AMA

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.

Life Lessons

So by popular demand*, or rather at least one person's demand, now at the end of my ER rotation I have more to blog about my actual ER rotation.

I'm sure everyone reading this has seen that awesomely cheesey poster that lists like a million things that you learn in kindergarten that make you a wonderful person. Well, this month in the ER I've compiled a similar list that will help make you a healthy person. At least as healthy as luck and/or stupidity will permit.

• Don't wear flip flops while mowing the lawn. Don't put your hand under a stalled lawn mower that is still turned on. Don't try to take a riding lawn mower out of the back of a pick-up truck all by yourself. All are really good ways to lose body parts. If you know the neumonic - it's usually a body part that you wouldn't use lidocaine with epinephrine on that you lose. If you don't know the neumonic, well, I'm not going to post it here because while I do like the attention from random google searches, that's not the attention I want.
• Don't cuss out homeless men with knives who ask you for money. They might stab you. A couple times.
• Don't zip your pants up too fast without looking to see what's still in the zipper. I didn't think that this actually happened, but as I discovered this month, it does. And it looks very painful.
• Don't lie to the doctor about what happened to you. For example, don't tell the doctors at 2 different hospitals that you fell off a swing if you actually were bitten by a cottonmouth snake. Some of them might believe you and your treatment might get delayed 6 hours and you might risk loosing body parts.
• Don't punch glass windows. Don't jump through glass windows. Don't lean all your body weight on glass windows. Don't push really hard on glass windows. Glass breaks. Broken glass is sharp. It will cut you. Deep. There will be blood. Lots of it.
• Don't insert objects PR. P stands for "per". R stands for a word that starts with R and sounds like "wrecked 'um". It might just disappear on you. And that's a really embarrassing story to have to tell the doctor.
• Don't think that you are too good for eye protection. Especially if you are breaking up concrete (it might just end up inside your eye) or working with methyl chlorobenzene (it might just burn your corneas right off).
• Don't think that vizine eye drops is all you need if you get methyl chlorobenzene in your eyes. And don't wait 2 days to go to the hospital.
• Don't do drugs. Especially fry (marijuana dipped in embalming fluid). It will make you crazy. Irreversible-forever-for-the-rest-of-your-life crazy.
• Don't think you no longer need your psychiatric anti-psychotic meds. You will go psychotic if you stop them.
• Don't think you don't need a seatbelt. Unless you are curious what it's like to break a steering wheel in half with your chest or go through the windshield.
• Don't put your feet over the passenger air bag. It will come out very fast and it will hurt you very badly.
• Don't accept unscreened blood transfusions from Mexico.
• Don't beat your child to death. The police are pretty good at figuring that one out.
• Don't let your kid ride a broken bicycle outside after 11 PM. It might just be asking for disaster.
• Don't come into an ER and ask for a pain medicine by name and dose. You won't get it, or much of anything else after that.
• Don't stop coumadin all of a sudden because you think it's not doing anything. If you had a stroke before and they put you on coumadin, it's pretty likely that you'll have another if you stop the coumadin.
• Don't get 20 tattoos and then be a cry baby about getting stitches. Or about getting shot by your father-in-law with a shotgun.
• Don't change your tire on a too-narrow shoulder of a busy 6 lane freeway. Unless you want to get hit by a car.
• Don't jaywalk and think you can beat any car. You can't. And cars weigh roughly 10 times what you do. And don't break as easily.
• Don't shoot at the police. They shoot back.
• Don't eat like an American.
• Don't think that you don't need pre-natal care. You do.
• Don't think that if the doctor told you to be on bedrest that this means don't go to work, but spend all day out and around town doing a million things.
• Don't bring all your personal belongings to the ER with you in a cardboard box. And then drop it all over the trauma bay as they are taking you out to a bed.
• Don't come to the ER and say you have a spider bite unless you saw an actual spider on you and saw and felt it actually bite you.
• Don't eat batteries.
• Don't come to the ER in a busy academic hospital unless you want some random medical student to anonymously blog about your stupidity.

So there you have it. Real convential wisdom for your bathroom wall.

*I say this is by popular demand, but I have no actual way of confirming this since apparently the popular demand all read this site previously via an RSS aggregator and never actually came and visited my site nor did they artificially inflate my self importance by raising my site visits counted by sitemeter.

Chief Complaint

I just finished my first night shift this month and am having trouble sleeping so I thought I'd say a word or two about E.R. Really, E.R. boils down to those two words - Chief Complaint. You are responsible for finding out why the patient is at the hospital and then figuring out if said chief complaint is worthy of hospital admission or worthy of a trip back home.

One of the coolest features of the EMR (electronic medical records for you lay-people) software our ER uses is that you can pull up a list of all the people in rooms, in waiting, and inbound and it tells you their name, location, how long they've been waiting or roomed, and what their chief complaint is. This is the absolute funnest tool in the ER. By far. Because if you happen to have a short break in the action, you can log on and see who's coming and why. I guess the other super cool part about it is that the people in triage are instructed to list the chief complaint exactly in the patients' own words and not to translate it into medical terminology.

So, from two nights worth of working, here's a short sampling of what came through.

• I broke a window and am bleeding - (Pretty accurate assessment I thought. I put 25 stitches in that person's arm. 24 beers + nagging spouse + glass = disaster waiting to happen)
• My parts are huge - (to clarify, those were man parts he referred to, and indeed they were perhaps the largest man parts I have ever seen.)
• bicycle in foot - (this was actually EMS's words since it was a small child who was crying. She really did have a bicycle impaled through her foot.)
• I chainsawed my leg - (disappointed I didn't get to meet this one)
• broken skull s/p jumping from moving vehicle - (this one was cheating too since the chief complaint actually came from doctors at another hospital. S/P means "status post" and is doctor-ese for "after".)
• broke my arms - (Yup. We didn't do much diagnosing past that one)
• woman problems - (enough said)
• f%$# you - (this guy wasn't too happy with being at the ER. He also said that was his wife's name. And his name. And his address. I guess that makes it all easy to remember)

Anyway, on a totally seperate note, I just wanted to give a nod to a not so average family for mentioning me in their blog. Sitemeter tells me that in the past 3 days I've doubled in traffic from people linking in from their page. Despite one of their members leaving deceptive comments on one of my posts.