Chapter 43: .38 Special

August 31, 1989, McKinley, Ohio

"Mary's labs are back," Al said, coming up to me and handing me the printouts.

"What did you see?"

"Low blood glucose; low A1C; borderline hypokalemia and hyponatremia."

"Thanks. Krista, what does that tell you?"

"That she likely has the eating disorder you suspected."

"I agree. It's been long enough that we should do another glucose stick test to see if the apple juice and peanut butter crackers had the proper effect."

We went back to the exam room, and I informed Mary of her test results, and then Krista performed the glucose stick test.

"90," she reported.

"OK," I acknowledged. "Mary, I'm going to have a nutritionist come speak to you about your diet. I don't believe you're taking in sufficient calories, given your activity levels. That would explain all of your symptoms."

"I hate gaining weight," Mary countered.

I nodded, "I understand, but in my professional, clinical opinion, you're underweight for your age, height, and sex. But I'm a trauma surgeon, not a nutritionist or dietician. Let me have someone come speak to you and investigate."

"I don't think that's necessary," she replied.

"I do, and your symptoms will get worse, and you might even pass out. Your blood glucose was low, and much lower would be dangerous. If you leave, you'll have to sign an AMA form — that you're leaving against medical advice, and another doctor will come talk to you to confirm. It's in your best interest to at least speak with the nutritionist."

"I don't want to," she said.

"Then let me go fill out the paperwork and bring in another doctor to confirm your decision."

"It's not necessary. I just want to leave."

"I understand, but in order to protect the hospital and me from legal problems, in the case that you do pass out and hurt yourself or someone, I really need you to sign the form. I promise it'll take less than ten minutes. Would you do it for me, please?"

"You could really get in trouble?"

"Yes. There's a law, the Emergency Medical Treatment and Active Labor Act, that requires evaluation and treatment of anyone who comes into our Emergency Department."

"OK," she said, acquiescing.

"We'll be right back," I said.

Krista, Al, and I stepped out of the room into the corridor.

"You'll just let her leave?" Al asked.

"Legally, I have to," I replied. "She hasn't expressed a desire to harm herself nor anyone else."

"But she is harming herself, right?"

"Not in a way that would allow me to act," I replied. "Let's go see Doctor Gibbs or Doctor Nielson."

We walked down the hall to the Attending's office and neither of them was there, so I checked with Ellie, who said Doctor Nielson was in the lounge. The three of us went there so I could speak with him. I presented the patient, and he frowned.

"I don't like it," he said.

"Neither do I," I replied. "But unless we put her on a psych hold, she's going to leave. And I don't think suspected anorexia is sufficient for a hold. She's stable, the food raised her blood glucose to a reasonable level, she's lucid, intelligent, and has good hygiene. She's thin but not emaciated.

"She rejected a nutritionist, and I can't imagine she'd speak to a pshrink. If I wanted to try for a bank shot, I'd use subterfuge to have Psych be the second doctor on the AMA form, but they won't do it. They'll insist on identifying themselves as Psych, and that would blow the whole thing out of the water."

"You're referring to your choice with regard to handling Mr. Alien Encounter?"

"Yes. Everything was fine until the Psych Resident decided to wreck what had been a successful encounter. They'd likely do that here, too. Doubly so because it's one of my patients."

"Krista, Al, excuse us," Doctor Nielson said. "Mike, let's go to the office."

We left and went to the Attending's office.

"Are you suggesting Psych would retaliate against a patient because of what happened with Lawson's friend?"

"I would never make that accusation," I replied. "But they do not agree with my methods, and that has been the case for a few years. I've seen the very real effects of how textbook approaches to mental healthcare have devastated lives and worsened care for individuals we could help. I mean, seriously, is Mr. Alien Encounter better for what they did? He was harmless and preferred not to be on his meds. I understand that non-compliance with medication is a problem, but if the patient is not dangerous and is functioning, even in a quirky way, why are they on meds?"

Doctor Nielson nodded, "I get you, and you absolutely have a surgeon's distaste for drugs."

"And yet, I make regular use of them in the ED with no objections. There is a difference between the use of life-saving drugs and drugs that, well, drug someone into submission to some foolish idea of 'normal'."

"You are going to have to find a way to work with Psych," Doctor Nielson counseled. "Even if you're right, you can't dictate to them how they run their service. And at this point, the well is poisoned with regard to suggestions coming from you."

I nodded, "I understand. The thing is, I only care about what is best for my patients, not what is best or easiest for me. If that's a problem, well, then I made a very, very bad decision in fourth grade."

"It's not a problem, in and of itself, obviously, as it's the basic guideline for physicians. But when you go counter to the accepted standard of care, it does come back on you, for better or worse. Fill out the AMA form, and let's go see your patient and I'll see if I can convince her to change her mind. I doubt it because if there's anyone here who's more empathetic and more patient-focused than you, I don't know who it might be."

We went to the nurses' station, where I filled out the AMA form, then asked Krista and Al to join us, and the four of us went into the treatment room.

"Mary, this is Doctor Nielson, one of my supervisors," I said. "He wants to discuss your decision to leave AMA."

"Hi, Mary," Doctor Nielson said. "I've looked over your chart and discussed it with Doctor Mike. We really do believe it's in your best interests to speak to a nutritionist, but as he said, that decision is ultimately yours to make. I'm concerned that you might pass out and harm yourself or others because of your low blood glucose levels. Your potassium and sodium levels are low as well, which usually are a sign of improper nutrition and can also lead to the kinds of symptoms you reported."

"I don't want to," Mary said.

Doctor Nielson nodded, "OK. If you'll sign this form, you're free to go."

He handed her the clipboard with the form I'd filled out.

"Why does it say I could die?" she asked after reading it over.

"Because you could," I interjected. "If you were to have a syncopal event — that is, in common terms, a fainting spell — while you were driving or in some other situation where there was some kind of risk of serious injury, you could die."

"But anyone could faint at any time," she countered.

I nodded, "That's true. But your risk is much higher than the average person your age. The decision is yours, and I encourage you to speak to a nutritionist. If you choose not to, and you do leave, you need to eat better."

"I'm fine," she said, signing the form.

She handed the clipboard back to Doctor Nielson, got up, and walked out.

"We'll see her again," I observed once the door had closed. "Most likely transported by EMS."

"Unfortunately, I think you're right," Doctor Nielson said.

"Isn't there anything we can do?" Al asked.

"Do you think she'd tolerate a psych consult if she wouldn't speak to a nutritionist?"

"No, but couldn't they put her on a psych hold?"

"They could," Doctor Nielson interjected. "But they won't because they'd have no legs to stand on if she challenged them. If there was any indication she was purposefully harming herself, they might. She's not eating properly, but if that were cause for a psych hold, about ninety-five percent of the county could be put on a psych hold!"

"Isn't the evidence of purging enough?" Krista asked.

"Not really," Doctor Nielson said. "Prior to the ACLU lawsuits in the late 70s and early 80s against involuntary commitment, we had more leeway, but even then, she wouldn't have met the criteria."

"In the end," I said, "no matter what the ailment, we can only offer treatment, not force it without a court order, and there is no chance we'd get one in this case."

"What about referring her to a social worker?" Al asked.

"She doesn't meet the criteria," Doctor Nielson replied.

"It just stinks that there is nothing we can do," Al observed.

"That is something we all have to accept," Doctor Nielson said. "In the end, only the patient or their designated representative can decide."

We left the room, and Nurse Lisa came up to me.

"Doctor Varma has a five-year-old who is non-communicative. He wondered if you had a moment to see if you could get him to open up."

"How did he present?"

"A fractured wrist; Doctor Varma suspects it's a result of abuse."

"Which is a good reason for the kid to clam up," I replied. "Which room?"

"Exam 5."

"Mary, Al, let me do this with Naveen and Lisa, please. There will already be too many people in the room if Naveen's students are there."

They went to the lounge, Doctor Nielson walked over to the nurses' station, and I followed Lisa to Exam 5. I waited in the corridor at her request, and Naveen stepped out to speak to me.

"John Tyler; five; fractured wrist, likely the result of abuse; bruises consistent with abuse as well. Mother claims he's 'accident prone'. Nothing appreciable on auscultation and vitals in range for a five-year-old."

"Nutrition?"

"Good, along with hygiene."

"Is the mom in the room?"

"Yes."

"Let's see if we can get her out."

"She refused."

"Did you order X-rays?"

"He's waiting on Radiology."

"That's the way to do it," I said. "She can't go into the room with the X-ray equipment. How do you want to play it?"

He smiled, "Surgical consult. Radiology should call any minute now."

As if on cue, Julie, his Fourth Year, stuck her head out of the exam room and said Radiology was ready. Doctor Varma, Lisa, and I went into the exam room.

"Hi, Mrs. Tyler," I said. "I'm Doctor Mike, a surgical Resident and with your permission, I'll examine John, then take him for his X-rays."

"OK," she agreed.

"Hi, John," I said to the five-year-old. "I'm Doctor Mike. How are you?"

He didn't answer, but I could tell from his eyes that he understood what I'd asked him.

"I need to check your wrist, then we're going to take some X-rays."

He said nothing, and the only reaction I had from his was flinching when I carefully examined his wrist. I noticed contusions on his arms and one on his lower back when I listened to his lungs. It was my belief that Doctor Varma's conclusions were correct about John being abused.

"Lisa," I said. "Let's get John into a wheelchair, and you and I can take him to Radiology."

She acknowledged me, and once Julie had retrieved a wheelchair, she helped John into it. I opted to push, and Julie held the door. As I had expected. Mrs. Tyler got up to follow us.

"You should wait here," I said to her. "You can't go into the X-ray room."

"Why?"

"Because only the patient, the X-ray tech, and medical staff are permitted in the room. And we'll leave when the X-rays are taken. The X-ray tech stands behind a lead screen to take the X-ray."

"I won't leave John alone!" she protested.

"I understand," I replied, "But hospital rules and government regulations for the use of X-ray equipment cannot be waived."

"Then I'll take him somewhere else!"

In this case, I could actually prevent that, unlike with Mary. While it was true Mrs. Tyler could sign an AMA form, Social Services would take immediate emergency custody of John based on his injuries.

"Mrs. Tyler, I don't want to be confrontational, but John has a potentially serious injury, and we can't let you leave without diagnosis and treatment."

"I'm his mother!"

"Yes, you are, but once you brought him in, we're obligated by law to treat him."

"Not without my permission!"

"You signed the permission form," I countered.

"Then I revoke that!"

"It's not that simple," I said. "For a minor, I'd be required to call Family Services to evaluate your decision."

"You have no right!" she protested.

"It's not about having the right," I replied. "It's about having the legal obligation. May I suggest you allow us to take the X-rays and not escalate the situation?"

"I won't leave him alone!"

"Nurse Lisa and I will be with him the entire time except for about five minutes in the X-ray room, and the tech will be with him the entire time."

"That's not good enough!"

"Lisa, call the on-duty social worker, please."

"I'm taking him!" Mrs. Tyler declared.

"I can't allow you to do that," I said. "Lisa, call security first, then call the social worker."

"Right away, Doctor!"

Mrs. Tyler moved to try to get John from the wheelchair, but I stood in her way. She tried to shove me out of the way, but I was five inches taller and had at least sixty pounds on her, not to mention understanding from karate how to keep my balance.

"Code Yellow, ED! Code Yellow, ED!"

It was a matter of seconds before a uniformed security guard hurried into the ED from the main lobby, and I signaled him.

"Social Services has been called for this patient," I said. "His mother is combative and trying to take him. She shoved me."

"Ma'am, step away from the doctor and the wheelchair," the security guard said.

"I won't! And no rent-a-cop is going to tell ME what to do!"

He might be a rent-a-cop, but I knew he was a special limited deputy and could arrest her. He wasn't armed, but he could have armed backup via a simple radio call.

"Ma'am, step away, or I'll place you under arrest," he said.

"I know my rights! No rent-a-cop can arrest anyone!"

"Ma'am, last warning."

She didn't budge.

"Ma'am, under the authority of the Sheriff of Hayes County, I'm placing you under arrest. You need to come with me."

She refused, which didn't surprise me. A second security guard arrived and together they escorted a now screaming Mrs. Tyler away from us.

"It's OK, John," I said. "Your mom is just upset about your wrist."

Lisa returned, and together, we walked down the hall, with me pushing the wheelchair. I now had more time to talk to John, though I decided to wait until after he had his X-ray. We arrived in Radiology, and the tech took over, leaving Lisa and me in the anteroom.

"I'd say she knows we figured out he's battered," Lisa said quietly.

"For sure," I confirmed. "Was she combative before I came in?"

"Only in the sense she refused to let John out of her sight. That's pretty common for frantic moms, but she wasn't frantic."

"How did the injury happen?"

"We only have her word that he was playing outside and came into the house crying. Neither Naveen nor I think that's the truth. Obviously, nothing was said, but I could tell from Naveen's body language and the tone of his voice."

"Did John say anything?"

"No. His mom answered every question put to him. Other than wincing when his arm was examined, he's been non-responsive."

"This probably exceeds my skill set," I replied. "Let's call for a pediatric consult. They have a pair of Residents with child psych certification."

"I'll make the call."

She went to the phone just as Jeannie Wilders came into the ante-room. I filled her in, and she concurred with the pediatric consult.

"Doctor Olson is on his way down," Lisa announced. "I'll stay with John because he knows me."

"Thanks," I said. "I'll leave this in both your capable hands."

"Thanks, Mike," Ms. Wilders said.

I left Radiology and returned to the ED, where Naveen was speaking to Doctor Gibbs.

"Where's the patient?" Doctor Gibbs asked.

"Radiology. Jeannie Wilders is with Lisa, and Matt Olson is on his way down. They need a psych-certified pediatrician for this one. It's beyond 'Kid Whisperer' territory. How's the mom?"

"Threatening to sue anyone and everyone," Doctor Gibbs said. "Security called for a Sheriff's Deputy. I was hoping she'd calm down, and we could simply let it go, assuming you don't want to file a complaint."

"I don't. It would serve no purpose. Jeannie Wilders will initiate the necessary process for taking emergency custody of what I'm positive Naveen's exam notes will show is a battered child."

"Absolutely," he confirmed. "I wrote on the chart that he needs a complete series of X-rays to look for other broken bones. Nate found two other visits in the past eighteen months on his billing computer. I sent Kim to search the charts."

"Mom?" Doctor Gibbs inquired. "Or is she covering for the dad?"

"I think it has to be her," Naveen said. "She said her husband travels for business and is away."

"Stress," I proposed. "Not that that excuses her."

"I agree," Naveen said. "She seemed stressed when she came in, though initially I attributed it to her son being injured."

"A natural inference," Doctor Gibbs confirmed. "Both of you fill out the paperwork, please."

"The bane of every doctor's existence!" Naveen declared.

"Preach it, Brother!" I declared.

"You won't hear an objection from me to that sentiment," Doctor Gibbs said. "Paperwork, then go heal the sick!"

I filled out the necessary form and took it to Doctor Gibbs, then my medical students and I took a hand lac walk-in. I debated with myself who should suture and decided it had to be Al, as suturing was basically the only procedure a Third Year could perform without permission from an Attending. We had just finished with that patient when Deputy Kenseth came up to me.

"I need a statement from you, Doc."

I nodded, "I'll give one, but I'm not going to press charges. She's in enough trouble as it is."