Consequence of Leaving the Hospital Against Medical Advice

A fifty-one year old man was found unconscious in Radcliff Park with slow breathing, an elevated blood sugar above 500, and other injuries, and despite the paramedic’s attempts, they could not wake him. The ambulance transported him to the closest hospital, and an IV was started en route. Dr. Babington was prepped, and his team was ready for the arrival of the unconscious patient.

The ambulance pulled up to the outer bay of the hospital, and the man was moved quickly inside and into a trauma room. He had active bleeding on the forehead, cuts on both arms and blood stained down his left leg. Initially, it was hard to tell what had happened to him and how much damage there was.

The first responders worried it might have been from an attack, and the wounds were consistent with this type of injury. The patient had an ID and was found to be Mr. Fomina.

Dr. Babington said, “Check the head and neck for any open wounds or other signs of head trauma.

Nurse Blye Vernon said, “Looks clean. There are some old scrapes, but nothing new, except the laceration to the forehead.

What about pupil reaction?

They’re round and equal seized. They react normally.

Good. We might need to order a head CT just to make sure,” replied Dr. Babington.

Nurse Blye nodded and moved her inspection to the forehead. She began to clean the wound to see how deep it was.

We’ve got some puncture marks,” said Nurse Jonathan Smiley as he worked on the left arm. “If I had to guess, probably some bites from a dog.

Let’s start an antibiotic,” said Dr. Babington. “Are the bites fresh or old?

Fresh.

Dr. Babington began pressing on the chest and abdomen. He listened to the lungs. “What is his blood sugar?

A third nurse, Bobbie Armstead, said, “Still in the 500’s.

Start an Insulin drip,” said Dr. Babington. “We need to get his blood sugars more under control. Has anyone looked at his lower legs?

On it,” said Nurse Blye. A few minutes later, she said, “He has a pressure ulcer on the bottom of his left foot. He has had two of his toes amputated on his right foot.

Is this guy in our system?

An ancillary staff standing near the door said, “He’s been here twice before. A year ago and three years ago. We have him listed as homeless, a veteran, who has been going to the homeless clinic on 53rd Street for his medications. He has been on Insulin for over ten years.

What did we see him for last time?

Intoxication and Pneumonia the most recent time. Before that, it was for Diabetic Ketoacidosis, and both times he stayed overnight. He had an ambulation of his toes three years ago.

Well,” said Dr. Babington. “It looks like he was attacked. He has injuries consistent with being punched and/or kicked. I’m not sure how the dog fits into this. Let’s get him some fluids, Chest X-ray, and a head CT. Right now, he is stable, but we need that blood sugar down. Let’s order some STAT labs and we need to get a urine. We can cath him if needed. Let me know if he becomes unstable.

The three nurses nodded and got to work. The fluids were already running, and setting up an Insulin drip was easy. Within twenty minutes, his blood sugars were starting to improve. During that time, they cathed him and got a sample of blood to be sent for testing. The urine was dark, almost amber in color. There wasn’t a lot they were able to get. They placed an indwelling Foley catheter to remain in his bladder and collect urine continually. Next, they sent him first for the head CT. This was followed by a chest X-ray.

The chest X-ray showed pneumonia, and antibiotics were started. Within an hour, several things had happened. He had been ruled out of anything alarming in the brain, such as significant head trauma, stroke, or brain bleed. He was started on antibiotics both for the bite and the pneumonia. He had no broken bones but was in Ketoacidosis, a condition of high blood sugar without proper treatment.

Dr. Babington was pleased with the findings and was hopeful that the patient would start to improve. Mr. Fomina made a turn for the better a short time later. His blood sugars and urine color improved, and the treatment was starting to work.

When Mr. Fomina woke up, however, he was in a panic. He started screaming and thrashing and nearly ripped his IV and Insulin drip from his arm. He was crazed, speaking incoherently and yelling that something was missing. The staff tried to control him, but it wasn’t working. At some point, he was given an injection to rest.

A few hours later, he woke up far calmer and more relaxed. The treatments provided were really starting to improve his conditions. He was less pale, and his injuries were bandaged. He was hungry and less paranoid.

Dr. Babington came in as soon as he could. He asked, “Mr. Fomina, how are you feeling?

When can I get out of here?” Mr. Fomina was eating a sandwich.

We have a few more tests to run, but you’re doing much better. Your blood sugars have been stable in the last hour or so. We need to get more fluids into you.

I’m fine, doctor. I just need to leave here.

What is the rush?

You wouldn’t understand.

It looks like you were attacked, and your blood sugar was really elevated.

I can’t afford medications such as Insulin. I’m doing the best that I can. That’s not what is important right now.

Mr. Fomina was beginning to get agitated again.

Dr. Babington asked, “What is the most important thing for you?

Finding my dog. Someone tried stealing him.

Is that where you got those dog bites?

Someone came to take him. I was trying to get him back. I was hit and kicked, but they were stealing my dog.

Who?

It doesn’t matter. You wouldn’t believe me.

Dr. Babington asked, “Who?

It was the government. They are using my dog to spy on me.

I see,” said Dr. Babington. “I’m going to call in the nurse, and we can try to help you.

I want to leave. Right now!!” Mr. Fomina began screaming again. “I know my rights. You can’t hold me. I want to leave AMA.

Raising two hands, Dr. Babington asked, “You want to leave against medical advice. That doesn’t have to happen.

I need to find my dog.” In one quick swipe, he pulled out his IV. Glancing down at the Foley Cath, he said, “You can remove this, or I will.

Fine,” said Dr. Babington. “I will call in a nurse, and we can prepare your things.

Thank you. I just need to find my dog.

Mr. Fomina signed the AMA and was discharged from the hospital. He left with a script for Insulin, antibiotics, and a referral to a shelter near 47th Street, not far from where he was found.

Two weeks later, he was brought back to the hospital with symptoms similar to before. His blood sugars were sky-high, and he hadn’t showered in weeks. The infection in his arm had gone untreated, and his skin was red and irritated. This time, he hadn’t been assaulted, but he had lost more than ten pounds of weight. He looked far worse than before.

This time, it took nearly two days for the IV fluids, medications, and Insulin to bring Mr. Fomina into a steady state. He was sick, pale, and uncomfortable, and the ulcers on his feet had worsened dramatically. It was obvious he wasn’t feeling very well.

It was an entirely different staff at the hospital that day, except for one nurse, but they were able to review the chart, and the treatment again was initiated. They gave fluids and IV antibiotics to help with the infection. When he awoke and could answer questions, they had a plan in place. They had a social worker available and had contacted a shelter and a local agency that could provide some of his diabetic medications.

Mr. Fomina didn’t care. He was beside himself. “I just need to find my dog.

The doctor said, “We have someone willing to call all the animal shelters. We will help you look for your dog if you stay here for treatment. Just give us his name and a picture or a description. We will do everything we can to help.

This caused Mr. Fomina to pause and consider their proposal. After thinking about it for a few minutes, he nodded and sat back to rest. More fluids were ordered, blood work tested, and they scheduled a shower in fifteen minutes. Afterward, they would bandage his feet.

Mr. Fomina was calm, and when the social worker came in, he could describe the dog, a mixed golden retriever named Rosco. It turned out that the government hadn’t stolen his dog, but rather another homeless man who had been attacked a few times wanted Mr. Fomina’s dog for protection. The two had fought. His dog had accidentally bitten him when he was getting taken. When Mr. Fomina was released the last time, he couldn’t track down the guy who stole his dog.

Nurse Jonathan came in and removed the line to his IV. A dressing was placed over the area so he could shower. Mr. Fomina was escorted to the shower and given some privacy.

They knocked on the door when he didn’t come out after fifteen minutes. There was no answer. They called the charge nurse and were given permission to enter the room. Nurse Jonathan was given a key, and he and another nurse went in. The shower was still on, but Mr. Fomina had vanished out a back door. The hospital was searched, but Mr. Fomina was gone.

Despite their best efforts, the patient had chosen to leave the hospital. Sometimes we are our own worst enemies.

Three days later, the ambulance was called to Radcliff Park for an unconscious male. By the time the paramedic arrived, the man had passed away. Statements were taken, and many of the workers in the area recognized the guy. He would go day and night, screaming and searching for his dog. It was heartbreaking for the paramedics and hospital staff to learn what happened to Mr. Fomina. He had been so fixated on finding his dog that he refused to take care of himself, and ultimately it cost him his life.

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