There is significant practice variability when providers are asked to determine if a patient is intoxicated. Some providers will evaluate a patient to determine if a patient is “clinically sober”, while other providers will rely on a patient’s blood alcohol concentration (BAC) to evaluate a patient’s level of intoxication. There is very little data to suggest that either approach is superior; however, both practice patterns have significant limitations and carry a certain degree of medicolegal risk.
Patients who leave the emergency department against medical advice (AMA) are at an increased risk of having a bad medical outcome, and can be a source of significant medicolegal risk to providers. Earlier we reviewed eight elements to address when signing a patient out AMA. There are two common myths regarding patients who leave AMA that can complicate an already difficult situation.
On average, in-flight medical emergencies occur about 15 times per day. When asked by flight crews to help in a medical emergency, providers have fairly extensive legal protection, and in some cases have a legal obligation to help . In the U.S., all 50 states have some form of a “good Samaritan” law, which provides legal protection to medical providers who perform their services in response to medical emergencies outside the hospital. While these laws typically apply broadly to most out of hospital emergencies, in 1998 Congress specifically passed the Aviation Medical Assistance Act (AMAA) which offers legal protection to providers, who give assistance in the case of an in-flight emergency .
Case Example: 42 y/o male presents with right lower quadrant abdominal pain and has significant tenderness at McBurney’s point on exam. While waiting for a CT scan to evaluate for possible appendicitis the patient rips out his IV and tells the nurse “I’m leaving, I don’t want to sit here all night, and you can’t make me stay.” The nurse pulls you out of another room and hands you the standard against medical advice (AMA) paperwork.