Archives for July 30, 2003

War on Terror My Butt

Air marshals pulled from key flights
In case anyone wants my opinion, President GWBush should be insanely glad he has a couple of wars going on, because virtually every other aspect of The War On Terror is a bust.

Fire Norm Mineta. Today. The same agency that oversees hiring Air Marshalls grounded at least 100 because their background investigations weren’t up to snuff. This, after bureaucratic obstructionism has killed arming pilots, a popular and reasonable action to protect the flying public from terrorists.

Now comes word that the key target flights (overseas and transcontinental) won’t have Air Marshals as a cost-cutting move (overnight stays killing the budget and all). This is, pardon the crude language, crap.

At least one part of the War on Terror has to go right, and the answer is clear: can Mineta. Today.

Leaving Against Medical Advice

Mr. Hassle’s Long Underpants
Doc Shazam had one of those frustrating moments in medicine, and was healthy enough to blog about it instead of ruminating. This gave me pause, and I decided to try to explain how I approach this issue.

First, Leaving AMA is a medico-legal minefield. It is not cured by having the patient sign an AMA form (I recall an attorney explaining that the signature on an AMA form only means they were awake when they left, no more).

So, before they leave, I generally try to talk to the patient, and their family. First, ‘why do you want to leave’? Anger/time/unfulfilled expectations are the vast majority. Some are mad they had to wait 8 hours (for a 3 month outpatient workup), and just leave out of pique. I have never managed to persuade these patients to stay, though I try.

Others have to be home to care for their families, etc. I can occasionally get them to put their health first, but it’s rare, and usually involves some calls to get their home roles filled.

The unfulfilled expectations are usually not grounded in medical reality; you’re going to admit me for pain management/observation? I wanted my (expensive, tricky and/or dangerous surgery) today (invariably night/weekend/holiday). I try to connect the dots about timing, necessity, etc., and get about 1/2 to stay.

I have adopted an idea from one of my colleagues, and I ask the family of the patient, “how do you feel about this? They aren’t going to sue me when they die, you are, so what do you think?” Even if they don’t stay, I got them to think about the future beyond the car keys.

I try very hard to make this whole thing non-adversarial, and offer all the services of the hospital, and tell them I don’t care about the cost, I care only about their care. Then, if they still elect to leave, I assure them that there are no hard feelings on our part, and that we’d be glad to have them come back. I usually always mean it.

Medicine isn’t perfect, and neither are people. I really think we try hard for each individual, and I never like it when the AMA form comes out.

Wow, I sound like Mary Poppins. I’m not, trust me.

Update: And, yes, the Texas Dems left AMA too. They didn’t sign the form.