Monday, October 10, 2005

The Resident’s Guide to AMA

There were also patients that were grateful. It’s certainly hard waking at five in the morning to get to work but the satisfaction of knowing you helped a soul in need is more than enough to provide the necessary burst of energy. I slaved away most days collecting samples for various tests and running between families. Such was my intern year.

Yet once in a while, I won’t lie, there was that one patient, just one patient, I hated. Maybe “hated” is too strong a word. I didn’t hate him but I certainly wished something bad would happen to him. Deep in my soul, and believe me that I felt guilty, I wanted him to hurt. He was verbally abusive, he would put me down, he wouldn’t follow any of my recommendations and he would waste my precious time. He didn’t need to be in the hospital but he knew we couldn’t discharge him and this would turn into a very expensive hotel bed, with his own private doc.

There are patients you’ll hate for various reasons. Maybe they're ungrateful, verbally abusive, unlikable, strange or just plain unnecessary work. For me, they were usually the ones that didn’t need to be in the hospital but refused to leave. Yes, there are patients who refuse to leave. They are usually homeless and therefore, legally, they cannot be discharged or they are foreigners with no visas who need chronic care. So they stay.

Don’t misunderstand me, most of them are kind people and I have no bad intentions towards them, they understand the unfortunate circumstance and try to stay out of your way, creating very little problems. Rarely though, there is that one patient who’s mere presence incites nausea.

The only way to rid yourself of these patients whom you cannot discharge and don't want to leave is the AMA (Against Medical Advice) form. As soon as they sign this form they are free to roam the earth, free as birds, away from your wonderful efforts and your daily notes. Half way through my intern year I realized that, although I am only an intern, I have no obligation to absorb disrespect, or better yet, abuse. In fact, I realized something else slightly more sinister, although occasionally this borders on the unethical.

There are methods, when employed effectively, that can ameliorate some of this unnecessary workload. You will now discover the Madman’s Resident's Guide to obtaining the AMA. Follow these steps and your patient will leave, I promise.

1. Diet modification: The way to a man’s heart is through his stomach. So what if your charming patient’s diet order needed renewal and you happen to suddenly suspect he’s become a diabetic who’s developed chronic kidney disease. I know no one who would blame you for being prudent and ordering a “Low sodium and potassium, No concentrated sweets” diet, at least until the hemoglobin A1c comes back…”What? You say the test takes five days to return? Well, better safe than sorry”. In that case you may even be justified leaving him NPO for the next meal until you sort out if he needs immediate access. "What you say, his kidneys are working just fine?"

Phlebotomy: Of course your patient is refusing blood draws, you know that. But, you also know that having a phlebotomist wake you at three AM is simply irritating and if done religiously can damn near drive someone insane. So if you happen to continually order three AM labs you can’t be blamed, you were simply optimistic that this time he would consent. What he didn’t? Damn it, maybe tomorrow.

Intern Rounds: Instinct will sway you to see this patient last. But don’t do this, see him first and as early as possible. When arriving in his room be very dramatic, open all lights, swing open all the curtains, make a lot of noise. Ask very specific questions, stuff he’ll really need to think to answer. Forget the “how are you doing today?” instead try “Did you see the storm in Texas yesterday? How much snow did they get again?” This makes it really difficult to return to sleep (especially after you’ve turned on the lights and pulled open the curtains and asked him to sit up and walk for you so you can observe). The harder it is to sleep, the quicker he’ll get agitated. Do this often, several times every day, unnecessarily. Don’t be apologetic!

Nursing and Bed Board: (**Should only be used when all other measures have failed)Fortunately, there are two patients in every room. Presumably, you have no control over who the other patient is. But, knowing the right people can sometimes pay off, big time. I mean, dementia and incontinence and uncontrolled flatulence big time. I mean, vomiting and delirium in a loud old lady big time. I also mean ventilator and multiple alarms in the middle of the night. What do you mean he wants to move rooms? Sorry, doesn’t work that way here.

Have an AMA form ready in the chart. Instruct the signout person not to put up a big fight. The patient will be in another ER and someone else’s problem very soon.

Again, you didn’t hear this from me.