Wednesday, April 9, 2008


I've considering posting about this multiple times over the past two years. AMA. It stands for a lot of things. Like acquired member assets, or Academy of Model Aeronautics. It's actually also a word that means "metabolic waste products and toxins that have accumulated in body and mind and which obstruct the healthy functioning of mind and body". On a related topic, it also stands for the American Medical Association.

But even more importantly, it stands for against medical advice. It's a phrase that means you took off from the hospital without being discharged. It generally conotates that you absolutely don't agree with your doctor and would rather be billed for all services since no insurance company will pay for a hospital stay that ends in a patient going AMA.

I knew going AMA existed before coming to medical school, but have been interested in its multiple faces since being on the wards. My first encounter with it was with a patient who came in for an organ transplant. If all goes well, they spend a bit of time in the ICU followed by about a week in a regular floor room. One patient during my first month had one of these kind of transplants. Everything was great and he was getting close to being discharged. To encourage this, we encouraged him to get up and walk around, as doing so has been shown to decrease length of hospital stay for most patients. Well, this patient interpreted that "going for a walk" meant leaving the hospital and strolling around, IV pole in tow, down the park across the street. The nurses caught on after about 4 or 5 hours that the patient was gone and not in the hospital anymore, so they started filling out the AMA paperwork. When the patient finally returned to find an empty room, they were clearly angry that the hospital would do that when they were just trying to do what the doctors had asked.

While amusing, other times its less so. Like the patient that showed up with **automatic admission** complaint earlier this week. They knew all sorts of details and used medical jargon in a bit of a peculiar way, sometimes seeming to feign not really knowing the right word, but then in the end getting it out anyway. Lots of patients show up and say they're in pain and sometime in the past that one that starts with a "D" helped. They then look in the corner and go "hmmmm" and then say, "Oh yeah! Demerol. 100mg in my IV." This patient was one of those. They also are ALWAYS allergic to a lot of stuff. Because if you're allergic to ibuprofen, morphine, vicodin, etc, etc, etc (add pain meds here) then you know that they can't give it to you. If you're allergic to everything but *drug of choice* then that's the only one they can give you.

Anyway, so this patient shows up following this pattern, but to a new high. They supplied medical record type information saying they'd been in the hospital recently for the same thing. Except when we called said hospital, they'd never heard of this patient. The patient also wasn't just allergic to all the other medicines, they were also allergic to the workup for **automatic admission**. No iodine. Not even xenon.

Seeing through the ploy, the patient was given no narcotic pain meds. Period. They were restricted to their room in the ED, and not allowed to leave the unit. And within a few hours, the patient demanded the AMA form. By name.

I've previously witnessed such things as punitive exams (like DRE's) and procedures (like colonoscopies) that aren't exactly necessary, but justifiable. They're done to discourage frequent flying of that particular hospital's ER. If you do enough mean stuff to a patient, they won't come back.

But what's always bothered me is what if they really are in pain? What if? There was another patient who left AMA this week that I felt bad about. They genuinely appeared to me to be in pain. And had several good reasons to be in pain. But also knew the names of a few pain meds that worked for them. But didn't get any. And left really upset. And part of me feels like they were just there for the pain meds, and part feels like we just did a bad job helping them.


Tiny Shrink said...

I think most of us struggle with this phenomenon at some point or other. We've all been "taken" by some patient who gave a convincing story, we felt sorry, we gave pain meds, and then we got burned: they left AMA, they became abusive, they didn't get enough meds so they yelled at us, etc. Yet, as Dr. King said in that pain lecture in March, what is worse, treating a bunch of addicts with pain meds, or denying pain meds to legitimate pain? Where is our threshold? And if someone has a chronic or recurrent disorder, and knows how much medication makes them feel better, why does that automatically make them an addict? I'm sure that previous kidney stone sufferers would be angry if the ER offered them Tylenol for their renal colic; they remember that it took opioids or (ketorolac? what NSAID?) to relieve the pain last time.

That said, I don't have an easy answer to this, because I still find myself going "yeah, yeah, you're just looking for free drugs" with some patients.

Dr.Jon said...

I have also come to struggle with the question of what if I am wrong with the "drug seekers". So I have a sorta algorithm. First I am very specific with the allergy questions...what happens, how long after, etc... Lot's of research shows, as you can well imagine, that most "allergies" aren't. Especially to opiates and antibiotics. The histamine rash with opiates and the diarrhea with abx. I also pay close attention to vitals. IF the patient claims to be in 10/10 pain (which that all are), it is very unlikely that will by 102/59 and 60HR. Autonomic-ly, your body just doesn't work like that.
A lot of these people take advantage of ER docs that 1. don't spend a whole bunch of time asking questions, and 2. are defensive as all heck (in terms of defensive medicine). When you take all the above into account, you will be able to get a better idea of what is really going on.