A 29-year-old patient with a history of psychiatric problems sprained her ankle walking near a ditch. One month later, she is admitted to the hospital because she has trouble walking up stairs. During her hospitalization, she has an EKG, multiple lab tests and other radiographic testing. She was discharged, but was still in pain and walking on crutches. A week after being discharged, she went back to the hospital for knee and ankle pain. X-rays were normal. She was discharged but refused to leave. She called an ambulance that took her to a second hospital. There, ultrasound testing of both legs was negative for blood clots. She was homeless, so she was given a list of shelters. She returned the following morning complaining of abdominal pain and was discharged four hours later. She refused to leave or to sign discharge papers. She was wheeled in a wheelchair to the hospital exit and asked to leave the premises. She then told the security guard that she couldn’t even stand up. She was re-examined by the emergency physician and then discharged into police custody. A police officer was heard on a hospital surveillance video telling a fire chief that the hospital staff thought the patient was a “drug seeker.”
We’ve all seen patients who complain of vague or changing symptoms despite normal evaluations in the emergency department. Often, we find there is some secondary gain involved, whether it is a work note, a prescription, or even as a means to get out of jail. Sometimes we’ll get a request to “medically clear” the patient – for example, when a patient is released to police custody, when a patient is being transferred to a psychiatric facility, or when a patient goes back to work.
That’s where the plot in this case takes a twist.
The treating emergency physician created a “Fit for Confinement” report for the police officer before the patient was discharged, essentially stating that the patient was “medically cleared.” With that report in hand, the police wheeled the patient out of the hospital in handcuffs, placed her in a police car, and took her to jail. When she arrived at jail, she told the officers that she couldn’t get out of the police car, so they dragged her by her arms into the police station and laid her on the concrete floor of a jail cell.
A few hours later, she was dead.
An autopsy showed that the patient died from pulmonary emboli and had blood clots in both of her legs.
The Police Chief tried to cast blame for the bad outcome on the emergency physician, telling the newspapers that “A lot of times people don’t want to stay in jail and will claim to be sick. We depend on medical officials to tell us they’re OK.”
The medical providers and the hospitals that cared for the patient were later sued over her death.
What can we learn from this case?
Exercise Caution in Labeling Patient Symptoms or Behavior
First, while the emergency department may see its share of “drug seekers,’ we should try to establish a reasonable basis for such a label before we use it. Just as we don’t label all patients with chest pain as “heart attacks” without further investigation, we shouldn’t label all patients with pain as having some ulterior motive to obtain controlled substances without evaluating the patient’s complaints. The patient in this case may have had some characteristics of drug-seeking behavior, but she also stated that she couldn’t more her legs and that she couldn’t walk — complaints not usually associated with receiving pain medications.
Consider What Is Meant By “Medical Clearance”
We should consider the importance and meaning of writing “medically cleared” on any discharge form, whether it is for psychiatric patients, for incarcerated patients, or for a work release. To a layperson, the term “medically cleared” may mean that the patient has no medical problems and no potential to get worse. To a medical provider, the term “medically cleared” may mean something entirely different. Rather than using the blanket statement that a patient is “medically cleared,” which can be subject to interpretation; we could make the limitations of an evaluation in the emergency department more evident.
Better wording for a “medical clearance” form might contain language such as the following:
“The patient was evaluated in this emergency department and has no manifestation of an emergency medical condition at this time. However, the patient should be re-evaluated if symptoms worsen, if new symptoms develop, or if any problems occur. Emergency medical evaluations are not a substitute for regular medical care.”
In one case, I was told by the administrator at a psychiatric facility that my patient would not be accepted in transfer unless the chart specifically stated that the patient was “medically cleared.” So I added to the chart the phrase “medically cleared” and put two asterisks after the term. At the end of the chart I added “** the term “medically cleared” means that “the patient was evaluated in this emergency department and has no manifestation of an emergency medical condition at this time. However, the patient should be re-evaluated if symptoms worsen, if new symptoms develop, or if any problems occur. Emergency medical evaluations are not a substitute for regular medical care.” I also named the administrator and stated that she was made aware of this definition and agreed with transfer.
Now I have this language as a “dot phrase” on my EMR system.