Tuesday, September 27, 2011

Scope of Practice

One night the EMS brought in a girl who was found unresponsive in her home. By the time she arrived at the ER she was answering questions, mostly appropriately, albeit with a significant delay. We were able to get a complete but contradictory history from her. She denied remembering anything, although she said she had had one drink and some marijuana with her friends that morning. We told her this looked like a drug overdose but she didn’t respond to that. She was a very pretty 21 year old, but she was far too thin for her body type and her forearms were crisscrossed by dozens of fine white scars. Physical exam was mostly unremarkable, except for a general lethargy and delayed/weakened motor responses in her extremities, and her pupils which were pinpointed, no focused and sluggishly reactive to light. She did not have the ability to follow a light with her eyes. All ocular movement was erratic and saltatory.

We did a urinalysis (UA) tox screen on her and it came back hot for barbiturates. Looking back in her file I found that this was her fourth time in the ER for prescription drug use. To top it all off, she was a pharmacy tech.

We had a long discussion with the ER doc about what we could do. We were all agreed that she shouldn’t be working in a pharmacy, but he said there was nothing we could do without violating patient doctor privilege. I argued that the laws contain a clause that states that if the patient is in imminent danger of causing harm to herself or others we not only have a right but a responsibility to report it to the appropriate authorities. In my view if a druggy is handing out drugs, her dipping into her own stock is the least of my worries. My worry is that she’ll be high at work and she’ll mislabel a bottle or put the wrong pills in it, or the wrong dose, or give it to the wrong patient and that could literally kill someone. Has it happened yet? No. I don’t think waiting for it to happen is a good plan. She needs to get fired for everyone else’s safety.

And what about her? Why the drugs and the alcohol and the cutting? Her mother showed up at the ER and wanted to take her home against her will. The charge nurse explained to her that we could not release her into anyone’s custody because she was not a minor. We could not keep her if she didn’t want to leave, we could not sign her over to her mother if she didn’t want to go. Her mother argued back, unable to see the plain facts of the situation through her grief and frustration. Didn’t we see that if she went back to her own house she would just get stuck with her friends again, and these friends were really bad. It was all their fault her daughter was doing drugs. If the patient could come home with her she (the mother) would keep the bad influences out of her life and she would turn around. Why couldn’t we just see that?

I couldn’t help but wonder, if that parental love hasn’t been sufficient thus far, what makes her think it’s going to become magically effective now? Regardless, legally there was nothing we could do. Like it or not, she was 21 years old. She was legally responsible for her own decisions and we could no more remand her into her mother’s custody than we could detox her. She was not in danger of her life. She was not overdosed, she was just stoned. That’s what those drugs are supposed to do. Even if she had been in danger the only treatment is to stick a tube in her stomach and pump out any pills that haven’t been absorbed, dilute with activated charcoal and support heart rate and respirations until the effects wear off.

What was up with her? The problem was far beyond emergency room scope of practice. Did her parents not love her? Had she been abused as a child? Had she not been able to find any good friends? Whatever the myriad single elements that made it up, they all came to one thing. The problem was that she had a deep, throbbing, aching, abysmal hole in the depths of her soul. That is beyond my scope of practice.

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