Tuesday, February 4, 2014

Dr. Orthochick: Rings

I recently had a hand consult from the ICU for a lady who fell when she had a heart attack and broke her wrist.

Nurse: Are you going in to see her?
Me: Yeah
Nurse: I'll go in with you.

Bad sign right there, folks.

Anyway, the patient said someone had told her that while she was in the hospital, she shouldn't do anything she wasn't comfortable with. So far this had extended to any cardiac procedures, medications, x-rays, or breathing treatments. I fully believe in patient autonomy and with very few exceptions (TB, meningitis) no, I don't think care should be forced on anyone, but if you're going to refuse everything anyway, why bother going to the hospital?

I was not the exception.

Me: So you broke your wrist blah, blah, blah...would you mind taking off your rings?
Patient: I'm not taking off my rings
Me: Well, I worry your hand is going to swell and then your rings will cut off circulation to your fingers. Would you like me to help you take them off?
Patient: No, you can't take them off me.
Nurse: I can take them off you.
Patient: You can't take my rings off! It's going to hurt!
Me: OK, so why don't we give you some pain meds first and then we'll try and if it's hurting you, we'll stop?
Patient: No. You are not taking off my rings. I was told to not do anything I wasn't comfortable with doing and I do not want you to take off my rings.
Nurse: I really think I can do it without hurting you
Patient: I have not taken off my rings in 50 years and I am not doing it now.
Me: The reason I'm asking is because I'm worried they could cut off circulation to your fingers and your finger could die and have to be amputated.
Patient: No one is taking off my rings. It would hurt too much.
Me: Well if you want, we could get a ring cutter and cut them off?
Patient: The only person who can cut off my rings is a jeweler. If you bring a jeweler in here, he can do it the special way. But that is the only way my rings are coming off.
Nurse: We're not bringing in a jeweler. You have two options, either we cut them off or I can get them off without hurting you.
Me: I don't want you to lose a finger.
Patient: You are not a jeweler. [to nurse] You are not a jeweler. The only person who can take my rings off is a jeweler.

...and that is why I will never be a great doctor. Because no, I am not going try and hunt down a jeweler at 10 at night to ask him to please come over to the hospital to cut off a lady's rings. I realize if this was a TV show then that's what I would do, the patient would hug me, and the jeweler would do it for free, but really, my life is not a TV show and the sad truth is, I don't care more than my patients do. If I have explained the risks of losing a finger and offered options and the patient voices understanding of the risks and still declines, then I'm done. I'm not going to move hell and high water to try and save a patient's finger if she's not willing to try a little. I tried calling her son because she said she discussed all major decisions with him, but she didn't know the number and the one in the chart was wrong so I couldn't pursue that one further. I'm not even sure how I would get a hold of a jeweler at night. I can't imagine there's the jeweler on call or something.

I also offered to splint the patient, she said no, we discussed the risks that if her fracture displaced she might need surgery, she still said no, and that was the end of that really aggravating consult. I mean, that's a good half hour of my life I will never get back that was wasted arguing with a patient about taking off her rings and putting on a splint.

(and just in case you're wondering, psychiatry had already seen her and determined that she had capacity and was therefore able to make her own medical decisions and refuse things as she saw fit. So it's not that she was demented and legally if I hold her down and rip off her rings after she's refused, it's battery.)


  1. Document the hell out of it and d/c to home.

    1. Yes. From time to time I will write a near certain "celestial discharge" note. Given capacity and witnessed and documented understanding, we will d/c people to go home, get worse, and die. Obviously you try everything else first, but sometimes you can and do come to the end. It bothered me for a while, but there's people here that do want help.

      We have one Dr. Death that this happens to quite a bit, probably b/c he works straight nights.

  2. please provide updates on this one if available

    1. please do! Did she come back to get fitted for finger prosthesis?

  3. Unfortunately, patients have the right to be idiots.

  4. Groan...I see this frequently in my clinic. Parents bring their kids in, for example with a sore throat. The kids refuses the strep swab. It becomes a battle. The parents ask me not to do it. Or with ear pain, and the ears are packed with wax, and I can't see the TMs. When I begin to remove the wax with using a curette, the child protests, and the parents ask me to stop. When I explain that I can't treat the child without a diagnosis, they usually tell me it is ok, and leave. Sometimes they argue with me. I agree with Dr Grumpy: document document, document....

    1. Agree completely! I mean, why the hell are you here and complaining about your symptoms yet don't want treatment? What do you expect us to do? Wave a magic wand and bippity-boppity-boo, it's all better?!? This may sound harsh, but charge them for the appointment time (they wasted) and like you and Grumpy said, document the hell out of it.

      This is the part on the practitioner side of medicine that I am still having difficulty coming to terms with: why do people make appointments for their problems when they know damn well they're not going to like or want the treatments?!? I just don't get it...

    2. Some people seem to believe that, just by staying at the hospital, you will get better. It is the nearness of so many doctors. Health penetrates you by osmosis.

  5. So did she lose her finger??? I'm on the edge of my seat here!

  6. That is where having a jeweler boyfriend (me) would come in handy! I never thought it would happen in a hospital. I'm definitely going to tell him. He is going to have a good laugh.

  7. Not necessary to cut off rings: http://www.youtube.com/watch?v=wIti9y-693E

  8. We have had a few incidences where we had to bring in the firemen to cut off patient's rings/bracelets that have become stuck and cause oedema of the distal limb. True story. It is always an exciting event when it happens.

    (I am a silent reader, so, Hi!)