Clinical Dilemma

[Tobra]

I have this lady I go to see at the hospital. Diabetic, utterly non-compliant, schizoprenic, treatment challenge with a capital "T". She has refused her insulin, her Vancomycin(hardcore IV antibiotic) and anything beyond removing a toe. In the last 10 days, she has been admitted to 4 different hospitals, leaving AMA(against medical advice) on each occasion. As an aside, she has the Kalifonication version of Medicaid, which is called Medi-cal, clever word play eh? I am relatively sure that the State of Cali will refuse to reimburse for any of these admissions, but am not certain. Insurance companies often will refuse to pay if the patient leaves AMA.

One of the three toes she has on her R foot is black, smelling surprisingly not too bad. She appears to have a bone infection in two of her three remaining metatarsal heads(at the ball of the foot) per MRI. To fix it so she has a chance of keeping that leg, she needs a trans metatarsal amputation, where you cut the bones about an inch or so back from the ball of the foot, flap the skin from the bottom of the foot. If I do what she wants me to do, it will fail, because there is no way her 300 pound ass is going to be hopping around on one metatarsal head and not wear another hole in the bottom of her foot. I guess the question is, do you do a procedure on an extremely unwell person, medically and mentally, that will be unsuccessful in resolving her problem for more than a few weeks. I have explained to her that she will almost certainly have one or both of her legs off if she does not do what I am suggesting.

Oh, and she was born on the same day and year as my ex wife, what are the odds on that one?

[m21sniper]

Any way for you to wash your hands of her entirely?

[quicksix]

Any chance you could refer her to ucd,or was that one of the hospitals she ama'd from

[Moses]

Originally Posted by quicksix

Any chance you could refer her to ucd,or was that one of the hospitals she ama'd from

Yep. "I'm not comfortable managing a case as complicated as yours. Best if we transfer your care to the University."

She's a great teaching case for the residents.

[artplumber]

From a purely CLI standpoint, what's the vasc supply like?

From a medico-legal standpoint, send her to a center.

[M.D. Holloway]

365 to 1

Who knows what really goes on between their ears...

[Crowbob]

I wonder if your question is answered in the Obamacare plan? Not to ignite a political argument or anything, but seriously, are these ethical/practical issues dealt with in the new bill? My understanding is that a lot of this medical decision-making is taken out of the hands of physicians. Until then, if thus lady is not acting in her own best interest, can't she be found incompetent? Wouldn't that take the pressure off you?

[Tobra]

She left AMA on Sunday. She seemed to understand that there was an infection, but she believed it would get better just taking off the toe.

She refused angiogram, doppler was better thanI expected, judging by how her feet and legs looked.

Can't believe she has not seeded the hardware in her legs with whatever is in her foot. She refused every other dose of Vanco, BG in the 500's Incredible how much a human body can take.

[Hugh R]

I'd say transfer IF you can absolve yourself of liability.

[Tobra]

sorry for the arcane lingo, left AMA means she split the scene of her own accord, officially SEP(somebody else's problem)

[WilsonTC]

Shouldn't this be in "technical"?

[jyl]

Originally Posted by Crowbob

My understanding is that a lot of this medical decision-making is taken out of the hands of physicians.

What is the basis of this belief?

[DanielDudley]

It isn't always possible to save people from themselves.

[bivenator]

Going with Moses on this. A great opportunity for residents. A teachable moment if you will.

If she is going AMA at four different hospitals, it would seem she needs the state to take over her care.

[m21sniper]

Why should the state take over?

let her die.

[bivenator]

Hey, I'm all for letting her die. It would seem that is what she wants. Butt, that is not how we roll in this heartless country with so many uninsured. She will get medical care if she continues to show up at a hospital regardless of her financial situation or ability to make decisions concerning her care.

[Tidybuoy]

How bout a steady drip of propofal

[daepp]

Originally Posted by m21sniper

Why should the state take over?

let her die.

That is very ugly. If this were my forum you'd be gone. Now on Ignore.

[m21sniper]

Originally Posted by DAEpperson

That is very ugly. If this were my forum you'd be gone. Now on Ignore.

If it were my forum i'd still not care what you think.

Originally Posted by bivenator

Hey, I'm all for letting her die. It would seem that is what she wants. Butt, that is not how we roll in this heartless country with so many uninsured. She will get medical care if she continues to show up at a hospital regardless of her financial situation or ability to make decisions concerning her care.

And because of that we're bankrupt and we're being forced down the road of communistic tyranny.

I say in the real world sacrifices must be made for our freedom. Let's start with this crazed chick and her toe.

[rfloz]

Does she have a family member that can step in and get appointed as guardian or just get a power of attorney for health care from her?

Failing that, can you get her to a hospital that can/will seek appointment of a conservator?

Any of the above should be able to mandate that she undergo appropriate treatment.

Good luck.