Chapter Two Hospital
"You really need to re-think this."
"I'm an adult; I know my rights. I'll sign a self-discharge form. Treatment without consent is an offence of battery. Just don't touch me, or I'll lodge an official complaint. "
The consultant glares. She's gone from being concerned to frustrated, and now, finally, she is infuriated at the young man's obstinacy.
The blonde-haired, blue-eyed Kate Summers is often praised for her sympathetic bedside manner- not an easy accolade to earn in an Emergency Department. She is not above using a clever combination of cajoling, psychological techniques and headmistress-style admonishing to try to get a reluctant patient to calm down enough to let the team do their work. After years of experience, she's become very good at handling difficult patients. But as soon as the local anaesthetic goes in and he's recovered enough to start answering questions about the incident, this patient started refusing treatment.
She tries again. As a mother of two children, she is used to having to argue with young people who resist logic, but this patient is proving to be a tougher nut to crack than her toddler.
"A dog bite injury this serious is not something that can be ignored."
"I'm not ignoring it, just not agreeing to being admitted to hospital. I'll get it stitched up in a doctor's surgery. You have no right to hold me; get the Patients Advice Liaison person in here- I know you have to have this service."
The boy is sitting up on the Emergency Room bed, his right hand pressing down hard on the bit of his left forearm where the IV cannula had been, until he'd pulled it out a moment ago. She doubts that he would have had enough saline to fix his circulating blood volume. She'd watched him sway a bit when he sat up on the trolley; if he had passed out from hypovolemic shock it would serve him right.
Not a very professional thought, Kate admits to herself, but she's had one of those mornings following one of those nights, hard on the heels of a yesterday she'd rather forget. She's been on-call all night after a difficult day shift yesterday. The junior doctor she'd passed the baton to at midnight had been too nervous to handle a number of cases on her own, so she'd been up and down like a yoyo answering her phone all night. The consultant who should have taken the shift at eight this morning has called in sick and the hospital manager is scrambling to get a replacement in. Until that person arrives, Kate can't just walk away.
This patient's threat of a PALS complaint is just the final straw.
She rehashes the last few minutes to see if she's done anything to warrant such hostility. Her first step had been to remove what the ambulance team had applied- a pressure dressing over wet gauze, packed into the a twenty centimetre gash. Even before the local anaesthetic had taken effect, the patient had started protesting. "I didn't agree to being brought here. Stop whatever you're doing."
She knows the routine well enough to do it in her sleep- after whacking in some local anaesthetic, take a good look, chop out the dead bits, wash it out, and stitch it up. In the face of his hostility, she had reverted to the formal medical terms: "The procedure is simple- inspection, debridement, irrigation and closure- I promise we'll be as quick as we can." That was before she realised how deep the wound was. Once the bloodied gauze had been unpacked, the calf had gaped like a split banana.
That's when she had decided distraction therapy might be in order. "What's your first name? We've just got a set of initials, Mister Holmes."
"Sherlock, but that's irrelevant. I want to leave now."
Could that be a made-up name, she wonders. "How did it happen?"
"That's none of your business. I don't have to tell you anything."
He's obviously feeling light headed, so lies back on the trolley, on his right side, as she inspects the wound more closely and realises that this is no simple dog bite. There are extensive signs of crushed tissue, and even in the viable areas, the bruising will be significant. And it is deep— leading her to consider the possibility of arterial, nerve and even bone damage.
She checks for a pulse on the left foot and is reassured. She then uses her finger to stroke both sides of the foot. "Can you feel that?"
"No, but it won't stop me from leaving."
"The fact that it's numb means that your sural nerve has taken a beating. And on top of that, the Achilles tendon is severed. I'm sorry…" She tries to remember the young man's name; he'd just said it, but she's been concentrating on the wound
"…Mister Holmes, we're going to have to keep you in. This needs surgery." Kate's memory needs a caffeine top-up. It is an odd first name; it will come back to her later.
She's begun planning the debridement- she will need to cut away the unviable tissue, and prepare the wound bed, get him on antibiotics, and then get him admitted; the surgery will need to be scheduled soon. She knows this is going to be an ortho referral- probably plastics, too, if the nerve is damaged, as she suspects.
"Didn't you hear me? I want to leave." The patient is now sounding not just impatient, but angry.
She bends over the wound site and replies in her most reassuring tone, "You aren't going to be able to walk on this leg for some time. The Achilles tendon is severed. That means foot drop- in layman's terms, your foot won't work. Even after surgery, it'll be weeks before you can put any weight on it. And the wound needs to be investigated for damage to the nerve, veins – even to the bone. On top of all that, dog bites are notoriously dirty, so we need to wash out as much bacteria as possible. Then start an IV drip of antibiotics. We wouldn't want to get an infection."
That provokes a derisory sniff. "WE aren't doing this. It's my leg. Tape a bandage back on it and I'm out of here."
That makes her stand upright in surprise. Most patients would be more worried by now, after being told the extent of the injury. "Are you completely stupid? This is not something that you can walk away from. If you don't have surgery, you could end up permanently disabled. And infection from any one of the dozen bacteria in a dog's mouth is very serious- sepsis kills people. Just be sensible and let us do our job. If you need something to take the edge off the anxiety, I can prescribe it."
"No. Get a self-discharge form in here and I will sign it. You're done here."
She nods to Thomas, the health care assistant, who had been irrigating the wound with a saline solution. The local anaesthetic in his hand will deaden some of the sensation, which works in their favour.
To keep his attention away from what was going on back there, Doctor Summers wants the patient focused on her, so she keeps talking. Her medical professional tone of authority has not worked, so she tries another tack. "Over two thirds of the patients who try to self-discharge are under the influence of drugs or alcohol. Are you one of those, Mister Holmes?"
"No, I'm clean."
A revealing choice of words. No one but a drug user ever phrases it like that. Despite his posh accent, Kate knows that addicts came in all shapes and sizes, but before she can say anything more, he continues, "and in any case, that's irrelevant to the decision, because getting a proper drugs test result would take days. You can't stop me leaving unless I am visibly impaired—which I am clearly not. You have to take my word for it."
Diversionary tactics then. "Is there someone we can call for you?"
"Yes, a taxi. I want to leave now."
She smiles at the way he has deftly parried her thrust. He's done this before.
"I meant a parent." She needs his date of birth, to see if he's had other hospital admissions. If there is a clinical reason to hold him, she'll use that. "How old are you? Minors can't make a self-discharge." The young man looks just that- young. Behind the bravado and the vocabulary, up close she could see he is most probably a teenager. There is an outside chance he is underage, even though he looks to be a university student, given the scarf that was wrapped around the leg when the EMTs had picked him up.
"My parents are both dead. I am on my own, an adult and able to make this decision. So, you have to let me leave."
"I need proof of that."
He gives a histrionic sigh. "Date of birth 6 January 1979. Call the Cambridge University Office to get confirmation, or Trinity College. Tell your minion to stop doing whatever he is doing back there or I will file a formal complaint of battery. And get the form in here for me to sign now."
Most of the patients who are under the influence would be cursing a blue streak by now; verbal abuse of medical staff was sadly routine in cases like these. But this young man is being civil, if a bit peremptory. Bound by hospital rules, she can't argue with his demand, even though every instinct screams that he needs to be treated here.
Kate starts to rehearse mentally the first set of criteria for a self-discharge. "If you know about the form, then you've done this before. I need to have the answers to a set of questions." She walks to the other side of the trolley, where she can make proper eye contact with him. Kate crosses her arms, not afraid to signal her willingness to confront him on this. "First, you say you're clean, but I need specific detail re timing. Have you taken any drugs or consumed any alcohol in the last twenty four hours?"
"No. The only drugs I've had are the ones you injected into me. Are you so thick that you didn't hear me the first time? Whether I'm under the influence or not is irrelevant. Don't try to play tricks, doctor. You wouldn't have a legal leg to stand on."
"Right now, I'm more worried about you having a leg to stand on, if you walk out of here. The question goes to the matter of capacity."
That makes him shove himself from his side and sit bolt upright, putting the wound out of Thomas's reach. It must have hurt, pushing the wound into the surface of the trolley, but he doesn't blanch. After glaring at Thomas, the student turns back to her, saying through clenched teeth, "I am a mentally competent adult with the capacity to make this decision, Doctor. Don't you dare suggest otherwise."
Then calming himself down, he affects an air of boredom. "'I have capacity. I understand that I have a dog bite, I am aware that you want to admit me for exploration, debridement, wash out and repair, with an option on intravenous antibiotics; I understand the consequences of not having this done – infection and sepsis. I'm an organic chemistry student, by the way, so I do know that I could die from septic shock, Doctor. And yes- let's add in there loss of function in the foot; and yet in spite of all of this, as a competent adult, I want to leave now.'
That clinches it for her; he has had experience in this, because the last question when determining competency is whether the patient could communicate their decision. Stifling her exasperation, "can you explain to me why you want to leave, despite all the risks?"
"That's not on the check list. I'm not required to give you a reason."
Doctor Summers raises her hands in surrender, "I'll go get the forms from reception but in the meantime, I'm ordering a referral to mental health services. So just sit there quietly until he comes down here."
She is at the door of the Resus Room when he shouts, "You can't do that!"
Kate stops and turns back to him. This is the first sign of his control breaking and it confirmed her hunch. "Yes, I can. Under the Mental Health Act 1983, Section 5 (2), I can order a 72 hour hold on you. And if that isn't enough, it's hospital policy." She recited from the form, "where the consequences of refusing treatment are serious or life threatening, discussion and assistance must be sought from the consultant—that's me, by the way, hello— and other relevant processionals such as the Psychiatric Liaison Service, who I am just about to call. So sit tight and wait, Mister Holmes."
Despite that bluff, once she's out of the Resus room. Kate delays making the formal referral call to the Psych service. She knows full well that they aren't usually involved in capacity cases, but she wants to stall long enough to do some checking. A Psych hold would only apply if the patient has a record of self-inflicted injuries or overdoses, or is so far gone that he is claiming to see pink aliens on the ceiling. She's not spotted any self-harm scars on his wrist. Kate needs something concrete, a record of something previously odd, maybe lithium levels on his blood tests or an admission that was mental health related. She can't really ask Psychiatric Services to see the patient just because he is not playing ball. But there is something that is really bugging her about this young man, and she isn't quite willing yet to throw in the towel. So, for the moment she'll try to play for more time.
Doctor Summers goes to the nurses' station and starts rummaging around in the file trays. She asks the Senior Nurse, "Could you get in touch with Trinity College, please? I need confirmation of the age of one of their students- Sherlock Holmes." Kate takes a brief moment of satisfaction when she realises that her adrenaline fuelled annoyance has brought the patient's name back to the front of her mind.
"I'd be grateful if you could also get whoever answers at Trinity to pass onto his tutor or whoever looks after pastoral care there the fact that their student has been injured, and see if they have a next of kin on file. If they give you a d.o.b, then you could run a quick check to see if there've been any previous hospital admissions. And, lastly, I'm being thick, but where are the self-discharge forms being kept these days? And I need a Section 5(2), as well." As she picks up the phone, the nurse smirks, pointing her thumb over her shoulder in the vague direction of the doors to the waiting room. "We moved the sign outs to the reception desk. People were getting pissed off at the waiting times and discharging themselves by the dozen, so it made sense to keep them out there. Gives staff a chance to spot them on the way out."
Doctor Summers gives her a rueful smile. "Good idea- it's useful to keep a record of when they realise that the waiting times for non-urgent cases are so long; it might help prove our case for more staff."
oOo
Kate has just collected the form for a Section 5 (2) hold from the receptionist when a man wearing motorbike leathers approaches the desk. At first she thinks he is a new walk-in, but then he speaks quietly to her.
"Excuse me, but you're a consultant, aren't you? Can you give me an update on Sherlock Holmes, the young man who was brought in here suffering from a dog bite?"
"Who are you?"
"My name is Robert Dryden. I've been keeping my eye on him- on behalf of his brother."
"I'm not allowed to talk about his condition to anyone other than family members. He said he's an orphan. He wants to discharge himself, rather than get treatment. Do you think this brother of his could talk some sense into him? Do you know how to reach him?"
Dryden's reaction is swift. "Let me get him on the phone now." He pulls out a mobile phone and hits speed dial. "Sir, I've got the consultant at the hospital here." He passes it over to her.
"Hello?" Kate is a tad unsure how to use the device; she's not used a blackberry before. It is something that she associates more with bankers and businessmen, and it makes her wonder about who the brother is.
"This is Mycroft Holmes. What's happened to Sherlock?"
Kate registers the fact that the man's voice is calm. Over the years she's dealt with a lot of family members by phone- nearly all of whom sound anxious and distressed when they realise that they are talking to an Emergency Department doctor.
She introduces herself, outlines the injury and Sherlock's determination to discharge himself. Before she can ask him if he could have a word with his brother, however, he interrupts.
"Don't allow that, Doctor. Not under any circumstances."
Almost apologetically, she tries to explain. "I can't really stop him, unless you tell me otherwise. Unless he's under 18, he knows his rights. Even the psych opinion I've asked for is just a delaying tactic; he's sure to pass it- you have to be barking mad, or a danger to yourself or others before they'll rule incompetence. I've no evidence to hold him."
There is a sigh on the other end of the phone. "My brother is classified as a vulnerable adult, Doctor Summers. He is nineteen years old and on the Autistic Spectrum. I am his legal guardian and have medical power of attorney. The man who handed you this phone is a bodyguard- he's the one who phoned me about the attack, which I am taking very seriously, even if my brother isn't. Sherlock should not to be released without my permission and if you think that he needs surgery, then he does not have that permission."
"Oh?!" She is surprised. What limited contact she's had with autistic patients had been with children, and in those cases a paediatric consultant became involved. The sharp tongued articulate young man she's just been sparring with does not conform to those images of developmentally challenged children. "I think you'd better be the one to tell him that. I'm not sure he'll listen to me."
There is a snort of suppressed laughter on the other end. "He won't, but don't take it personally. He won't listen to me, either. This isn't a case of persuasion, Doctor. Sedate him if you have to; once he knows that he's not getting out and that I'm aware of his situation, he's a serious flight risk."
Her silence as she digests this must have hinted at her discomfort, because the man on the other end continues to explain, "He hates hospitals- positively phobic- but if you are looking for a reason to treat him against his wishes, then I can document two overdoses and one suicide attempt."
"I'll need proof of all that, especially your status as legal guardian; send it to me as quick as you can by fax."
Kate passes on the fax line number while she runs down her mental checklist for a patient at risk of absconding: brought into the ED against his own wishes, unaccompanied, agitated, angry, frustrated by delay- and a total lack of engagement with the seriousness of his injuries. Yep- he ticked all the right boxes.
The calm voice at the other end of the phone continues, "I'll do that immediately, but in the meantime, if I were you, I'd order extra security right now to make sure he stays put."
Kate has already come to that decision. She looks down at the note she'd just scrawled on the receptionist's pad: call security; we've got a runner.
"Mister Holmes; I'll get back to you. I need to make sure he doesn't leave." She hands the mobile phone back to the biker, and ran back into the ED's Resus room.
It is empty. "Shit!" Kate bolts out and scans down the corridor to where she sees the back side of a trauma nurse's red scrubs- he must be chatting to the nurse at the station around the corner. She marches up to him and demands, "Where's your patient, Thomas?"
"Gone for a pee." He nods towards the patient's toilet door behind her.
"How long's he been in there?"
A frown crossed his brow. "Don't know; a while. I gave him a pair of crutches, and he hobbled down here while I cleared up the Resus Room. Don't worry- he's not wearing a gown but with one leg of his trousers cut off, he'd going to be a little obvious if he tries to scarper."
"Want to bet?" She mutters under her breath.
A few minutes later, Ron Gilbey, the security porter, gets the toilet door unlocked. The three of them peer into an empty room. Thomas scrubs the back of his neck, shaking his head in disbelief. "I saw him go in there. He was really struggling with the crutches. How the hell…?"
Gilbey smirks, and points to the on-call room next to the toilet. "You were down the corridor at the Resus Room, weren't you?" When the Assistant nods, the security man's smirk broadens. "He must have walked in and stayed just long enough to fool you into going back in the room and then scarpered through the on-call door, though how the hell he locked the door from the outside is a puzzle. It's stalled us just long enough. I'll call up the tapes and see what happened, but I'll bet someone his height walked out of the on-call room, wearing scrubs."
Kate purses her lips and then draws a deep breath. "Look for someone limping badly. He can't walk on a severed Achilles tendon. And if he's never used crutches before, he won't be going anywhere fast."