Insulin, anyone?
It was 1991. I was on call and on Service Call at the hospital. It was early evening when I got a call from the Emergency Department (ED) that there was a patient needing admission to the ICU and I was next up on the call list for admitting patients without a primary care physician who admitted to the hospital.
I jumped into my car and whizzed down the highway to the hospital. ICU admissions always required promptly arriving at the hospital. After parking in the physician’s parking lot I ran into the ED. I checked in at the nurse’s desk and they pointed to an ED bay that was crowded with various caregivers, from ambulance crew to nurses to respiratory therapists to physicians. I ran over, introduced myself and announced that I would be the admitting physician and wanted a summary of the case. Here’s what I was told.
The patient was found seizing in the street. Bystanders called 911 and an ambulance was dispatched to the scene. They found an approximately 30 year-old woman having serial seizures. They medicated her with valium and transported her to the hospital. The ED team was having a hard time stopping her seizures. Her initial work-up revealed an extremely low blood glucose, below 30. As most people know, very low blood glucose levels (severe hypoglycemia) cause seizures. They had given her several doses of D 50 (a 50% solution of glucose) and they were still having trouble getting that glucose level higher. Because of the low blood glucoses and difficulty controlling the seizures, the ED physician placed a central IV line. As I recollect, it was a subclavian central IV line.
We brought the patient up to the ICU and over the next 12 hours got her stabilized and seizure free by infusing glucose and antiseizure medications. The hospital administrative staff, having gone through her wallet, had found out her name and the local police department did a search for her family. It turned out, this patient was actually from Toronto, Canada (we were in a Canada border state) and had a very interesting history. The patient had a trail of hospital admissions from Canada into the U.S. which were very suspicious. We called the last hospital she was in and the story they gave us was that the patient was doing “things” to herself to get herself admitted to the hospital. Injecting herself with insulin and causing seizures was one way she had gained admissions to hospitals. As I recollect, she also injected herself with feces to start a bacterial infection at least once. Once admitted, she was a problem patient, causing disruption, etc. She usually signed out against medical advice (AMA) when she decided it was time to “move on”.
Now, back then and even today in most states, older insulins (like pork regular insulin) is actually over the counter and so are insulin syringes. Our patient would go to a pharmacy, say she was a diabetic who was out of insulin, get insulin and syringes and then inject herself with large doses of insulin. She was not diabetic. We were the fifth U.S. hospital she had been in that year.
We confronted her with this information and had an endocrinologist and psychiatrist consult ordered. During the next day, she again had an episode of very low blood glucose requiring intervention. I was suspicious that she had a supply of insulin hidden somewhere in her room. None of the admitting or floor nursing staff had looked through her purse. I went into her room, grabbed her purse and found several vials of insulin and a fistful of insulin syringes. This infuriated the patient who proclaimed she was going to sign out AMA.
At that point, this was actually not risky for the patient as her only finding from two days of testing was she was giving herself insulin. She had no other significant medical problems. The issue was, she still had that central IV line in, giving her an easy, direct access to her blood stream. I told her we would have her sign AMA papers (this absolves the hospital, the staff and myself from a lawsuit if the patient deteriorated after leaving the hospital), but, we had to remove the central IV line.
The patient refused to let us remove it.
Of course, we didn’t want to let her leave with a direct central circulation access with her history of her injecting herself! We tried to approach her to take it out and she would grab the bed covers and assume a fetal position, protecting the central line entrance site. The only way we could get that line out would be to have a half dozen nursing staff and security staff descend on the patient and wrestle her into four point restraints.
It was about 10:00 at night when the patient was yelling that she wanted to leave the hospital and started creating a big fuss in the ICU. Not wanting to just let her go with that central line, I asked to have the hospital’s legal counsel summoned to get an understanding of what we could do to get that line out before the patient left (at this point, the staff was more than ready to get her out the door).
The hospital lawyer and I talked over the phone and she said she would come in. Twenty minutes later the lawyer arrived and she went in and interviewed the patient and reviewed her history of abusing herself. After that she came over and said 1) We had to let the patient leave AMA if she wanted to, and 2) If she wanted to leave with the central line in, we had to let her do that. We couldn’t wrestle her into submission and remove it as that would be assault and battery and not only could whoever participated in getting the line out be arrested, the patient could sue the hospital and all of us for attacking her! Of course we were all flabbergasted!
The lawyer helped us amend the AMA papers to include language specifically calling out the risks of leaving with the central line including a paragraph referring to her previous risky behavior.
The patient gleefully signed all of the papers and a nurse and security officer wheeled her to the exit of the hospital where the patient got into a taxi cab and disappeared into the night.
We never saw or heard from her again. I was thinking, she would be lucky to live another year, all because of the legal ramifications of this case; our being unable to force a person like that to have a central line removed, which was a mode of therapy applied by the hospital staff to help treat her, and which she would likely lethally abuse.
You can bet I factored that case into my future decisions regarding placing central IV lines……