Milwaukie ER overdose death

[betamale]

Final moments of ODing patient discharged by doctor who said he was ‘playing possum’ seen in disturbing bodycam footage

Jean DesCamps, 26, was admitted to Providence Milwaukie Hospital on Dec. 12 after he was found covered in feces and moving slowly on Portland’s TriMet MAX train.

nypost.com

read this and I just can't believe it. embarrassing

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[JacobMcCandles]

Well, it’s not too surprising when the job can suck your soul and compassion, especially when you see the same people over and over again for the same things.

 

[BoardingDoc]

Yeah, discharging obtunded patients isn't a good look. If this guy had a known hx of opioid abuse and "playing possum" and otherwise being a recurring a-hole I would have simply given him 2-4mg IV narcan. It's therapeutic for both you and the patient at that point. If they still don't get up --> increasingly noxious stimuli. I'm a big fan of inserting nasal trumpets in cases like this and with pseudoseizures. If they STILL won't wake up after I've done the above, they probably aren't faking and I've already helped secure their airway. Intubate PRN and do all the things.

 

[Rekt]

Yeah, discharging obtunded patients isn't a good look. If this guy had a known hx of opioid abuse and "playing possum" and otherwise being a recurring a-hole I would have simply given him 2-4mg IV narcan. It's therapeutic for both you and the patient at that point. If they still don't get up --> increasingly noxious stimuli. I'm a big fan of inserting nasal trumpets in cases like this and with pseudoseizures. If they STILL won't wake up after I've done the above, they probably aren't faking and I've already helped secure their airway. Intubate PRN and do all the things.

Yeah this is pretty clear cut gross negligence. I’ll be the first to say I can’t stand these patients and feel like my current shop has to be top percentile for the amount of druggie losers like this pt that are seen. But they still have to be able to walk and talk before they can be discharged. I have to have PD come weekly to remove people, but not because they’re obtunded. I also don’t waste time either, narcan to agitated freedom or tube them. Next.

 

[betamale]

we all deal with this everyday but still…this is inexcusable makes us all look horrible. and for some reason these news articles keep popping up on my newsfeed

Patient dumping complaints persist: Troubleshooters investigate the gap in services

A lot is going on outside University of Louisville Hospital, a level-one trauma center. Medical helicopters, ambulances, police, even arrests. But on Oct. 4 at dusk, something else caught the eye of an arriving ambulance crew.

www.wave3.com

safest thing to do is act like everyone is watching and recording everything you do.

 

[RustedFox]

Yeah this is pretty clear cut gross negligence. I’ll be the first to say I can’t stand these patients and feel like my current shop has to be top percentile for the amount of druggie losers like this pt that are seen. But they still have to be able to walk and talk before they can be discharged. I have to have PD come weekly to remove people, but not because they’re obtunded. I also don’t waste time either, narcan to agitated freedom or tube them. Next.

This is America.

 

[Rekt]

This is America.

The biggest cause of burn out is….

 

[BoardingDoc]

we all deal with this everyday but still…this is inexcusable makes us all look horrible. and for some reason these news articles keep popping up on my newsfeed

Patient dumping complaints persist: Troubleshooters investigate the gap in services

A lot is going on outside University of Louisville Hospital, a level-one trauma center. Medical helicopters, ambulances, police, even arrests. But on Oct. 4 at dusk, something else caught the eye of an arriving ambulance crew.

www.wave3.com

safest thing to do is act like everyone is watching and recording everything you do.

I read the article you linked. The ED literally did nothing wrong in the documented scenario. He's clearly homeless and does not appear to have any sort of acute medical emergency. He also was offered and refused a ride to a homeless shelter by the EMS crew that seemed so appalled that he was "kicked out." What precisely should have been done differently? What is the treatment or service that we offer that was not provided? I get that people were actually recording in this scenario, but I honestly don't think I'd have a problem defending myself were I one of the people that escorted this guy out.

 

[BoardingDoc]

Also, the hospital response (section in italics in the article) is very well written and addresses everything I said more eloquently and would be what I would refer people to if I were ever confronted about "not doing ... whatever."

 

[Iamnew2]

Final moments of ODing patient discharged by doctor who said he was ‘playing possum’ seen in disturbing bodycam footage

Jean DesCamps, 26, was admitted to Providence Milwaukie Hospital on Dec. 12 after he was found covered in feces and moving slowly on Portland’s TriMet MAX train.

nypost.com

read this and I just can't believe it. embarrassing

That's just embarrassing on the part of the physician.

 

[Iamnew2]

I read the article you linked. The ED literally did nothing wrong in the documented scenario. He's clearly homeless and does not appear to have any sort of acute medical emergency. He also was offered and refused a ride to a homeless shelter by the EMS crew that seemed so appalled that he was "kicked out." What precisely should have been done differently? What is the treatment or service that we offer that was not provided? I get that people were actually recording in this scenario, but I honestly don't think I'd have a problem defending myself were I one of the people that escorted this guy out.

He was od'ing and actually died, and the physician said that the guy - as much of a drug addict he might have been = was just playing possum and there was nothing to do. Well clearly he died he wasn't just playing possum. i get that these patients are frustrating and prob one of the reasons why ED staff and physicians are a bit soul less frequently but definitely should have been handled better.

 

[JacobMcCandles]

I read the article you linked. The ED literally did nothing wrong in the documented scenario. He's clearly homeless and does not appear to have any sort of acute medical emergency. He also was offered and refused a ride to a homeless shelter by the EMS crew that seemed so appalled that he was "kicked out." What precisely should have been done differently? What is the treatment or service that we offer that was not provided? I get that people were actually recording in this scenario, but I honestly don't think I'd have a problem defending myself were I one of the people that escorted this guy out.

There’s also a very high likelihood this gentleman has been banned from all the shelters, in my experience.

 

[Interpolfanclub]

Yeah this is pretty clear cut gross negligence. I’ll be the first to say I can’t stand these patients and feel like my current shop has to be top percentile for the amount of druggie losers like this pt that are seen. But they still have to be able to walk and talk before they can be discharged. I have to have PD come weekly to remove people, but not because they’re obtunded. I also don’t waste time either, narcan to agitated freedom or tube them. Next.

Agree. I don't get emotionally wrapped up in these patients, I just make a decision and move on. I find that in general the less training you have (LPNs, techs etc) the more you judge, criticize, argue with patients etc. This happens from docs too of course but less in my now pretty lengthy experience.

I also have a general rule that I don't discharge patients who can't walk on their own and younger docs would be wise to follow this advice no matter how many people are in your ear telling you that "they're here all the time" or "put them in the lobby and they'll find a way home" etc. etc. blah blah. Can't walk, can't be discharged. It will save you a lot of grief. I don't care what nurses think, I don't care what admin think, I'm the doc and if you cannot walk (regardless of why) you are being admitted, barring a very very rare situation.

I heard Greg Henry say when I was in my training that he leaves his biases and judgements at the door when he walks into the ER and I think this is a good way to do it. If you don't you will get burned eventually.

I also generally practice like I'm being recorded, because this has happened to me at least once that I know of and probably more that I didn't. You don't want to be the angry doc on a recording if something bad happens. So when I see patients, I'm respectful, do a thorough history and physical and try to leave emotion out of our encounter. When I was director, I would routinely tell my docs to assume they are being recorded by patients and family.

 

[RustedFox]

Watch this space.
I'll get back to you all on Monday nite.

 

[Kryptocoin]

The "wheelchair sign" is usually a bad omen for patient disposition. Can't walk or drink? Ain't going home.

The ER doctor and hospital should just settle. Can't take this to a jury.

 

[always.chillin]

The "wheelchair sign" is usually a bad omen for patient disposition. Can't walk or drink? Ain't going home.

The ER doctor and hospital should just settle. Can't take this to a jury.

They better hope this guy’s got no family otherwise he’s getting sued. Even family that gives no ****s about him will sue. It’s an easy payout.

 

[Kryptocoin]

They better hope this guy’s got no family otherwise he’s getting sued. Even family that gives no ****s about him will sue. It’s an easy payout.

Not sure what Oregon malpractice laws are but in Florida only spouses and minor children can bring malpractice claims for deceased adults over 25. Parents and siblings cannot sue on their behalf.

It's actually one of few things FL did right.

 

[Birdstrike]

Once upon a time we had a patient would come in faking seizures and the history was well documented. One day the person came in and the treating doc (not me) discharged them by wheelchair while "faking a psuedoseizure." Security made the very bad decision to "wheel him to the property line, then push him out of the wheelchair." He was then found in status epileptics on the road shoulder by a passerby. It just so happened that the seizure faker decided to have a real seizure that day.

The media picked up on the story and as you can imagine it didn't turn out well for anyone.

 

[CliveStaples]

Also, the hospital response (section in italics in the article) is very well written and addresses everything I said more eloquently and would be what I would refer people to if I were ever confronted about "not doing ... whatever."

I’m impressed they wrote the response that they did. Typically hospitals hide behind the “we cannot discuss for HIPAA reasons” excuse and nothing changes. I think their response was level headed enough that the average person could read this and think “this system sucks, but it’s not just the hospital’s fault.”

 

[Apollyon]

Once upon a time we had a patient would come in faking seizures and the history was well documented. One day the person came in and the treating doc discharged them by wheelchair while "faking a psuedoseizure." Security made the very bad decision to "wheel him to the property line, then push him out of the wheelchair." He was then found in status epileptics on the road shoulder by a passerby. It just so happened that the seizure faker decided to have a real seizure that day.

The media picked up on the story and as you can imagine it didn't turn out well for anyone.

People that fake seizures have seizures. Better to overtreat than undertreat.

 

[Interpolfanclub]

People that fake seizures have seizures. Better to overtreat than undertreat.

Completely agree, a significant number of people with pseudoseizures also have epilepsy. Unless they've got a recent neg EEG and well documented hx of non epileptic sz I assume they have sz. If it's hard for neurology to sort out as inpatient I don't lose any sleep over it. I used to agonize over stuff like this and don't anymore.

 

[Apollyon]

Completely agree, a significant number of people with pseudoseizures also have epilepsy. Unless they've got a recent neg EEG and well documented hx of non epileptic sz I assume they have sz. If it's hard for neurology to sort out as inpatient I don't lose any sleep over it. I used to agonize over stuff like this and don't anymore.

Yeah, it's not like 2mg of Ativan is going to bankrupt the hospital or put you out of a job. Double play, if it is pseudo, it will put them to sleep!

 

[Rendar5]

Obvious pseudo seizures get told to stop seizing because it’s not real by me and I walk out the room. If they run out yelling at me for telling them they were faking, then I’m good. If they dont, I order Ativan as I leave the room.

Not obvious ones I don’t bother and just treat.

 

[GassYous]

The hospital didn't cause his death. It's sad that we hold physicians responsible for the consequences of a lifetime of bad choices and self neglect

 

[WorkNoteEmergency]

Teaching point for all the youngsters, gotta be able to walk to leave the ER (assuming you can walk to start with). Next level skills involve getting the person who doesn’t want to leave to stand up.

First linked story above is pretty egregious and that doc will pay for everyone else using the ED as a dumping ground.

 

[The Knife & Gun Club]

Completely agree, a significant number of people with pseudoseizures also have epilepsy. Unless they've got a recent neg EEG and well documented hx of non epileptic sz I assume they have sz. If it's hard for neurology to sort out as inpatient I don't lose any sleep over it. I used to agonize over stuff like this and don't anymore.

Challenge I used to run into was that neurology would refuse to admit someone with known pseudo seizures, and medicine would refuse to admit and demand neurology admit them.

This culminated with someone actively pseudo-seizing being seen by neuro in the ED and discharged by neuro. The person went to the parking lot, pseudo-seized again, hit their head, and threatened lawsuits to everyone under the sun in the system.

 

[The Knife & Gun Club]

Teaching point for all the youngsters, gotta be able to walk to leave the ER (assuming you can walk to start with). Next level skills involve getting the person who doesn’t want to leave to stand up.

First linked story above is pretty egregious and that doc will pay for everyone else using the ED as a dumping ground.

I’m curious how do you approach the “no wheelchair” dilemma?

Person is wheelchair bound but for unclear reasons. Like they can walk but use a wheelchair. EMS picks them up but leaves the wheelchair at home.

May or may not have ED social worker there that day but even if you do the social worker can not get a new wheel chair from insurance without a prior auth which takes 48 hours. So pt can’t leave but also Hospitalist won’t admit for inability to ambulate because they’ve already been seen by PT/OT and deemed unable to ambulate…the therapy necessary is a wheelchair.

So they board for 48 h in the ED awaiting prior auth for new wheel chair 🫠

 

[Birdstrike]

People that fake seizures have seizures. Better to overtreat than undertreat.

Agree.

 

[BoardingDoc]

He was od'ing and actually died, and the physician said that the guy - as much of a drug addict he might have been = was just playing possum and there was nothing to do. Well clearly he died he wasn't just playing possum. i get that these patients are frustrating and prob one of the reasons why ED staff and physicians are a bit soul less frequently but definitely should have been handled better.

Reread the thread and the post I quoted. There were 2 linked articles in this thread. The one that I was responding to (and quoted) is not the one you think I was responding to.

 

[BoardingDoc]

There’s also a very high likelihood this gentleman has been banned from all the shelters, in my experience.

Certainly not an uncommon occurrence. In this case, the article says the guy was approached by workers from a local shelter who offered to bring him there however. That said, even if a person gets themselves banned from every shelter in the area, I don't see how that changes the ER's job.

 

[WorkNoteEmergency]

I’m curious how do you approach the “no wheelchair” dilemma?

Person is wheelchair bound but for unclear reasons. Like they can walk but use a wheelchair. EMS picks them up but leaves the wheelchair at home.

May or may not have ED social worker there that day but even if you do the social worker can not get a new wheel chair from insurance without a prior auth which takes 48 hours. So pt can’t leave but also Hospitalist won’t admit for inability to ambulate because they’ve already been seen by PT/OT and deemed unable to ambulate…the therapy necessary is a wheelchair.

So they board for 48 h in the ED awaiting prior auth for new wheel chair 🫠

Well the “able to walk but uses wheelchair” is kinda weird but in general it’s transport service to take home if generally non-ambulatory and can’t find a friend or family to step up (not uncommon). I also write prescriptions for wheelchairs and walkers as a w/c handout isn’t something any place I’ve worked has ever done.

 

[DeadCactus]

Some emergency medicine staff get too emotionally wrapped up in laying down the law and not falling for "tricks". Then they get caught up in their biases (or worse, the biases of the other ED staff) and make poor decisions like this. There are some hard-stops in emergency medicine where you really should pause and carefully consider exactly what signs and symptoms the patient had, what emergencies they may be having, and what you've done to evaluate those emergencies. Diagnosing malingering, requiring force to discharge a patient, and discharging someone who can't leave under their own power are major red flags.

 

[Siggy]

Once upon a time we had a patient would come in faking seizures and the history was well documented. One day the person came in and the treating doc (not me) discharged them by wheelchair while "faking a psuedoseizure." Security made the very bad decision to "wheel him to the property line, then push him out of the wheelchair." He was then found in status epileptics on the road shoulder by a passerby. It just so happened that the seizure faker decided to have a real seizure that day.

The media picked up on the story and as you can imagine it didn't turn out well for anyone.

Frequent fliers are the worst because eventually they'll have a real emergency, but people will prematurely close on what their normal complaint is.

 

[JacobMcCandles]

Frequent fliers are the worst because eventually they'll have a real emergency, but people will prematurely close on what their normal complaint is.

It’s almost a given that a frequent flier will have a much higher chance at a bad outcome than someone who isn’t a high utilizer, however, their bad outcome to visit ratio will be much lower than what we would deem a normal healthcare utilizer. I empathize with physicians because these patients are just ticking time bombs and many times it’s Russian roulette on who is going to get caught holding the bad outcome bag.

 

[Dr Mantis Toboggan]

Frequent fliers are the worst because eventually they'll have a real emergency, but people will prematurely close on what their normal complaint is.

Yup and I’d argue they have some culpability if there’s a bad outcome but I realize that’s not how the legal system/QA process works.

I’ve seen some people who come in literally 100s of times a year for chest pain etc. You can’t troponin/dimer someone every day, but that one time someone doesn’t and it’s real…

 

[Mount Asclepius]

EM requires flexibility. Sometimes you have to admit people just because they can’t walk. Sometimes you have to kick people out. I try to avoid hard rules although at the same time attempt to maintain consistency without emotion in my approach.

 

[goodoldalky]

Sounds like the patient received some naloxone in the ED initially. However, many opiates' effect lasts longer than the naloxone, which can cause the respiratory depression to return after 60-90 mins. Sounds like that may be what happened here. I tend to avoid using it unless necessary to avoid intubation and instead wait until they have metabolized.

 

[Iamnew2]

EM requires flexibility. Sometimes you have to admit people just because they can’t walk. Sometimes you have to kick people out. I try to avoid hard rules although at the same time attempt to maintain consistency without emotion in my approach.

Emotion in medicine is problematic I agree.

 

[rokshana]

Emotion in medicine is problematic I agree.

But no longer being able to have emotion is also problematic

 

[Iamnew2]

But no longer being able to have emotion is also problematic

Empathy and care is different than having our emotions lead our care.

 

[The Knife & Gun Club]

Well the “able to walk but uses wheelchair” is kinda weird but in general it’s transport service to take home if generally non-ambulatory and can’t find a friend or family to step up (not uncommon). I also write prescriptions for wheelchairs and walkers as a w/c handout isn’t something any place I’ve worked has ever done.

Yea I prescribe wheelchairs and walkers all the time. But most often they come from the street where the wheelchair was left on a street corner and there’s no way to get it back and no way to get a transport company to take them back to their preferred street corner.

I probably see 2-3 cases like this a week when I’m working in the ED. It’s tough because hospital admin always reads it he riot act and Hospitalist throw a fit but the person refuses to use their functioning legs which can be really tough.

Obviously you don’t want to kick people out who have an acute change in their functional status which can make it tough to differentiate

 

[southerndoc]

The "wheelchair sign" is usually a bad omen for patient disposition. Can't walk or drink? Ain't going home.

The ER doctor and hospital should just settle. Can't take this to a jury.

I'm sure they will. Also I'm fairly certain the ER doc (who wasn't named in the article) likely will be criminally charged.

 

[ShockIndex]

I read the article you linked. The ED literally did nothing wrong in the documented scenario. He's clearly homeless and does not appear to have any sort of acute medical emergency. He also was offered and refused a ride to a homeless shelter by the EMS crew that seemed so appalled that he was "kicked out." What precisely should have been done differently? What is the treatment or service that we offer that was not provided? I get that people were actually recording in this scenario, but I honestly don't think I'd have a problem defending myself were I one of the people that escorted this guy out.

Let’me get this straight. An EMT’s sense of social justice and virtue is violated when she sees the hospital escort a homeless, belligerent malingerer out of the facility. So, she snaps some pictures and chats with him to confirm his victimhood under the boot of the evil hospital. She then peaces-out to her next call and becomes sufficiently triggered to notify the media when she comes back from her call and the guy is still there, in front of the hospital. Right?

Well, I fault the EMTs who abandoned him to go to another call before securing him sustainable housing. That was heartless. At the very least, she could have taken him with her on the call - just put him in the front passenger seat. He could have manned the siren on the way to the call; maybe stick his head out of the passenger window to yell at drivers who do not pull over fast enough. Then, he could have rode in the back with the patient to the hospital, held their hand, and kept them company. I bet the experience might have changed his life.

But no. This heartless EMT had other priorities and left him on the street like a dog.

 

[DeadCactus]

You can’t troponin/dimer someone every day, but that one time someone doesn’t and it’s real.

I get the general point you’re making but I’m pretty content ordering a troponin and d-dimer everyday. It’s not like I have strong literature saying the previous 99 days of chest pain evaluation mean they aren’t having ACS when they show up on day 100 with chest pain. New ED visit (especially for one of the highest risk chief complaints); I’m starting from a blank slate and doing what I would do for anyone else.

Super utilizers are a hospital and system problem; the hospital needs to come up with a documented care plan and policy if they want to save resources. Instead they want to pressure us to short-cut evaluations while jumping the curb to run us over with the bus when something goes wrong.

 

[Iamnew2]

I'm sure they will. Also I'm fairly certain the ER doc (who wasn't named in the article) likely will be criminally charged.

That is doubtful but it's

I get the general point you’re making but I’m pretty content ordering a troponin and d-dimer everyday. It’s not like I have strong literature saying the previous 99 days of chest pain evaluation mean they aren’t having ACS when they show up on day 100 with chest pain. New ED visit (especially for one of the highest risk chief complaints); I’m starting from a blank slate and doing what I would do for anyone else.

Super utilizers are a hospital and system problem; the hospital needs to come up with a documented care plan and policy if they want to save resources. Instead they want to pressure us to short-cut evaluations while jumping the curb to run us over with the bus when something goes wrong.

The bus running us over when something goes wrong is particularly true!

 

[Dr Mantis Toboggan]

I get the general point you’re making but I’m pretty content ordering a troponin and d-dimer everyday. It’s not like I have strong literature saying the previous 99 days of chest pain evaluation mean they aren’t having ACS when they show up on day 100 with chest pain. New ED visit (especially for one of the highest risk chief complaints); I’m starting from a blank slate and doing what I would do for anyone else.

Super utilizers are a hospital and system problem; the hospital needs to come up with a documented care plan and policy if they want to save resources. Instead they want to pressure us to short-cut evaluations while jumping the curb to run us over with the bus when something goes wrong.

How about multiple times in one shift lol?

 

[GassYous]

Challenge I used to run into was that neurology would refuse to admit someone with known pseudo seizures, and medicine would refuse to admit and demand neurology admit them.

This culminated with someone actively pseudo-seizing being seen by neuro in the ED and discharged by neuro. The person went to the parking lot, pseudo-seized again, hit their head, and threatened lawsuits to everyone under the sun in the system.

These people are the worst. Had a lady with a history of pseudo seizures after every procedure yet surgeons keep insisting on booking her. She pseudo seizes again, nursing staff flips out, patient gets ativan, stroke called, vomits and nearly aspirates in ct which gets an airway called and nearly gets intubated and all this because she has psychological problems. Why can't people just be normal

 

[Mount Asclepius]

I wish general society understood the sheer number of people with just mild personality disorders (not severe psychiatric illness) that we see on a regular basis in the ED. Family and friends are shocked when I talk about many patients and high utilizers of the ED.

 

[greatnt249]

Super utilizers are a hospital and system problem; the hospital needs to come up with a documented care plan and policy if they want to save resources. Instead they want to pressure us to short-cut evaluations while jumping the curb to run us over with the bus when something goes wrong.

I don't know anyone who has ever been thanked or congratulated for "saving the hospital resources," but I'm sure that we'd be the first to be thrown under the bus by our own admin if a bad outcome occurred. This is not me advocating ordering every and all tests all the time, but if we're expected to rigidly abide by "choosing wisely," then I thinks it's completely reasonable for those imposing those guidelines to be held liable for bad outcomes as well (looking at you hospital admin and insurance peer-to-peer "practitioners").

 

[cyanide12345678]

I don't know anyone who has ever been thanked or congratulated for "saving the hospital resources," but I'm sure that we'd be the first to be thrown under the bus by our own admin if a bad outcome occurred. This is not me advocating ordered every and all tests all the time, but if we're expected to rigidly abide by "choosing wisely," then I thinks it's completely reasonable for those imposing those guidelines to be held liable for bad outcomes as well (looking at you hospital admin and insurance peer-to-peer "practitioners").

Yeah…my CT utilization rate is 32 percent in my group for ages 18-65 for non trauma patients. I’m in the top 20 percent of utilizers.

No one cares. I’m not changing my practice. I’ve been sued once for literally existing and responding to a code blue. Took one full year to be dropped without prejudice.

I don’t care about utilization. Patients in fact love tests and leave happier when they’ve been thoroughly checked out. And to be perfectly honest, when it’s really busy and im jumping from room to room, chances are my work ups are going to be more thorough as that’s when i know i can miss something. My LOS are still slightly below average so my through put is still okay.

But no one ever got in trouble for ordering that CT scan.