Let's say you have a patient who comes in with chest pain and you do an extensive workup including CTs, serial troponins, Echos, stress test, PMD discussions. However, despite a thoroughly negative workup the patient still feels sick and refuses to leave. Would you call security on this patient to leave?
Chances are you’ve had to bring security or police in to escort a patient out of the ED before. Some cases are pretty straight forward- if a patient is violent, aggressive, or dangerous, then they should be removed from the ER once they are medically cleared.
However, other times it’s not so clear who we should call security on to escort them out of the ED. Especially if the patient is not a threat to staff and the patient believes that they are too sick to leave. These decisions are very case by case dependent and sometimes you will end up having to call security.
But keep in mind that patients have had significant negative outcomes including death after being escorted out of the ED when they initially did not want to leave because they felt like they were too sick.
Over the next few days, we will discuss a few tips to prevent bad outcomes when it comes to these difficult patients/ scenarios.
Tip 1:
Re-consider your workup
Ask yourself:
How sure are you of your diagnosis?
Is this a high utilizer who normally leaves in the morning after a good night’s rest and food?
We all make mistakes and we all may miss something. If you have come to a roadblock with a patient who you feel you have worked up thoroughly but still feels so sick they won’t leave, take a step back. Go back and expound upon your history and physical. Ask questions to the patient you didn’t ask the first time. Rethink your differential.
These patients are often not good candidates for a minimalist workup. One of our responsibilities as ED doctors, is to rule out dangerous morbidity and mortality- affecting conditions. Yes, we as ED doctors have to judiciously order tests but in general, we should have a lower threshold for these patients.
For example, you have a patient with abdominal pain who you haven’t done any labs or imaging because their belly is soft without rebound and guarding. The patient states they still feel unwell and are not comfortable leaving. In this situation, you should reconsider your workup. You have much more justification on calling security for exit escort on a patient with abdominal pain who you did labs and CT on than no workup at all. It gives you as well as the patient more reassurance.
Address any abnormal vital sign prior to discharge and use as a general sign of ‘badness.’
To sum up:
Err on the side of caution and order more tests if you have to. Reconsider your differential and workup.
Made it this far? Ready for tip 2?! Tune in next time for part two!
Stay well,
TR Adam