POTD: Against Medical Advice

When patients request to be discharged before receiving the full recommended evaluation and/or treatment, we often consider this a discharge against medical advice (AMA). The rate of AMA discharges is increasing with recent studies showing they account for approximately 2% of all ED discharges.

As you can imagine, leaving AMA poses significant risks to the patient and the provider. Patients who leave AMA are found to have higher rates of adverse outcomes including readmission, prolonged hospitalization, and increased mortality. Then, when an adverse event occurs, these patients are 10 times more likely to sue the providers who cared for them. Some estimates suggest that 1 in 300 AMA discharges result in a lawsuit, compared to 1 in 30,000 standard discharges.  

With that being said, patients will inevitably choose to leave AMA so it’s important for us to understand how to handle this to minimize risks for both parties. One article I found suggests using the “AIMED” framework, which I personally found helpful and will outline here.

A: Assess if the patient has capacity to make an AMA decision.

• Capacity requires (1) understanding all treatment options including the risks and benefits, (2) expressing a clear choice, (3) appreciating the consequences of that choice, and (4) ability to justify one’s reasoning.

I: Investigate why the patient wants to leave.

• Common reasons include personal obligations (e.g., children, pets, work), financial concerns, dissatisfaction with the care, distrust of the medical system, subjective improvement of symptoms, or withdrawal symptoms.

M: Mitigate premature discharge by offering the patient comfort measures, alternatives, or compromises tailored to their specific concern.

• This may include providing medication for withdrawal or involving social work to assist with their outside responsibilities.

• Be careful not to make false promises because this will create distrust toward you and the healthcare system.

E: Explain & Evaluate

• Explain the patient’s illness and your treatment plan in simple terms.

  • First review the patient’s presenting symptoms, the results of initial tests, and your working differential. Then, discuss your recommendations (further testing, observation, admission, etc) including the benefits of this plan. Next, explain the potential risks of leaving, including severe complications such as permanent disability or death.

• Evaluate that the patient understands the consequences of their choice and has all the necessary information to make an informed decision.

• Provide comprehensive discharge instructions, including specific follow-up appointments, referrals, and prescriptions. Emphasize that the patient can return to the emergency department at any time.

D: Document everything thoroughly.

• Include an assessment of the patient’s capacity and a detailed record of your conversation about the original treatment plan, alternative options, risks of leaving, and the plan for outpatient care.

• Here are two example templates I found online:

  • The patient expresses the desire to leave against medical advice (AMA). Their reasoning for leaving AMA is due to ***. They presented with a chief complaint of *** and I have explained my concern that based on their complaint in addition to my history, physical exam, and studies returned to date that this may represent ***. In addition, I explained that their work-up is currently incomplete and I would recommend *** to complete it. I also explained my concern that leaving at this time places them at risk for their condition worsening, critical illness, and death or permanent disability including ***. I have also offered alternative treatments options including ***. The patient explained in their own words all of my concerns including the consequences of refusing further treatment including death or permanent disability. I have also discussed my concerns with *** who was also unable to convince the patient to stay. The patient is clinically sober and has no injury that would affect their cognition. In addition, they appear to have intact insight, judgement and reason and in my opinion has the capacity to make their own healthcare decisions. Given that the patient was unwilling to stay I *** to increase the probability of a good outcome. I ensured there were no communication barriers with the patient by ***. A written informed refusal document was *** signed by the patient after our conversation. Outpatient follow-up was offered with ***. The patient was encouraged to seek care immediately if they would like to complete the work-up or if they have any new concerns. This conversation was witnessed by ***. AMA paperwork was*** completed and signed.

  • The patient is clinically not intoxicated, free from distracting pain or injury, appears to have intact insight, judgment and reason and in my medical opinion has the capacity to make decisions. The patient is also not under any duress to leave the hospital. In this scenario, it would be battery to subject a patient to treatment against his/her will. I have voiced my concerns for the patient's health given that a full evaluation and treatment had not occurred. I have discussed the need for continued evaluation to determine if their symptoms are caused by a condition that present risk of death or morbidity. Risks including but not limited to death, permanent disability, prolonged hospitalization, prolonged illness, were discussed. I tried offering alternative options in hopes that the patient might be amenable to partial evaluation and treatment which would be medically beneficial to the patient, though the patient declined my options and insisted on leaving. Because I have been unable to convince the patient to stay, I answered all of their questions about their condition and asked them to return to the ED as soon as possible to complete their evaluation, especially if their symptoms worsen or do not improve. I emphasized that leaving against medical advice does not preclude returning here for further evaluation. I asked the patient to return if they change their mind about the further evaluation and treatment. I strongly encouraged the patient to return to this Emergency Department or any Emergency Department at any time, particularly with worsening symptoms.

According to malpractice attorneys, good documentation in the EMR is superior to an AMA form. In fact, most AMA forms offer very little medicolegal protection for providers. While it is good practice to have your patient sign the AMA form, your time is better spent writing a thorough note about your conversation with the patient rather than fighting with Taylor Health and the South Side Printers.

Finally, I want to address the misconception that leaving AMA will result in insurance coverage being denied for the visit. This is entirely false. Multiple studies have shown that leaving AMA does not place any additional financial burden on the patient, and these visits were reimbursed the same as other visits.

Sources:

https://www.emra.org/emresident/article/lit-review-ama-discharge

https://www.nuemblog.com/blog/ama

https://www.aliem.com/ama-two-high-risk-myths-misconceptions/

https://www.aliem.com/proper-way-to-go-against-medical-advice/

https://pmc.ncbi.nlm.nih.gov/articles/PMC7909809/

https://www.wikem.org/wiki/Against_medical_advice

POTD: Nasal Septal Hematomas

*Disclaimer: This POTD contains multiple images of the inner nares. Proceed at your own risk.*

The nasal septum is a combination of bony and cartilaginous structures that forms the midline of the nasal cavity. When the nose sustains trauma, blood can accumulate in the space between the septal cartilage and the perichondrium, a surrounding connective tissue layer. This collection of blood is known as a nasal septal hematoma.

Nasal septal hematomas are relatively rare, occurring in only about 1% of patients with nasal trauma. However, they are often overlooked. One study estimated that approximately 50% of nasal septal hematomas have a delayed diagnoses.

Prompt diagnosis is important because untreated nasal septal hematomas can cause irreversible nasal deformities. The perichondrium, the only blood supply for the nasal cartilage, becomes separated from the underlying cartilage when a hematoma forms. This condition makes the cartilage susceptible to avascular necrosis. Necrotic nasal cartilage can collapse and create a “saddle nose deformity.”

To avoid delayed diagnosis, providers should evaluate all trauma patients for the presence of a nasal septal hematoma. These patients typically complain of nasal obstruction (95%), pain (50%), and rhinorrhea (25%).

The best way to look for nasal septal hematomas is to examine the inner nares using an otoscope. If a hematoma is present, it will appear as a red, blue, or purple bulge extending from the septal mucosa. The hematoma will feel boggy (soft and watery) when palpated and will not shrink in size when vasoconstrictive agents like Afrin are administered. Since we are not ENTs, I have included some images below of normal nares, nares with nasal septal hematomas, and nares with other conditions that can mimic the appearance of a hematoma.

Normal Nares

Nasal Septal Hematoma

Nasal Spur (cartilaginous outgrowth, will be more firm than a hematoma)

Nasal Septal Deviation (septum is off center so looks like a protrusion) 

Nasal Polyp (soft grape like growth from the nasal mucosa, usually clear/white/yellow) 

Once a nasal septal hematoma is diagnosed, urgent drainage is necessary to prevent complications. To perform this procedure, you’ll need the following equipment: a light source (such as an otoscope or Schiller’s headlamp), lidocaine with epinephrine, pledgets (which can be found in the trauma bay), an empty 5 mL syringe attached to an 18G needle, a 11-blade scalpel, forceps, a 10 mL saline-filled syringe attached to an 18G angiocatheter, and two rhino rockets. Ideally, a nasal speculum would be used for better visualization, but I’ve never personally seen one at Maimo.

Here is a step-by-step guide:

1. Position the patient supine with their neck slightly extended.

2. Soak two pledgets (or rolled-up sterile gauze) in lidocaine with epinephrine. Insert one into each nostril and ensure they touch both sides of the nasal septum. Leave these in place for 5-10 minutes before removing them. Afterwards you may inject a small amount of local lidocaine at the anticipated incision site.

3. Insert the 18G needle into the hematoma and aspirate the blood using the 5ml syringe.

4. Use the scalpel to make a horizontal incision along the inferior border of the hematoma. Be careful not to cut the cartilaginous septum.

5. Evacuate the hematoma by using forceps to extract any clotted blood.

6. Irrigate the hematoma by inserting the 18G angiocatheter into the incision and flushing it with sterile saline.

7. Pack the nose with bilateral rhino rockets. You must pack both nares to keep the septum midline.

Once the hematoma has been evacuated, the patient can be discharged. They should be prescribed prophylactic antibiotics, typically Augmentin 875 mg PO BID for 7 days. They must follow up with an ENT specialist or return to the ED within 24-48 hours for nasal packing removal.

Sources:

https://www.ncbi.nlm.nih.gov/books/NBK470247/

https://www.tamingthesru.com/blog/masteringminorcare/nasalseptalhematoma?rq=minor%20care

https://wikem.org/wiki/Nasal_septal_hematoma

https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=683&sectionid=45343819

POTD: Auricular Lacerations

The external ear, also known as the auricle or pinna, has unique anatomical features that influence wound management in this area. For today’s POTD, I’m going to review the anatomy of the outer ear and the management of auricular lacerations.

Anatomy

The term “outer ear” specifically refers to the auricle (or pinna) and the external auditory canal. The auricle can be divided into six sub-units: the helix, antihelix, conch, tragus, anti-tragus, and the lobule.

All of these structures, except the lobule, are composed of thick avascular cartilage that supports the ear’s shape and structure. This cartilage is surrounded by a poorly vascularized perichondrium, which is then covered by a tightly adherent connective tissue and skin layer.

Auricular Lacerations

When the ear sustains a laceration, it should be repaired using primary closure, similar to any other laceration. Simple lacerations (involving only the skin) or complex lacerations (exposing or extending through the cartilage layer) can be repaired by us ER doctors. However, for more advanced lacerations such as split earlobes, avulsions, or lacerations extending into the external auditory canal, an evaluation by an ENT or plastic surgeon is recommended.

Auricular Nerve Block

The ear is innervated by several nerves, including the auriculotemporal nerve, greater auricular nerve, lesser occipital nerve, and the vagus nerve. An auricular nerve block can be performed to anesthetize all areas of the ear except the conch (which is innervated by the vagus nerve).

• Draw up 10-20 ml of lidocaine without epi and attach a small 25g or 27g needle. (Remember the max dose of lido without epi is 7 mg/kg or 0.7 ml/kg)

• Enter skin at the point just below the ear, advance the needle posteriorly along the skin over the mastoid bone behind the ear, and inject 3-5 ml while withdrawing the needle

• Once the needle is close to the original puncture site, don’t remove it but redirect it anterior to the ear and inject another 3-5 ml while withdrawing the needle fully out of the skin

• Repeat the same process entering from above the ear.

• Enter skin at the point just above the ear, advance the needle posteriorly, inject 3-5 ml while withdrawing the needle, redirect the needle anteriorly and inject another 3-5 mL in front of the ear while withdrawing the needle.

Laceration Repair

Once the ear is anesthetized, irrigate the wound and assess for any exposed cartilage.

If there’s no exposed cartilage, repair the skin with 6-0 non-absorbable sutures using a standard simple interrupted technique.

If there’s exposed cartilage, you can still repair the wound with 5-0 or 6-0 non-absorbable sutures. However, you must ensure the skin is well-approximated and fully covers the cartilage. This might require the use of deep 5-0 absorbable sutures if the wound is full-thickness (through and through) or irregular.

Dressing

After the ear has been repaired, it is recommended to apply a bulky pressure dressing to avoid the dreaded cauliflower ear. Cauliflower ear is a deformity of the ear that arises when normal healthy ear cartilage is replaced by fibrocartilage. This occurs when the cartilage is left exposed or it suffers pressure necrosis from a hematoma forming between the skin and cartilage (as shown in the image below).

Head Wrap Technique: Apply petroleum gauze around the wound and pack it into the helix. Apply a generous amount of dry gauze anterior and posterior to the ear. Compress this dressing tightly to the head with kerlix gauze.  

Bolster Technique: Sandwich the wounded area between cotton rolls or small rolls of gauze, securing these in place by suturing them to the ear.

Ear Splint technique: Wet a small amount of plaster and coat it with a thin layer of cotton webril dressing to create a splint. Firmly press the splint in place against the ear with a wad of gauze. Cover the ear with several layers of gauze. Secure the splint to the head with a kerlix wrap around the head.
Review the steps here: https://www.aliem.com/trick-of-trade-splinting-ear/

Quick Caveat: Some argue that auricular hematomas are rare, and a pressure dressing can hinder wound healing through vascular compromise.

Antibiotics

As with any wound, ensure the patient’s tetanus status and administer an updated tetanus vaccine if necessary.

Historically, prophylactic antibiotics were commonly prescribed for ear lacerations. Evidence now suggests that they may not be universally required. The consensus among medical professionals, including UpToDate and multiple emergency medicine blogs, is that antibiotics (such as Augmentin or clindamycin) should be prescribed if the wound is visibly contaminated, if cartilage is exposed or requires repair, or if the patient is immunocompromised to increase their risk for infection.

Follow-Up

Technically speaking the best practice is to recommend the patient return in 24 hours to assess the wound for the development of an auricular hematoma. After this initial assessment, they should return in 4-5 days for suture removal.

 Sources:

https://accessmedicine.mhmedical.com/content.aspx?bookid=2969&sectionid=250461381

https://www.uptodate.com/contents/assessment-and-management-of-auricle-ear-lacerations

https://wikem.org/wiki/Ear_laceration