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Dear Mr or Mrs Next US President,Thank you for visiting Grand Rounds, the weekly collection of the best health and medical blog posts, in the midst of your very busy schedule.

I’m late, he wasn’t.  Good GR!

Forcing Care on Patients

Yesterday there was a Associated Press news item about a lawsuit involving an Emergency Physician and a forced rectal exam:

Man: NY Hospital Forced Rectal Exam

The Associated PressNEW YORK (AP) — A construction worker claimed in a lawsuit that when he went to a hospital after being hit on the forehead by a falling wooden beam, emergency room staffers forcibly gave him a rectal examination.

Brian Persaud, 38, says in court papers that after he denied a request by NewYork-Presbyterian Hospital emergency room employees to examine his rectum, he was “assaulted, battered and falsely imprisoned.”

His lawyer, Gerrard M. Marrone, said he and Persaud later learned the exam was one way of determining whether he had suffered spinal damage in the accident.

Marrone said his client got eight stitches for a cut over his eyebrow.

Then, Marrone said, emergency room staffers insisted on examining his rectum and held him down while he begged, “Please don’t do that.” He said Persaud hit a doctor while flailing around and staffers gave him an injection, which knocked him out, and performed the rectal exam.

Persaud woke up handcuffed to a bed and with an oxygen tube down his throat, the lawyer said, and spent three days in a detention center….

Hospital spokesman Bryan Dotson said, “While it would be inappropriate for us to comment on specifics of the case, we believe it is completely without merit and intend to contest it vigorously.”

Today it was linked to on the WSJ Law Blog, linking to Slate’s ‘Explainer’ column, the best part of which is this:

Slate MagazineThe idea of consent as a patient’s right goes back at least to 1914, when Benjamin Cardozo (who would later become a Supreme Court justice) ruled in a New York case that “[e]very human being of adult years and sound mind has a right to determine what shall be done with his own body.”

I have absolutely no problem with that answer, and it also lays out the situation in which I am ethically and professionally compelled to act against the wishes of my patients, the patient not of sound mind who refuses potentially lifesaving examination and treatment. 

Here’s my typical ‘against their will’ patient (who’s not there for a psych diagnosis, different story): Adult male brought in from a motor vehicle accident with some moderate damage to the car, usually tachycardic and normotensive, with signs of trauma externally (small lacerations or contusions) but nothing that makes anyone in the room immediately concerned.

Then comes the mental status examination, and the problems start.  The patient is ‘altered’, which can be described a lot of ways but for me  boils down to ‘not right right now’.  Yes, it could just be alcohol or drug intoxication (most people will, initially, cooperate and tell you what they’ve taken, but not all) but even if they cop to the drugs and booze, it that really all that’s going on?  Does this patient have a head injury causing their slurred speech, their restless combativeness and their unwillingness to cooperate, or not?

There are a couple of ways to find out, and at this point in this patients’ care they’re both fraught with problems: wait and see (and hope for the best), or examine and treat to exclude life and limb threats against their verbalized wishes (to guard against the worst).  This is where “First, Do No Harm” becomes a work in progress, balancing the risks of sedation (or infrequently sedation, paralysis and intubation, which are real but small) to facilitate a medical evaluation to exclude badness versus the also small but real risk the patient has a severe injury being masked by alcohol or drugs, which waiting to diagnose could spell disaster.

I’ll tell you that I’ve done both, and that’s where the professional judgement comes in, deciding based on training and experience who to watch and who to press ahead with.  It’s not an easy decision, and it’s much much harder to go against any patient’s verbal desires, but if I’m concerned enough I do it.  Frankly I’d much rather work up 100 patients with an altered mental status against their will than miss the patient with a life threat that I ascribed their altered sensorium to alcohol or drugs, and it was just a confounding problem.

Here’s the patient who personifies the issue (a mixture of real patient experiences to obscure it, but all this has happened with my personal patients): adult male, 275# (all muscle) brought in cuffed after a car chase with the PD.  Wrecks car, has a 4 inch lac across the forehead, and is diaphoretic with a HR at 130.  Patient is alert, answers most questions, denies drugs (the PD says he’s a frequent cocaine user, they’ve arrested him before), moves all extremities, but won’t allow any interventions.  Nice nurses try their best to bond (I only really bond well with older vets and LOL’s) and he’ll allow his BP, but that’s it; no IV’s, nothing.  Speech is direct but goal-directed (toward leaving), and none of us can talk him into letting us do anything.

My problem as the treating EM doc: do I let him walk out?  His lac will eventually heal, but I’m very very worried about head injury and the real possibility of internal bleeding from his accident.  If he has any of those, it’s terrible for him if I let him go (and not good for me either, I’d get to try that career change I talk about).  Yes, all this weird behavior and the abnormal vitals can be explained by cocaine use, but am I willing to risk his life on that assumption?

No.  We tried five adults holding an arm while giving 5mg of Vitamin H (Haldol) with 10mg of Versed, and he was still wide awake an struggling, no way we’d get a CT done.  This was only the second time in my career I’d used IM sux to knock a combative patient down (quadruple your IV dose), and it worked; his intubation and workup proceeded very smoothly.  He benefited from not struggling with other adults, decreased BP and heart rate, and we sewed up his lac while he was out.

I’d like to tell you we found a big bleed and saved his life, but this is reality.  His CT’s were normal, Trauma washed their hands of him as a cocaine ingestion, so when he woke up in the ER 4 hours later (we were sedating him while intubated) he was calm and cooperative.  He apologized to all of us profusely, told us he’d been taking cocaine heavily ‘and I get out of control sometimes’.  He went home, safe.  I slept well, because though it was a risk to go against his wishes, it was a much better choice than letting him go, for both of us.

I’m not well-versed enough in the jargon of ethicists to use their terms, but doing right for patients very occasionally means not doing what they tell you they want. 

It’s rare, and it happens.

Hat tip to reader Chris, and many thanks to my commenters.  I’m not gone, it’s just a slump.