate the patient to make sure he/she is not only clearing their drug o' choice, but is doing so at an appropriate pace, has no new complaints, or new deficits, etc. Even my regulars will act "irregular" on a occasion and warrant further testing. Found myself a gluteal compartment syndrome once

 

[WilcoWorld]

I'm much bigger fan of MTE: metabolize to exam

The receiving doc should re-evaluate the patient to make sure he/she is not only clearing their drug o' choice, but is doing so at an appropriate pace, has no new complaints, or new deficits, etc. Even my regulars will act "irregular" on a occasion and warrant further testing. Found myself a gluteal compartment syndrome once

Sounds like a pain in the a$$.

 

[gro2001]

He was two months into intern year. I'm quite sure you, as well as every other attending on this board has done something stupid that early in your training, my roommate was just unlucky enough that his mistake actually had consequences (although it's questionable whether a cervical collar would have actually prevented anything...not that this matters when sued).

Absolutely. I have done quite a number of stupid things. And that didn't stop with intern year.

I would never blame a second month intern for something like that. I would blame whoever was supposed to be supervising them though. If the intern had the chance to evaluate the patient, sign him out, have the patient sober up and the next shift's junior resident re-evaluate the patient and notice something was wrong, at some point in that process a senior resident or attending should have noticed the mistake.

I agree with you about the questionable utility of the cervical collar (and also about how it's irrelevant to liability). I would say I am a cervical collar agnostic. But thats the widely accepted therapy for by most reasonable emergency physicians and neurosurgeons for suspected cervical fracture which this is until the patient can be ruled out clinically or through imaging.

 

[Daiphon]

I'm much bigger fan of MTE: metabolize to exam

The receiving doc should re-evaluate the patient to make sure he/she is not only clearing their drug o' choice, but is doing so at an appropriate pace, has no new complaints, or new deficits, etc. Even my regulars will act "irregular" on a occasion and warrant further testing. Found myself a gluteal compartment syndrome once

Agree... but MTF is more appropriate.

See, it's like WTF only @ss over head drunk. d=)

 

[Old_Mil]

Think back to the boy who cried wolf. The moral of that story is not that the townspeople were bad people, it's that the boy brought it on himself.

True. Unfortunately Aesop has been replaced in the curriculum by Honey Boo Boo.

 

[SoCuteMD]

I'm much bigger fan of MTE: metabolize to exam

The receiving doc should re-evaluate the patient to make sure he/she is not only clearing their drug o' choice, but is doing so at an appropriate pace, has no new complaints, or new deficits, etc. Even my regulars will act "irregular" on a occasion and warrant further testing. Found myself a gluteal compartment syndrome once

Agree. I never sign out my patients as "MTF." I always document the plan as "re-evaluation" and sign out the patient that way.