Crash Cart: Seniors Going AMA More Often; Red, White, and Black & Blue; Point-of-View Tech

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This week: Older patients sometimes have good reason to leave; Ordinary and unusual Fourth of July tales; New tech gives own point-of-view. Join in as our editors discuss the week’s headlines.

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ED physicians working the Fourth of July expect run-of-the-mill summertime incidents and some firework injuries.

But sometimes the bombs don’t burst in air (lodging unexploded in a patient) and the “blue” is in a baby diaper. Original Article by ABC.

William Sullivan, DO, JD: Amusing anecdotes. It never ceases to amaze me how ridiculous some people can be with explosives. YouTube is full of videos of people shooting (or attempting to shoot) rockets from their rear ends and blowing up pretty much any combustible substance. The stories in this article and other “Hold my beer while I …” stories just serve as a further reminder that emergency physicians have pretty much unlimited job security.

E. Paul DeKoning, MD, MS: My son and I love to watch crazy things with fireworks on YouTube. You should check out 300 rockets. Amazing what one can do with 300 rockets, a solenoid, a pickup truck, and a drone. We avoid the ones where limbs get blown off–that’s just gross. Also, same son may or may not have had blue poop from too much frosting. So relieved it’s nothing serious!

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When older patients disregards medical advice and decides to leave, they may be making the right call.

A large national sample from 2013 found that 50,650 hospitalizations of patients over age 65 ended with A.M.A. discharges—and the numbers are rising, though still not 1% of of senior hospitalizations. Original Article by The New York Times.

William Sullivan, DO, JD: This article irks me. First, the 20/20 hindsight that Dr. Callahan exhibits when describing the treatment of her father with a near-syncopal event is depressing. “He should have been discharged right from the E.R.,” she said. “This was cookbook medicine, done without thinking. It was very adversarial.” If she was so sure that her father should have been discharged from the ER, then why did she allow him to be admitted? She could have taken him home immediately. There’s no doubt in my mind that if her father (“with a long history of cardiac problems”) went home, had an arrhythmia and died, she would have been the first one pointing fingers at the emergency physicians for discharging him without proper evaluation. Then some NYU bioethicist states that physicians are essentially using AMA forms as “coercive” weapons and that physicians are being “paternalistic” for requiring patients to sign AMA forms and accept responsibility for their actions. He needs to look up the terms “coercive” and “paternalistic” in a dictionary before doing any more media interviews. If competent patients want to make bad decisions, it is entirely their right to do so. An AMA form simply documents that patients are aware of the risks and benefits of the decisions they are making. Somehow twisting this process to suggest that the AMA process is “coercive” and suggesting that medical providers should just take responsibility for a patient’s poor decisions is nothing more than a cheap shot by the article’s author, Paula Span. Shameful.

E. Paul DeKoning, MD, MS: I’m not buying it. I just find this whole article hard to swallow. It’s not against the law to make bad decisions and, while I don’t always agree with my patients’ decisions, i find it hard to believe that the setting the author describes is common place. If even real. I actually seldom have patients sign the AMA form–I find it to be adversarial and accomplishes little. Instead, I sit down and we have a conversation. A real one about all the bad things that could happen (but frankly probably won’t). And then I document the aforementioned conversation. Everyone leaves happy (at least happier) and I don’t lose sleep about being sued. Patients sue doctors they’re mad at.I tend to be a strong believer that the above approach avoids the pissed off patient who’s ready to sue. I can’t imagine any physician I know acting the way the author describes, holding patients against their will. Last time I checked, if they have capacity, that’s illegal.

Ryan McKennon, DO: Like Paul, I rarely have people sign the “AMA” form and simply document a discussion we had about the risks and benefits. That being said, what’s the big deal? If you disagree with your doctor and want to leave, why is so much offense taken at signing a form that states exactly that? The forms are typically very short and written in plain language explaining the conversation that has already taken place. People have no problem signing a credit card application that is 20 pages, small print, written in legal jargon but lose their mind if they have to sign the AMA form which has been explained to them. It certainly does not rise to the level of coercion “use of force or intimidation to obtain compliance” – dictionary.com.

Nicholas Genes, MD, PhD: I don’t understand how this article about ED patients wanting to leave only gives lip-service to the concept of medical decision-making capacity. Preventing an actively suicidal patient from leaving isn’t controversial (right?). Preventing a delirious older adult from walking out alone in the middle of the night isn’t controversial (right?). I agree with the earlier comments about shared-decision making with family, in lieu of an AMA form. I know and work with Dr. Callahan and am surprised this conversation (and its documentation) didn’t happen in this NJ ED. Maybe there was an attempt at it but the ED doctor really was being unreasonable. Usually when a patient wants to go, in the custody of their physician family member, that’s a good thing, and I just document that we spoke and they understand the risks of leaving before the workup is complete.

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New POV technology should provide insight into physician decision making, according to a July AEM study.

The study is the first time the own-point-of-view perspective has been used in the study of medical decision-making, particularly clinical decision-making in emergency medicine. Original Article by ScienceDaily.

William Sullivan, DO, JD: The study alleges that recalling reasoning during a patient visit is better with Google Glass-like “point of view” setups than with using a camera recording from the corner of a room because fixed cameras aren’t suited to fast-moving environments, can’t capture facial expressions, may catch other information, and may increase a physician’s self-awareness. Not sure that facial expressions or perceived self-awareness are going to make much of a difference in me recalling my reasoning for ordering a cardiac workup in an elderly patient with chest pain, and there aren’t any studies comparing the two modalities of recall, so I remain skeptical of the application. I hope this isn’t just a way to justify implementing some future iteration of Google Glass into the medical workflow.

E. Paul DeKoning, MD, MS: Invention is the mother of necessity–sounds like technology looking for an application. I thought this went away when Google Glass took a face plant. The Joint Commission could implement a similar technique in helping me remember what I was thinking when I chose to eat that sandwich at my workstation that one time. Wait, no I didn’t. That was somebody else and I’ve got POV footage to prove it.

Ryan McKennon, DO: For some reason the article has me envisioning an Orwellian future where will all end up wearing body cameras like police officers do. Just needed to get around all the HIPAA problems first.

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